Substance Abuse Treatment

 

For Adults in the Criminal 

Justice System 

A Treatment 

Improvement 

Protocol 

TIP 

44 
 

 

 

Substance Abuse 

Treatment 

For Adults in the Criminal 

Justice System 

A Treatment 

Improvement 

Protocol
 

TIP
 44
 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Public Health Service 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 

1 Choke Cherry Road 

Rockville, MD 20857 
Acknowledgments

This publication was prepared under contract

numbers 270-99-7072 and 270-04-7049 by the

Knowledge Application Program, a Joint

Venture of The CDM Group, Inc. and JBS

International, Inc., for the Substance Abuse

and Mental Health Services Administration

(SAMHSA), U.S. Department of Health and

Human Services (HHS). Christina Currier

served as the Government Project Officer.

Disclaimer

The views, opinions, and content expressed

herein are those of the authors and do not

necessarily reflect the views, opinions, or

policies of SAMHSA or HHS. 

Public Domain Notice

All materials appearing in this volume except

those taken directly from copyrighted sources

are in the public domain and may be reproduced or copied without permission from

SAMHSA or the authors. Citation of the

source is appreciated. However, this publication may not be reproduced or distributed for

a fee without the specific, written authorization of the Office of Communications, 

SAMHSA, HHS.

Electronic Access and Copies

of Publication

TThis publication may be ordered from or

downloaded from SAMHSA’s Publications

Ordering Web page at http://store.samhsa.gov.

Or, please call 1-877-SAMHSA-7

(1-877-726-4727) (English and Español).

Recommended Citation

Center for Substance Abuse Treatment.

Substance Abuse Treatment for Adults in the

Criminal Justice System. Treatment

Improvement Protocol (TIP) Series 44. HHS

Publication No. (SMA) 13-4056. Rockville,

MD: Substance Abuse and Mental Health

Services Administration, 2005.

Originating Office

Quality Improvement and Workforce

Development Branch, Division of Services

Improvement, Center for Substance Abuse

Treatment, Substance Abuse and Mental

Health Services Administration, 1 Choke

Cherry Road, Rockville, MD 20857.

HHS Publication No. (SMA) 13-4056

Printed 2005

Reprinted 2009, 2011, 2013, and 2014

ii Acknowledgments
Contents 
 

What Is a TIP? ........................................................................................................ix 

Consensus Panel ......................................................................................................xi 

KAP Expert Panel and Federal Government Participants ..............................................xiii 

Foreword ...............................................................................................................xv 

Executive Summary ...............................................................................................xvii 

Chapter 1—Introduction ............................................................................................1 

Overview..................................................................................................................1 

The Purpose of This TIP .............................................................................................3 

Key Definitions..........................................................................................................4 

Audience for This TIP.................................................................................................5 

Contents of This TIP...................................................................................................5 

Chapter 2—Screening and Assessment..........................................................................7 

Overview..................................................................................................................7 

Definitions of Terms....................................................................................................7 

Screening Guidelines...................................................................................................9 

Assessment Guidelines................................................................................................10 

Key Issues Related to Screening and Assessment...............................................................13 

Areas To Address in Screening and Assessment ................................................................18 

Selection and Implementation of Instruments ..................................................................33 

Screening and Assessment Considerations for Specific Populations .......................................36 

Integrated Screening and Assessment—Sample Approaches ................................................39 

Conclusions and Recommendations ...............................................................................40 

Chapter 3—Triage and Placement in Treatment Services ...............................................43 

Overview ................................................................................................................43 

Treatment Levels and Components................................................................................43 

Potential Barriers to Triage and Placement.....................................................................47 

Creating a Triage and Placement System ........................................................................47 

Compiling Information To Guide Triage and Placement Decisions.........................................49 

Conclusions and Recommendations ...............................................................................56 

Chapter 4—Substance Abuse Treatment Planning .........................................................59 

Overview ................................................................................................................59 

Assessing the Severity of Substance Use Disorders ............................................................60 

Assessing the Severity of Co-Occurring Disorders .............................................................60 

Criminality and Psychopathy ......................................................................................63 

Client Motivation and Readiness for Change ...................................................................65 

Implementing an Effective Treatment Planning Process .....................................................67 

Conclusions and Recommendations ...............................................................................70 

Chapter 5—Major Treatment Issues and Approaches.....................................................71 

Overview ................................................................................................................71 

Clinical Strategies .....................................................................................................72 

iii
Program Components and Strategies .............................................................................84 

Conclusions and Recommendations ...............................................................................90 

Chapter 6—Adapting Offender Treatment for Specific Populations ..................................93 

Overview ................................................................................................................93 

Treatment Issues Related to Cultural Minorities...............................................................93 

Women’s Treatment Issues ..........................................................................................95 

Men’s Treatment Issues.............................................................................................101 

Working With Violent Offenders .................................................................................102 

Treatment Issues Based on Client’s Sexual Orientation .....................................................104 

Treatment Issues Based on the Client’s Cognitive/Learning, Physical, and Sensory Disabilities ..105 

Treatment Issues for Older Adults ...............................................................................107 

Treatment Issues for Clients From Rural Areas ..............................................................107 

Treatment Issues for People With Co-Occurring Substance Use and Mental Disorders .............108 

People With Infectious Diseases ..................................................................................116 

Sex Offenders.........................................................................................................119 

Conclusions and Recommendations .............................................................................122 

Chapter 7—Treatment Issues in Pretrial and Diversion Settings.....................................125 

Overview...............................................................................................................125 

Introduction ..........................................................................................................125 

Characteristics of the Population ................................................................................126 

Treatment Services in the Pretrial Justice System ...........................................................127 

Trial and Postverdict Periods.....................................................................................130 

Diversion to Treatment .............................................................................................131 

What Treatment Services Can Reasonably Be Provided in the Pretrial Setting?......................138 

Treatment Issues .....................................................................................................143 

Developing Pretrial Treatment Services ........................................................................146 

Resources..............................................................................................................151 

Conclusions and Recommendations .............................................................................154 

Chapter 8—Treatment Issues Specific to Jails.............................................................157 

Overview...............................................................................................................157 

Definitions.............................................................................................................157 

Trends..................................................................................................................158 

Treatment Services in Jails ........................................................................................159 

Description of the Population.....................................................................................159 

Key Issues Related to Treatment .................................................................................163 

What Treatment Services Can Reasonably Be Provided in a Jail Setting?..............................166 

Coordination of Jail Treatment Services .......................................................................175 

Examples of Jail Treatment Programs ..........................................................................183 

Research Related to Jail Treatment .............................................................................184 

Recommendations for Treatment Providers ...................................................................185 

Chapter 9—Treatment Issues Specific to Prisons ........................................................187 

Overview...............................................................................................................187 

Description of the Population.....................................................................................187 

Treatment Services in Prisons ....................................................................................190 

iv Contents
Key Issues Affecting Treatment in Prison Settings ...........................................................190 

What Treatment Services Can Reasonably Be Provided in the Prison Setting? .......................194 

In-Prison Therapeutic Communities ............................................................................199 

Specific Populations in Prisons...................................................................................204 

Systems Issues ........................................................................................................207 

Recommendations and Further Research ......................................................................210 

Chapter 10—Treatment for Offenders Under Community Supervision ............................213 

Overview...............................................................................................................213 

The Population.......................................................................................................214 

Levels of Supervision ...............................................................................................214 

Treatment Levels and Treatment Components ................................................................214 

What Treatment Services Can Reasonably Be Provided for People Under 

Community Supervision? .......................................................................................218 

Treatment Issues for People Under Community Supervision ..............................................220 

Treatment Issues Specific to People on Parole ................................................................226 

Treatment Issues Specific to Probationers .....................................................................229 

Strategies for Improving System Collaboration ...............................................................229 

Sample Programs ....................................................................................................231 

Conclusions and Recommendations .............................................................................233 

Chapter 11—Key Issues Related to Program Development...........................................235 

Overview...............................................................................................................235 

Reconciling Public Safety and Public Health Interests .....................................................235 

Interdependence of Criminal Justice and Treatment Systems .............................................236 

Program-Level Coordination......................................................................................242 

Research and Evaluation ..........................................................................................247 

Cost Issues.............................................................................................................251 

Key Goals of SAMHSA .............................................................................................252 

Conclusions ...........................................................................................................252 

Appendix A: Bibliography ......................................................................................255 

Appendix B: Glossary ...........................................................................................291 

Appendix C: Screening and Assessment Instruments ...................................................303 

Appendix D: Resource Panel...................................................................................309 

Appendix E: Cultural Competency and Diversity Network Participants ...........................313 

Appendix F: Special Consultants ..............................................................................315 

Appendix G: Field Reviewers...................................................................................317 

Appendix H: Acknowledgments................................................................................320 

Index ..................................................................................................................321 

CSAT TIPs and Publications....................................................................................335 

Figures 

Figure 2-1. Screening Guidelines by Domain....................................................................11 

Figure 2-2. Screening Guidelines by Setting.....................................................................12 

Figure 2-3. Recommended Substance Abuse Screening Instruments ......................................19 

Contents v
Figure 2-4. Instruments for Evaluating Readiness for Treatment..........................................23 

Figure 2-5. Instruments for Screening and Assessing Mental Disorders ..................................25 

Figure 2-6. Instruments Examining Psychopathy and Risk for Violence and Recidivism.............32 

Figure 3-1. Placement and Triage Strategies ....................................................................50 

Figure 4-1. Client’s Recovery Plan (CRP).......................................................................68 

Figure 5-1. Common Thinking Errors............................................................................75 

Figure 5-2. Strategies for Working With Offenders Based on Their Stage in Recovery ...............84 

Figure 6-1. Traits of ASPD (DSM-IV)...........................................................................113 

Figure 6-2. Borderline Personality Disorder ..................................................................114 

Figure 7-1. Substance Abuse Treatment Planning Chart for Treatment-Based Drug Courts .......134 

Figure 8-1. Treatment Components..............................................................................168 

Figure 8-2. Goals of the Treatment and Corrections System in the Jail Setting........................176 

Figure 8-3. Targeted Treatment for Special Populations Versus Mainstream Treatment for 

Larger Populations ..................................................................................178 

Figure 8-4. Varied Opinions Regarding Medication Use for Inmates in Jail Treatment Programs 180 

Figure 9-1. Reasons for Limitations to Providing Treatment to Prison Inmates.......................191 

Figure 9-2. Guidelines for Substance Abuse Treatment in Correctional Facilities ....................192 

Figure 9-3. Stay’n Out Program Outcomes ....................................................................202 

Figure 10-1. Comparison of Probationers and Parolees ....................................................215 

Figure 10-2. Paradigm of Collaboration........................................................................230 

Figure 11-1. CSAT Criminal Justice Treatment Planning Chart ..........................................238 

Figure 11-2. Barriers to Effective Treatment..................................................................243 

Figure 11-3. Outcome Information...............................................................................250 

Figure 11-4. Definition of Terms .................................................................................251 

Advice to the Counselor Boxes 

Chapter 2 


Screening and Assessment...........................................................................................13 

The Need to Rescreen ................................................................................................16 

Screening for Detoxification ........................................................................................21 

Screening for Co-Occurring Disorders ...........................................................................27 

Screening for Trauma ................................................................................................29 

Screening for Psychopathy..........................................................................................30 

Screening Specific Populations.....................................................................................38 

Chapter 3 


Triage and Placement ................................................................................................49 

Chapter 4 


Mental Health Issues .................................................................................................61 

Borderline Personality Disorder...................................................................................63 

Psychopathy............................................................................................................65 

Motivation for Change ...............................................................................................66 

Chapter 5 


Homelessness...........................................................................................................73 

Criminal Thinking ....................................................................................................74 

Family Involvement...................................................................................................78 

Addressing the Coerced Client .....................................................................................80 

Establishing Boundaries .............................................................................................81 

vi Contents
 

Establishing Counselor Credibility ................................................................................83 

Spiritual Approaches.................................................................................................89 

Chapter 6 


Culture and the Counselor ..........................................................................................95 

Treating Female Offenders ..........................................................................................97 

Parent Training ......................................................................................................100 

Rural Clients, Rural Counselors .................................................................................108 

“Good” and “Bad” Drugs..........................................................................................111 

Infectious Diseases...................................................................................................118 

Chapter 7 


General Considerations for Working With Clients in the Criminal Justice System ...................127 

Diversion to Treatment Decision Points ........................................................................128 

Information Management During the Pretrial Stage.........................................................130 

Operating in a Pretrial Setting....................................................................................143 

Addressing the Client’s Immediate Needs ......................................................................144 

Chapter 8 


Jailed Clients .........................................................................................................165 

Cross-Training........................................................................................................179 

Chapter 9 


Prison Treatment Approaches ....................................................................................198 

Heading Off Noncompliance.......................................................................................209 

Chapter 10 


Recommended Treatment Services for People Under Community Supervision........................221 

Treatment Issues for People Under Community Supervision ..............................................225 

Treatment Issues for People on Parole .........................................................................229 

Contents vii
 
What Is a TIP? 

Treatment Improvement Protocols (TIPs) are developed by the Center for 

Substance Abuse Treatment (CSAT), part of the Substance Abuse and 

Mental Health Services Administration (SAMHSA) within the U.S. 

Department of Health and Human Services (HHS). Each TIP involves the 

development of topic-specific best-practice guidelines for the prevention 

and treatment of substance use and mental disorders. TIPs draw on the 

experience and knowledge of clinical, research, and administrative experts 

of various forms of treatment and prevention. TIPs are distributed to 

facilities and individuals across the country. Published TIPs can be 

accessed via the Internet at http://STORE.samhsa.gov. 

Although each consensus-based TIP strives to include an evidence base for 

the practices it recommends, SAMHSA recognizes that behavioral health is 

continually evolving, and research frequently lags behind the innovations 

pioneered in the field. A major goal of each TIP is to convey "front-line" 

information quickly but responsibly. If research supports a particular 

approach, citations are provided. 

ix 
xi

Consensus Panel

Co-Chair

Roger H. Peters, Ph.D.

Professor

Department of Law and Mental Health 

Florida Mental Health Institute

University of South Florida

Tampa, Florida

Co-Chair

Harry K. Wexler, Ph.D.

Senior Principal Investigator

National Development and Research 

Institute, Inc.

New York, New York

Workgroup Leaders

Steven R. Belenko, Ph.D.

National Center on Addiction and Substance

Abuse

Columbia University

New York, New York

Nahama Broner, Ph.D.

Senior Research Psychologist

Center for Crime, Violence and Justice

Research

New York, New York 

Christopher J. Geiger

Vice President/Director of Criminal Justice

Programs

Walden House, Inc.

San Francisco, California

Kevin Knight, Ph.D.

Research Scientist

Texas Christian University

Fort Worth, Texas

Michael D. Link, M.C.J.

Chief

Division of Treatment and Planning

Ohio Department of Alcohol and Drug

Addiction Services

Columbus, Ohio

Henry Jay Richards, Ph.D.

Associate Professor

University of Washington

Seattle, Washington

Sally J. Stevens, Ph.D.

Research Professor

Social and Behavioral Sciences

Southwest Institute for Research on Women

University of Arizona

Tucson, Arizona

Panelists 

Elaine Abraham

Program Developer/Consultant

National Development and Research, Inc.

Chula Vista, California

E. Bernard Anderson, Jr., M.S., M.A.,

NCAC, ICADC, CCS

Regional Administrator

Correctional Treatment

Florida Addictions and Correctional 

Treatment Services, Inc.

Tallahassee, Florida

Annabelle Casas-Mendoza, M.A.

Family Treatment Drug Court 

65th District Court

El Paso, Texas

Note: The information given indicates each participant's affiliation during the time the panel was

convened and may no longer reflect the individual's current affiliation.
 

Deion Cash 

Executive Director 

Community Treatment & Correction 

Center, Inc. 

Canton, Ohio 

Kimberly S. Hee, M.A. 

Grants Program Specialist 

Office of the Mayor 

Criminal Justice Planning 

Los Angeles, California 

Mack Jenkins, B.A. 

Division Director 

Adult Court Services 

Orange County Probation Department 

Santa Ana, California 

Carl G. Leukefeld, D.S.W. 

Director 

Center on Drug and Alcohol Research 

University of Kentucky 

Lexington, Kentucky 

Erik J. Roskes, M.D. 

Director 

Forensic Treatment and Correctional Services 

School of Medicine 

Springfield Hospital Center 

Sykesville, Maryland 

xii Consensus Panel
xiii

Barry S. Brown, Ph.D.

Adjunct Professor

University of North Carolina at Wilmington

Carolina Beach, North Carolina

Jacqueline Butler, M.S.W., LISW, LPCC,

CCDC III, CJS

Professor of Clinical Psychiatry

College of Medicine

University of Cincinnati

Cincinnati, Ohio

Deion Cash

Executive Director

Community Treatment and Correction

Center, Inc.

Canton, Ohio

Debra A. Claymore, M.Ed.Adm.

Owner/Chief Executive Officer

WC Consulting, LLC

Loveland, Colorado 

Carlo C. DiClemente, Ph.D.

Chair

Department of Psychology

University of Maryland Baltimore County

Baltimore, Maryland 

Catherine E. Dube, Ed.D.

Independent Consultant

Brown University

Providence, Rhode Island

Jerry P. Flanzer, D.S.W., LCSW, CAC

Chief, Services

Division of Clinical and Services Research

National Institute on Drug Abuse

Bethesda, Maryland

Michael Galer, D.B.A.

Chairman of the Graduate School of Business

University of Phoenix—Greater Boston

Campus

Braintree, Massachusetts

Renata J. Henry, M.Ed.

Director

Division of Alcoholism, Drug Abuse, 

and Mental Health

Delaware Department of Health and Social

Services

New Castle, Delaware 

Joel Hochberg, M.A.

President

Asher & Partners

Los Angeles, California

Jack Hollis, Ph.D.

Associate Director

Center for Health Research

Kaiser Permanente

Portland, Oregon 

Mary Beth Johnson, M.S.W.

Director

Addiction Technology Transfer Center

University of Missouri—Kansas City

Kansas City, Missouri 

Eduardo Lopez, B.S.

Executive Producer

EVS Communications

Washington, DC

Holly A. Massett, Ph.D.

Academy for Educational Development

Washington, DC

KAP Expert Panel and Federal

Government Participants

Note: The information given indicates each participant's affiliation during the time the panel was

convened and may no longer reflect the individual's current affiliation.
Diane Miller 

Chief 

Scientific Communications Branch 

National Institute on Alcohol Abuse 

and Alcoholism 

Bethesda, Maryland 

Harry B. Montoya, M.A. 

President/Chief Executive Officer 

Hands Across Cultures 

Espanola, New Mexico 

Richard K. Ries, M.D. 

Director/Professor 

Outpatient Mental Health Services 

Dual Disorder Programs 

Seattle, Washington 

Gloria M. Rodriguez, D.S.W. 

Research Scientist 

Division of Addiction Services 

NJ Department of Health and Senior Services 

Trenton, New Jersey 

Everett Rogers, Ph.D. 

Center for Communications Programs 

Johns Hopkins University 

Baltimore, Maryland 

Jean R. Slutsky, P.A., M.S.P.H. 

Senior Health Policy Analyst 

Agency for Healthcare Research & Quality 

Rockville, Maryland 

Nedra Klein Weinreich, M.S. 

President 

Weinreich Communications 

Canoga Park, California 

Clarissa Wittenberg 

Director 

Office of Communications and 

Public Liaison 

National Institute of Mental Health 

Kensington, Maryland 

Consulting Members

Paul Purnell, M.A. 

Social Solutions, L.L.C. 

Potomac, Maryland 

Scott Ratzan, M.D., M.P.A., M.A. 

Academy for Educational Development 

Washington, DC 

Thomas W. Valente, Ph.D. 

Director, Master of Public Health Program 

Department of Preventive 

Medicine 

School of Medicine 

University of Southern California 

Alhambra, California 

Patricia A. Wright, Ed.D. 

Independent Consultant 

Baltimore, Maryland 

xiv KAP Expert Panel and Federal Government Participants
xv

The Substance Abuse and Mental Health Services Administration 

(SAMHSA) is the agency within the U.S. Department of Health and

Human Services that leads public health efforts to advance the behavioral

health of the nation. SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities.

The Treatment Improvement Protocol (TIP) series fulfills SAMHSA’s mission to reduce the impact of substance abuse and mental illness on

America's communities by providing evidence-based and best practice

guidance to clinicians, program administrators, and payers. TIPs are the

result of careful consideration of all relevant clinical and health services

research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program

administrators, and patient advocates debates and discusses their particular area of expertise until they reach a consensus on best practices. This

panel’s work is then reviewed and critiqued by field reviewers.

The talent, dedication, and hard work that TIPs panelists and reviewers

bring to this highly participatory process have helped bridge the gap

between the promise of research and the needs of practicing clinicians and

administrators to serve, in the most scientifically sound and effective ways,

people in need of behavioral health services. We are grateful to all who have

joined with us to contribute to advances in the behavioral health field.

Pamela S. Hyde, J.D.

Administrator

Substance Abuse and Mental Health Services Administration

Daryl W. Kade

Acting Director

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration

Foreword
Executive Summary

For men and women whose struggle with substance abuse brings them into 

contact with the legal system, the personal losses can be enormous: families can break apart, health deteriorates, freedom is restricted, and far too 

often, lives are lost. But this is just the beginning of the potential devastation. Personal costs to the victims of crime are immeasurable. The effects 

of every theft, burglary, and violent crime reverberate throughout the 

whole community. Economic losses include the costs of arresting, processing, and incarcerating offenders, as well as the costs of police protection, 

increased insurance rates, and property losses. 

Strong empirical evidence over the past few decades consistently has 

shown that substance abuse treatment reduces crime. For many people in 

need of alcohol and drug treatment, contact with the criminal justice system is their first opportunity for treatment. A substance use disorder may 

be recognized and diagnosed for the first time, and legal incentives to 

enter substance abuse treatment sometimes motivate the individual to 

begin recovery. For other offenders, arrest and incarceration are part of a 

recurring cycle of drug abuse and crime. Ingrained patterns of maladaptive coping skills, criminal values and beliefs, and a lack of job skills may 

require a more intensive treatment approach, particularly among offenders with a prolonged history of substance abuse and crime. 

This TIP was developed to provide recommendations and best practice 

guidelines to counselors and administrators based on the research literature and the experience of seasoned treatment professionals. It covers the 

full range of criminal justice settings and all the phases through which an 

individual progresses in the criminal justice system. It addresses both clinical and programmatic areas of treatment. The consensus panel defined 

the areas highlighted below as important in efforts to achieve the treatment objectives of recovery and a life in the community for everyone. 

xvii
Screening and

Assessment 

A vital first step in providing substance abuse 

treatment to people under criminal justice 

supervision is to identify offenders in need of 

treatment. In the criminal justice system, 

screening often is equated with “eligibility,” 

and assessment often is equated with “suitability.” To do this effectively, the consensus panel 

recommends that protocols be developed to 

determine which offenders need substance 

abuse treatment, assess the extent of their 

treatment needs, and ensure that they receive 

the treatment they need. Obtaining accurate 

and reliable information during screening and 

assessment can be a challenge; offenders do not 

always accurately report drug or alcohol problems. Other collateral sources of information 

(e.g., drug test results, correctional records) 

can be combined with self-report information 

to make referral decisions. For example, in 

many correctional facilities, urine tests are 

used to flag the need for treatment—even when 

an offender denies recent substance abuse. 

Many offenders who abuse substances have cooccurring mental disorders that can make 

treatment more complex. They should therefore be screened for other psychological or 

emotional problems. Offenders who are initially assessed as having symptoms of co-occurring 

disorders should be evaluated over an extended 

period of time to determine whether these 

symptoms resolve in the absence of substance 

use. 

A significant number of offenders who abuse 

substances also have histories of trauma and 

physical or sexual abuse. Screening and assessment of a history of physical and sexual abuse 

should be conducted routinely, particularly in 

settings that include female offenders. Staff 

training is needed to develop effective interviewing approaches related to the history of 

abuse, counseling approaches for addressing 

abuse and trauma issues, and in making referrals to mental health services. 

Triage and Placement 

in Treatment Services
 Information obtained in screening and assessment is used to place offenders in the treatment 

program that is best suited to their needs. More 

offenders can receive appropriate treatment if 

a range of substance abuse treatment options is 

provided in criminal justice settings, particularly in institutions and community settings 

where offenders are supervised for long periods 

of time. In addition to key information regarding substance abuse problems, risk for criminal 

recidivism, and mental health problems, triage 

and placement decisions also should consider 

the offender’s motivation and readiness for 

change, the length of sentence or incarceration, 

history of previous treatment, violence potential, and other related security or management 

issues. The consensus panel recommends that 

in general, offenders who have moderate-tohigh levels of substance abuse problems and 

criminal risk should be prioritized for placement in substance abuse treatment services, 

rather than in other types of institutional programs. 

Treatment Planning 

After placement, a treatment plan is developed 

that specifies which services the offender-client 

needs, at what level of intensity, and which of 

the available resources (e.g., personal, program-based, or criminal justice) will be most 

beneficial. The treatment plan takes into consideration the severity of substance abuserelated problems and the presence of co-occurring mental disorders because these influence 

the treatment approach. Also important are 

factors such as criminal attitudes and psychopathy, which may suggest persistent criminality unrelated to the need to maintain a drug 

habit. The degree to which an individual is 

motivated and ready for change is another critical factor that will determine whether motivational enhancement interventions, sanctions, or 

more self-directed treatments are appropriate. 

Finally, personal strengths are taken into 

xviii Executive Summary
account in planning. The offender should be 

involved in the treatment planning process. 

The most effective treatment programs have 

the resources necessary for comprehensive 

assessment and treatment planning activities 

including adequate staffing, clerical support, 

and access to computers and management 

information systems that contain information 

regarding the offender. Mechanisms for sharing 

information among agencies will expedite treatment as clients move through the criminal justice system. For example, monitoring, consultation, and written agreements are needed to 

define the types of information that will be 

shared, with whom, and under what circumstances. Procedures that ensure the smooth 

and timely flow of relevant information will 

enable staff to proceed with treatment without 

interruption. Effective management information systems allow for access to clinical information as well as other offender data. At the 

same time, however, confidentiality regulations 

require that clinical information be maintained 

separately from the corrections or supervision 

case files, and access to clinical files be restricted to staff who have primary clinical responsibilities. 

Major Treatment 

Issues and Approaches

Clients under criminal justice supervision 

share many of the same clinical issues faced by 

others receiving substance abuse treatment, 

but some are unique. For example, many 

offenders have problems with the very issues 

that brought them to the attention of law 

enforcement, particularly, criminal thinking 

and values. These clients often have problems 

dealing with anger and hostility and have the 

stigma of being criminals, along with the guilt 

and shame that accompany this stigma. Their 

identity as criminals may need to be offset by 

exposure to more prosocial values and identities such as those of family member and wage 

earner. 

Adapting Offender

Treatment for Specific 

Populations

General clinical strategies for working with 

offender-clients include interventions to 

address criminal thinking and to provide basic 

problemsolving skills; however, substance 

abuse treatment approaches should be modified to meet specific client needs. Because of 

their histories or life experiences, certain populations are recognized as having somewhat different treatment needs. For example, people 

from cultural minorities have had different 

stresses from those in the majority culture. 

Women are more likely to have been traumatized by physical and sexual abuse than men 

and to have urgent concerns about their children. Offenders with co-occurring substance 

use and mental disorders need help that integrates treatment for both. Other groups with 

specific needs include older adults, violent 

offenders, people with disabilities, and sex 

offenders. 

Treatment Issues

Specific to Pretrial and

Diversion Settings

Treatment varies not only because of the specific population to which an offender belongs but 

also because of a client’s stage in the criminal 

justice system. After arrest and before trial, a 

large number of individuals move relatively 

quickly through the system, and many different 

agencies are involved with each case and its 

supervision. If offered, the offender may opt 

for treatment instead of formal charges, trial, 

sentencing, incarceration, or to reduce the 

length of incarceration. 

Variations in local prosecution and diversion 

practices may affect a jurisdiction’s ability to 

develop criminal justice and treatment linkages. Not all jurisdictions have established procedures or programs for individuals who abuse 

substances; those jurisdictions that do have 

programs to treat offenders often maintain 

Executive Summary xix 
such programs with limited resources. 

However, the pressure of overcrowded jails 

and prisons is serving to expand and institutionalize programs for drug treatment in pretrial and diversion settings nationwide. Still, 

outside of formal drug court and diversion programs, treatment access is limited. Types of 

treatment used in the pretrial setting are necessarily brief and include brief motivational 

interventions, behavior contracts, and referrals to detoxification and other services. A 

variety of sanctions also are available. 

In the pretrial setting, the question of an individual’s guilt or innocence has not been legally 

determined. It is vitally important, therefore, 

to note that treatment should not compromise 

the due process rights of defendants. 

Treatment professionals need to bear in mind 

the presumption of innocence that exists during 

the pretrial period. Defendants’ due process 

rights affect what they are willing to agree to 

and the type of information that they are willing to disclose. Defendants should not be 

coerced into waiving due process rights, 

although a court may order substance abuse 

treatment as a condition of pretrial release. 

Treatment Issues
 

Specific to Jails
 Those incarcerated in jails are undergoing significant stress related to arrest, the uncertainties of their legal situation, and the potential 

loss of their job or custody of their children. 

Appropriate treatment services for these individuals are based on the expected duration of 

incarceration and the information obtained 

from screening for a variety of possible problems. Brief treatment (less than 30 days) usually focuses on supplying information and making referrals but can include motivational interviewing. Short-term programs (1–3 months) 

have the time to work on communication, problemsolving, and relapse prevention skills; introduce anger management techniques; and 

encourage participation in self-help groups. 

Longer term programs (3 months–1 year) can 

provide additional skills training, vocational 

and educational activities, and examine criminal thinking errors. The consensus panel recommends that jail staff implement discharge 

planning that includes gathering information 

regarding the need for a range of community 

services, including housing and health care. 

Treatment Issues
 

Specific to Prisons
 The unique characteristics of prisons have 

important implications for developing and 

implementing treatment programs. In-prison 

drug abuse treatment, particularly when followed by community-based continuing care 

treatment, has been credited with reducing 

short-term recidivism and relapse rates among 

offenders who are involved with drugs. More 

recently, the sustained effects on longer term 

outcomes have been documented by studies 

indicating that 9–12 months of prison treatment followed by at least 3 months of community treatment are needed to produce significant 

improvement and reductions in recidivism and 

relapse. Because of the comparative stability of 

the prison population, several treatment 

options of differing intensities can be made 

available. The full range of services can be 

offered, including comprehensive assessment; 

treatment planning; placement; group, individual, family, and specialty group counseling; 

self-help groups; educational and vocational 

training; and planning for transition to the 

community. Therapeutic communities (TCs) 

are among the most successful in-prison treatment programs. They are highly structured, 

hierarchical, and intense interventions lasting a 

minimum of 6 months. TC participants live 

together, often separate from the general prison 

population, and take responsibility for their 

recovery process. Participants work at increasingly more responsible positions as they learn 

self-sufficiency and become competent. 

xx Executive Summary
Treatment for

Offenders Under

Community

Supervision

Parolees and probationers are both under community supervision; nonetheless, they generally 

represent different ends of the criminal justice 

continuum. Whereas parolees are serving a 

term of conditional supervised release following 

a prison term, probationers are under community supervision instead of a jail or prison 

term. Both parolees and probationers generally 

can be controlled and managed effectively by a 

combination of treatment and surveillance 

while under community supervision at a far 

lower cost than incarceration in jail or prison. 

The level of supervision varies according to 

individual circumstances, including the terms 

under which probation or parole was granted. 

Offenders under community supervision in 

urban areas who have substance use disorders 

have available several levels treatment and 

supervision, including residential, outpatient, 

halfway, and day reporting centers. Parolees 

may have difficulty meeting their basic needs 

when they are released and benefit from case 

management services to help with housing and 

employment. Reunification with family members and social support may also prove problematic. 

Relapse prevention is extremely important for 

those under community supervision. Relapse, 

which is not unusual, can be met by increased 

supervision and an intensification of the level 

of treatment. Likewise, the intensity of supervision and treatment should decrease as the individual meets treatment goals. For both parolees 

and probationers, reassessment should be periodically conducted throughout the phase of 

community supervision. Following their contact 

with the criminal justice system, both parolees 

and probationers benefit from continuing contact with the substance abuse treatment system 

as a means of reducing relapse and recidivism. 

Key Issues Related to 

Program Development 

Offender-clients will best be served by substance abuse treatment and criminal justice 

systems that are working together to help them 

in recovery and in becoming law-abiding citizens. This requires leaders in both systems who 

promote their mutual goals, endorsement for 

mutual goals from leaders, clarification of the 

goals, and recruitment of stakeholders in pursuit of the goals. The challenge for substance 

abuse treatment practitioners and criminal justice professionals is to work together to provide 

a coordinated response to ensure that offenders’ needs are addressed while protecting public safety. 

Executive Summary xxi
 

 

In This
 

Chapter... 

The Purpose of This TIP 

Key Definitions 

Audience for This TIP 

Contents of This TIP 

1 Introduction
 

When the prison gates slam behind an inmate, he does not lose his 

human quality; his mind does not become closed to ideas; his intellect 

does not cease to feed on a free and open interchange of opinions; his 

yearning for self-respect does not end; nor is his quest for self-realization concluded. If anything, the needs for identity and self-respect are 

more compelling in the dehumanizing prison environment. 

—Thurgood Marshall (Procunier v. Martinez, 416 U.S. 396 [1974]) 

Overview 

Research consistently demonstrates a strong connection between criminal activity and substance abuse (Chaiken 1986; Inciardi 1979; Johnson 

et al. 1985). Eighty-four percent of State prison inmates who expected 

to be released in 1999 were involved with alcohol or illicit drugs at the 

time of their offense; 45 percent reported that they were under the 

influence when they committed their crime; and 21 percent indicated 

that they committed their offense for money to buy drugs (Office of 

National Drug Control Policy [ONDCP] 2003). Data from the Arrestee 

Drug Abuse Monitoring program indicate that in 2000, 64 percent of 

male arrestees tested positive for at least one of five illicit drugs 

(cocaine, opioids, marijuana, methamphetamines, and PCP). 

Additionally, 57 percent reported binge drinking in the 30 days prior to 

arrest, and 36 percent reported heavy drinking (Taylor et al. 2001). 

The consequences of crime related to substance abuse are substantial. 

The Bureau of Justice Statistics reports that in 1999 alone, 12,658 

homicides—4.5 percent of all homicides for that year—were drug related (Dorsey et al. 1999). The emotional costs to people with substance 

use disorders, their families, and the victims of their crimes are immeasurable. The ONDCP estimates that the total crime-related costs of drug 

abuse were more than $100 billion in 2000 (ONDCP 2001). 

The devastating emotional and financial costs of drug-related crimes 

have led to a number of strategies to break the link between drugs and 

1 
crime, including stricter drug laws, “three 

strikes and you’re out” legislation, increased 

surveillance, mandatory sentencing laws, and 

severe penalties for drunk drivers, to name 

just a few. These approaches have had mixed 

results, and opinions vary on their usefulness. 

One consistent research finding is that 

involvement in substance abuse treatment 

reduces recidivism (a tendency to return to 

criminal habits) for offenders who use drugs 

(Anglin and Hser 1990; Harwood et al. 1988; 

Hubbard et al. 1984, 1989; Knight et al. 

1999a; Martin et al. 1999; McLellan et al. 

1983; Wexler et al. 1988, 1999a; Wisdom 

1999). For example, when researchers conducted followup studies of clients treated 

through comprehensive treatment demonstration programs funded by the Center for 

Substance Abuse Treatment (CSAT), they 

found substantial reductions in criminal 

activity, including a 64-percent decrease in 

arrests (Wisdom 1999). In part because of the 

reduced criminal activity associated with substance abuse treatment for offenders, treatment has also been found to be cost-effective. 

According to the California Drug and Alcohol 

Treatment Assessment study (Gerstein et al. 

1994), for example, every dollar invested in 

treatment saved approximately $7 in future 

costs. 

In response to research demonstrating the 

success of treatment in reducing criminal 

activity as well as the cost benefits of such 

treatment, policymakers over the past two 

decades have implemented a wide variety of 

strategies at the Federal, State, and local levels. These initiatives are aimed at improving 

the availability and quality of treatment for 

offenders. Drug Courts—courts with special 

unified dockets for individuals charged with 

crimes who are drug or alcohol involved— 

serve to divert offenders with substance use 

disorders away from the criminal justice system into a supervised treatment plan or to 

incorporate a coerced treatment plan as part 

of a judicial sentence. Other programs have 

been established for people with special 

needs, including individuals with co-occurring 

mental disorders. At the same time, other initiatives have increased funding for people 

already in prisons and jails. Examples of such 

initiatives include 

• Project REFORM and later Project

RECOVERY. These programs, funded in

the late 1980s by the Bureau of Justice

Assistance (BJA) and in the early 1990s by

CSAT, provided technical assistance to 20

States in planning and developing substance

abuse programming for prisoners with substance abuse problems (Wexler 1995).

• Residential Substance Abuse Treatment for

State Prisoners Formula Grant Program.

This program funds States seeking to develop comprehensive approaches to treatment

for offenders who abuse substances, including intensive programs for inmates and

relapse prevention training. Further information is available at http://www.cfda.gov.

• The National Drug Control Strategy, prepared annually by the Office of National

Drug Control Policy (1997, 1998, 1999,

2000, 2001). This program has encouraged

the development of treatment and rehabilitation services for offenders who use drugs

(e.g., Treatment Accountability for Safer

Communities, formerly Treatment

Alternatives to Street Crime; drug court

programs; prison treatment programs). For

further information, go to

http://www.whitehouse.gov/ondcp.

• The BJA, Office of Justice Programs, U.S.

Department of Justice. Formerly known as

the Drug Courts Program Office, established to administer the drug court grant

program, the BJA provides financial and

technical assistance, training, and programmatic guidance for drug courts throughout

the country. BJA offers grants that enable

communities to develop, implement, or

improve drug courts. Information is available at http://www.BJA.gov

• The Serious and Violent Offender Reentry

Initiative. In conjunction with several

Federal partners, the U.S. Department of

Justice is spearheading this initiative to 

2 Chapter 1 
provide funding to promote successful reintegration of serious, high-risk offenders into 

the community. The Initiative seeks to 

address all obstacles to successful reentry, 

including substance abuse. Information is 

available online at 

http://www.CRIMESOLUTIONS.gov/0ROGRAM


$ETAILSASPX)$

In part because of initiatives such as these, 

the availability of substance abuse treatment 

for criminal offenders is on the rise. After 3 

years of decline in the mid-1990s, the number 

of inmates in drug treatment programs began 

rising again in 1997 and 1998 (Corrections 

Yearbook 1998). A report based on a 1997 

nationwide survey of Federal and State correctional facilities (Office of Applied Studies 

2000) indicates that 93.8 percent of Federal 

prisons and 56.3 percent of State prisons provide some form of substance abuse treatment. 

Although an increasing number of prisons 

offer some form of treatment, the actual number of programs and slots remains limited 

(National Center on Addiction and Substance 

Abuse at Columbia University 1998; Peters 

and Matthews 2002). For example, although 

more than half of prison inmates have a lifetime prevalence of drug use disorders (Peters 

et al. 1998), fewer than 15 percent of inmates 

receive substance abuse treatment services 

while in prison (Mumola 1999; Simpson et al. 

1999b). Moreover, while the number of substance abuse programs for offenders is on the 

rise, so too is the number of offenders in need 

of services. Substance abuse treatment services for offenders have not kept pace with 

the growing need for these services (Belenko 

and Peugh 1998; Simpson et al. 1999b). 

This TIP highlights some of the best practices 

and innovative programs created to treat 

offenders. It describes the unique needs of 

offenders with substance abuse and dependence disorders. Finally, it addresses the 

challenges counselors and criminal justice 

personnel are likely to face at every stage of 

the criminal justice continuum. 

The Purpose of This TIP
 This TIP updates and combines three TIPs 

originally published in 1994 and 1995: TIP 7, 

Screening and Assessment for Alcohol and 

Other Drug Abuse Among Adults in the 

Criminal Justice System (CSAT 1994d); TIP 

12, Combining Substance Abuse Treatment 

With Intermediate Sanctions for Adults in the 

Criminal Justice System (CSAT 1994a); and 

TIP 17, Planning for Alcohol and Other Drug 

Abuse Treatment for 

Adults in the 

Criminal Justice 

System (CSAT One consistent

research finding is 

that involvement 

in substance abuse

treatment reduces

recidivism for

offenders who use 

drugs. 

1995b). 

The new TIP presents clinical guidelines to assist counselors in dealing with 

problems that routinely arise because 

of their clients’ status in the criminal 

justice system. These 

clients have multiple 

needs; they often 

have poor health, 

have histories of 

trauma, lack job and 

communication 

skills, and have educational deficits. A special feature throughout 

the TIP—“Advice to the Counselor”—provides the TIP’s most direct and accessible 

guidance for the counselor. Readers with 

basic backgrounds, such as addiction counselors or other practitioners, can study these 

boxes first for the most immediate practical 

guidance. In particular, the Advice to the 

Counselor boxes provide a distillation of what 

the counselor needs to know and what steps 

to take, which can be followed by a more 

detailed reading of the relevant material in 

the section or chapter. 

The events of September 11, 2001, dramatically altered the political climate of our 

Nation and caused a shift in focus from the 

“tough on drugs” policies previously in place 

Introduction 3 
to the war on terrorism. These changes have 

impacted both the sanctions against people in 

the criminal justice system and the availability of substance abuse treatment for those 

populations. While it is beyond the scope of 

this TIP to address the implications of these 

shifts or to predict their ultimate outcomes, 

the core content of this document reflects the 

current best practices for providing substance 

abuse treatment for adults in the criminal 

justice system. 

This TIP aims to provide tools and resources 

to increase the availability and improve the 

quality of substance abuse treatment to criminal justice clients. It should assist the criminal justice system in meeting the challenges of 

working with offenders with substance use 

disorders and encourage the implementation 

of evidence-based clinical approaches to 

treatment. 

Other guiding principles of this publication 

are to 

•Provide the relevant information that will 

inform and enable treatment providers to 

feel more confident in their approach to 

offender and ex-offender populations. 

•Help people in community treatment understand the criminal justice system and how it 

works in step with their treatment services. 

•Encourage collaboration between the criminal justice and treatment communities. 

•Help readers understand the multiple perspectives that often lead to confusion and 

misunderstandings—public safety versus 

public health, treatment versus corrections, 

differing client needs, issues of culture and 

society, and local characteristics of the 

criminal justice system. 

•Provide practical solutions and approaches 

to complex problems. 

Key Definitions

In this TIP, the term “substance abuse” is 

used to denote both substance abuse and substance dependence as they are defined by the 

Diagnostic and Statistical Manual of Mental 

Disorders, Fourth Edition, Text Revision 

(DSM-IV-TR) (American Psychiatric 

Association 2000). This term was chosen partly because substance abuse treatment professionals commonly use the term “substance 

abuse” to describe any excessive use of addictive substances. Readers should attend to the 

context in which the term occurs to determine 

the possible range of meanings it covers; in 

most cases, however, the term will refer to all 

varieties of substance use disorders described 

by DSM-IV-TR. 

According to DSM-IV-TR, substance abuse is 

a maladaptive pattern of substance use 

marked by recurrent and significant negative 

consequences related to the repeated use of 

substances. Substance dependence is defined 

as a cluster of cognitive, behavioral, and 

physiological symptoms indicating that the 

individual is continuing use of the substance 

despite significant substance-related problems. A person experiencing substance dependence shows “a pattern of repeated selfadministration that usually results in tolerance, withdrawal, and compulsive drug-taking behavior” (p. 192). A diagnosis of substance dependence can be applied to every 

class of substances except caffeine. 

Treatment is defined according to the 

Institute of Medicine (IOM 1990), as cited in 

CSAT’s National Treatment Plan Initiative 

(CSAT 2000a, b): 

Treatment refers to the broad range of [primary and supportive] services—including 

identification, brief intervention, assessment, 

diagnosis, counseling, medical services, psychiatric services, psychological services, 

social services, and followup—provided for 

people with alcohol [and/or drug] problems. 

The overall goal of treatment is to reduce or 

eliminate the use of alcohol [and/or drugs] as 

a contributing factor to physical, psychological, and social dysfunction and to arrest, 

4 Chapter 1 
retard, or reverse the progress of any associated problems (CSAT 2000a, p. 7). 

The criminal justice system, as discussed in 

this TIP, includes four subsystems: pretrial 

and diversion settings, jails and detention 

centers, prisons (State and Federal), and 

community supervision settings. Definitions of 

other terms relevant to criminal justice and 

substance abuse treatment are given in 

appendix B, Glossary. 

For the purposes of this TIP, an offender is a 

person who has been arrested, charged with a 

crime, or convicted of a crime and under the 

supervision of the criminal justice system. 

Audience for This TIP

This TIP is written primarily for substance 

abuse counselors and clinicians who treat 

clients involved in the criminal justice system 

or who are under full or partial supervision 

and for administrators whose programs serve 

clients under criminal justice supervision. It 

also will be useful for counselors who work in 

correctional institutions and those in community agencies with clients on probation, parole, or 

pretrial release. 

Others who work in the criminal justice system may also find this TIP helpful. This 

includes judges and prosecutors; probation 

and parole officers, case managers, public 

defenders and other criminal defense attorneys; jail, detention center, and prison personnel; and people working in pretrial/diversion and in probation and parole settings. 

Program developers and grant writers will 

find that this TIP provides information about 

a variety of programs and resources. Finally, 

this TIP is of value to anyone concerned with 

reducing overcrowding in correctional facilities, addressing the crimes committed by 

untreated drug-involved offenders, and meeting the challenges that these offenders face on 

their journey toward recovery. 

Contents of This TIP

The chapters that follow will focus on the following areas: 

•Chapter 2 focuses on screening and assessment of criminal justice clients in the relevant domains. It includes a discussion of 

special concerns (e.g., gender and sexual 

orientation, literacy, a client’s primary language, and learning disabilities) and specific 

populations. See also appendix C, which 

contains more 

information on 

screening and 

assessment instru- This TIP aims to 

provide tools and

resources to 

increase the

availability and

improve the 

quality of 

substance abuse 

treatment to criminal justice clients.

ments. 

•Although it is rec-

ognized that treatment can be effective, it is also clear 

that different 

treatment 

approaches may 

work better with 

some clients than 

with others. 

Chapter 3 discusses triage and placement in treatment 

services and 

reviews the complex area of treatment matching. 

•Chapter 4 discusses 

the available treatment options in the 

criminal justice 

system. It also presents guidelines for developing treatment plans. 

•Chapter 5 addresses the major treatment 

issues for offenders who use substances. 

These include a wide range of themes, 

including engagement and retention, stigma 

and shame, the client–counselor relationship, and major treatment levels (e.g., residential, nonresidential, outpatient, community supervised, and self-help and other 

ancillary services). 

Introduction 5 
•Chapter 6 describes treatment issues and 

approaches for special populations for 

whom modifications in treatment may be 

appropriate: people of ethnic and racial 

minorities, women, violent offenders, people with disabilities, older inmates, people 

with co-occurring substance use and mental 

disorders, and sex offenders, among others. 

•Chapters 7 through 10 describe the specific 

treatment needs and strategies for individuals in particular criminal justice settings. 

Chapter 7 addresses treatment provided in 

diversion and other pretrial settings. 

Chapter 8 provides a detailed discussion of 

treatment for offenders in jails and detention centers, while chapter 9 focuses on 

offenders in prison. Chapter 10 outlines 

treatment for people under community 

supervision. 

•Finally, chapter 11 discusses the issues 

related to program development. 

6 Chapter 1 
 

 

2 Screening and
 

Assessment 

In This
 Chapter... 

Definitions of Terms 

Screening Guidelines 

Assessment Guidelines 

Key Issues Related to 

Screening and Assessment 

Areas To Address in 

Screening and Assessment 

Selection and 

Implementation of 

Instruments 

Screening and Assessment 

Considerations for 

Specific Populations 

Integrated Screening and 

Assessment—Sample 

Approaches 

Conclusions and 

Recommendations 

Overview 

Screening and in-depth assessment are important first steps in the substance abuse treatment process; currently no comprehensive national 

guidelines for screening and assessment approaches exist in the criminal 

justice system. In the absence of such guidelines, information in this chapter can help clinicians and counselors develop 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 that they need, rather than 

being released into the community with a high probability of re-offending. 

This chapter addresses the issues relevant to screening and assessment and 

makes recommendations for the appropriate use of screening and assessment tools in specific settings. For information on how to use screening 

and assessment to match the offender to services and to identify an appropriate treatment plan, see chapters 3 and 4. For more information on specific screening and assessment instruments see appendix C. 

Definitions of Terms

Information gathered during screening and assessment plays an important role in identifying offender needs and making appropriate referrals 

for services. Throughout this TIP, the following definitions are used for 

screening, assessment, and related terms in the criminal justice setting: 

•Screening—A process for evaluating someone for the possible presence of a particular problem. The screening process does not necessarily identify what kind of problem the person might have or how 

serious it might be but determines whether or not further assessment 

is warranted. Screening does not typically include assignment of DSM7 
IV-TR (Diagnostic and Statistical Manual of 

Mental Disorders, Fourth Edition, Text 

Revision [American Psychiatric Association 

{APA} 2000]) diagnoses of alcohol or drug 

abuse or dependence and may only identify 

DSM-related problem areas. During the 

screening process staff members use instruments that are limited in focus, simple in 

format, quick to administer, and usually 

able to be administered by nonprofessional 

staff. There are seldom any legal or professional restraints on who can be trained to 

conduct a screening. 

•Assessment—A process for defining the 

nature of a problem and developing specific 

treatment recommendations for addressing 

the problem. A basic assessment consists of 

gathering key information and engaging in a 

process with the client that enables the 

counselor to understand the client’s readiness for change, problem areas, any diagnosis(es), disabilities, and strengths. The 

assessment process typically requires 

trained professionals to administer and 

interpret results, based on their experience 

and training. A clinical diagnosis has 

important legal ramifications since judges 

tend to rely on assessments to identify an 

offender’s needs and risks, and to determine the offender’s disposition. 

In correctional settings, “screening” and 

“assessment” are equated with “eligibility” 

and “suitability,” respectively. “Eligibility” is 

determined in pretrial and jail settings by 

screening for offenders who may need substance abuse treatment. “Suitability” for 

placement in one of several different levels of 

treatment services is determined by an assessment to help identify key psychosocial problems related to referral to treatment and/or 

supervision. Accordingly, the following considerations are suggested: 

•Eligibility—Does the offender meet the system’s criteria for receiving treatment services? A quick screen, typically applicable 

in prisons and community corrections settings, can determine whether a person warrants assessment to determine if that person 

has a drug or alcohol problem. 

•Suitability—Is the offender suitable for the 

type of program services that are available? 

An assessment can determine whether the 

offender is capable of benefiting from treatment or responding to a particular intervention. The question of suitability arises 

once it has been determined that offenders 

meet the eligibility criteria for receiving services. 

In essence, screening and assessment vary 

based on the goals of the evaluation and the 

setting where they are used. For drug court 

and jail settings, a source for operational 

treatment and criminal justice definitions is 

the article “Guideline for Drug Courts on 

Common Myths About Screening and Assessment 

Following are several common myths about substance abuse screening and assessment, and the facts that 

debunk those myths. 

•Myth: Screening and assessment are no better than intuition in detecting a person’s need for treatment. 

•Fact: Objective screening and assessment measures can result in treatment that is better targeted to a 

client’s needs, resulting in better outcomes. 

•Myth: Only a single screening is needed to place people in different levels of treatment services. 

•Fact: Accurate evaluation requires a battery of assessment instruments that examine how substance 

use has affected all the domains of the client’s life. When treatment options are severely limited, however, a basic screening may be sufficient to determine both eligibility and suitability for treatment. 

8 Chapter 2 
•Myth: Untrained professionals can conduct screening and assessments. 

•Fact: Although some screenings can be administered and scored without significant training, placement decisions are greatly improved when they are made by professionally trained staff. This includes 

staff with relevant certification in substance abuse treatment, those with advanced professional 

degrees, and those with specialized training in the use of particular screening and assessment instruments. For those screening and assessment approaches that require an interview with the offender, 

specialized training is also needed in basic counseling techniques such as rapport building and reflective listening. Use of trained professional staff in the triage and placement process helps to minimize 

the number of inappropriate referrals for treatment. 

•Myth: Screening and assessment are always compromised because you cannot trust self-report information from offenders. 

•Fact: Research generally validates the reliability, and to some degree, the validity of information 

obtained through self-reports. Collateral sources such as the offender’s family and friends can 

improve the reliability of the information gathered (or “the full picture”). Offenders do supply a certain amount of misinformation in some settings to avoid unwanted consequences, however. 

•Myth: All screening and assessment instruments are equally effective. 

•Fact: Research shows significant variability in the reliability and validity of different instruments with 

different populations. 

•Myth: Because an instrument is widely used, it must be effective. 

•Fact: Many highly marketed and widely used instruments do not have a research base supporting the 

validity of their use. In fact, some of the widely marketed and used instruments have been shown to be 

less effective than those available in the public domain. 

•Myth: Screening and assessment should not examine the history of physical and sexual abuse and 

related trauma because this may aggravate the offender’s level of stress and psychological instability, 

and staff may not be able to deal effectively with the consequences. 

•Fact: Screening and assessment of all forms of abuse is essential for both male and female offenders, 

because it is now recognized that the effects of trauma contribute to many mental disorders. Clinical 

outcomes are likely to be compromised if these abuse and trauma issues are not explored, and if 

strategies addressing these issues are not developed and integrated into treatment plans for mental and 

substance use disorders. However, it is important to emphasize that in screening for a history of trauma it can be damaging to ask the client to describe traumatic events in detail. To screen, it is important to limit questioning to very brief and general questions, such as “Have you ever experienced 

childhood physical abuse? Sexual abuse? A serious accident? Violence or the threat of it? Have there 

been experiences in your life that were so traumatic they left you unable to cope with day-to-day life?” 

Screening and Assessment” (Peters and 

Peyton 1998). 

Screening Guidelines

This section presents broad guidelines and considerations for developing an effective screening protocol. (See section below for additional 

guidelines related to assessment protocols.) 

More specific guidelines based on the criminal 

justice setting and the characteristics of the 

population are discussed in later sections. 

When creating a screening protocol, counselors will need to ask the following questions: 

• What is the purpose of the screening? 

• What screening tools will be used and under 

what circumstances? 

Screening and Assessment 9 
Purpose of Screening 

The first issue to consider is the purpose of 

the screening. In addition to screening for 

drug use, counselors may consider screening 

for other problem areas. For example, given 

that many infectious diseases are associated 

with the use of drugs (Varghese and Fields 

1999), health screening can be important in 

identifying offenders in need of healthcare 

services to ensure that clients receive needed 

medication and to prevent the spread of disease. Screening to identify special needs for 

offenders with co-occurring mental problems 

can improve the effectiveness of treatment. It 

can identify individuals who may pose a 

threat to themselves or others, prevent crises, 

and promote immediate intervention. 

Screening content should identify key issues 

that need to be addressed in placing offenders 

in treatment. Content can be specific to several domains, including substance use, criminal, physical health, mental health, and special considerations. Figure 2-1 summarizes 

the information relevant to each domain. 

Screening guidelines will vary by setting. A 

professional screening of an individual who 

has just been arrested will include different 

questions and require different information 

than a long-term prisoner being considered 

for parole. For a probationer, screening 

might be used to determine the appropriate 

level of supervision; a jail inmate may be 

screened to assess his or her suitability for 

treatment. Figure 2-2 (see p. 12) highlights 

the different screening considerations for 

each setting. 

Selection of Screening Tools

In addition to identifying the purpose of 

screening, the protocol should also identify 

the screening tools to be used and the conditions under which they are used. Basic information 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 jurisdictions may be required to use a 

particular instrument or information source to 

gather information consistently from all offenders, even though corroborative information, 

such as urine test results, is often available. 

Such universal screenings can help route nonviolent, low-risk offenders to treatment placements in the community so that recovery can 

begin. A more detailed discussion of selection of 

screening instruments is provided later in this 

chapter. 

Assessment Guidelines
 The goal of assessment is to gather enough 

information about clients to describe how the 

treatment system can address their substance 

abuse problems and the impact of those problems. An assessment examines how the offender’s emotional and physical health, social 

roles, and employment could be affected by 

substance abuse (Center for Substance Abuse 

Treatment [CSAT] 1994a). In addition, 

assessments can help identify the factors that 

could prompt a return to drug use or criminal 

behavior. These include lack of social support 

networks, unstable employment history, poor 

health, criminality, unresolved legal problems, inadequate housing, lack of motivation 

to change, a history of physical and sexual 

abuse, mental illness, learning disabilities, 

and other social and psychological factors. 

These factors need to be carefully examined 

during assessment to plan for potential gaps 

10 Chapter 2 
Figure 2-1 

Screening Guidelines by Domain 

Domain Information 

Substance Use • Substance use history 

• Motivation and desire for treatment 

• Severity and frequency of use 

• Detoxification needs, acute intoxication 

• Treatment history (e.g., number and type of episodes, outcomes) 

Criminal • Criminal thinking 

Involvement • Current offense(s) 

• Prior charges 

• Prior convictions 

• Age at first offense 

• Type of offense(s) 

• Number of incarcerations 

• Prior successful completion of probation or parole drug use offenses 

• Prior involvement in diversionary programs 

• History of diagnosis of any personality disorder 

Health • Intoxication, infectious disease (tuberculosis, hepatitis, sexually transmitted diseases, HIV 

status) 

• Pregnancy 

• General health 

• Acute conditions 

Mental Health • Suicidality 

• History of treatment and prior diagnosis 

• Past diagnoses 

• Treatment outcome 

• Current and past medications 

• Acute symptoms 

• Psychopathy 

Special 

Considerations

• Educational level 

• Reading level/literacy 

• Language/cultural barriers 

• Physical disability 

• Developmental disability 

• Learning disability 

• Health and biomedical record 

• Housing 

• Dependents/family issues 

• History of abuse (victim and/or perpetrator), including trauma experienced as a result of 

physical and sexual abuse 

Screening and Assessment 11 
Figure 2-2 

Screening Guidelines by Setting 

Setting Purpose Special Considerations 

Jails • For early identification, if getting out of jail 

early 

• To determine eligibility for drug courts and 

pretrial diversion programs 

• For diversion to specialized mental health 

courts or programs focused on behavioral 

problems 

• To determine behavioral management problems and acute needs (including crisis intervention) 

• To identify suitability for placement in jail 

treatment programs 

• For classification to different housing units 

Look for previous correctional substance 

abuse treatment, readiness for treatment, 

past institutional behavior problems, 

prior correctional treatment, and court 

orders. 

Prisons • To match time left to serve with time for 

receiving treatment or for custody level classification 

• To identify suitability for placement in prison 

treatment programs 

Look at prison record, treatment history 

(including treatment for issues other than 

substance abuse), and behavior. 

Pretrial and • To determine the need for housing, transporta- Look for community or corrections 

Community tion, employment, or economic benefits records or collateral information (e.g., 

Supervision • To identify suitability for placement in community treatment programs 

• To assess for public safety risk and level of 

supervision needed, pursuant to consideration 

for placement in diversion programs 

information from family members). 

in services that can affect relapse and criminal recidivism. 

While assessments are more comprehensive 

than screenings, their depth and scope varies 

across settings according to the following factors: 

•Amount of time available to conduct the 

assessment 

•Physical setting of assessment (e.g., holding 

pen, booking room, medical unit, reception 

center, lockup, community/corrections office) 

•Factors influencing the confidentiality or privacy of the assessment process and the uses 

of assessment findings 

•Availability of qualified staff, caseload volume, and interagency cooperation 

•Availability of financial resources (e.g., 

staffing, type of assessment chosen) 

•Availability of treatment options in the 

community 

•Number of sources of information 

The instruments and sources of information 

used during an assessment are determined by 

the purpose of the assessment. Jurisdictions 

may elect the quickest and most efficient 

approach to assess who goes into treatment. 

In other cases, the court may want the greatest amount of information available about an 

12 Chapter 2 
Advice to the Counselor: 

Screening and Assessment 

• It is critical to administer screening and assessment 

instruments in a way that encourages honesty. Offenders

often think the results of these screenings will be used 

against them and may try to skew the results to influence the outcome of a trial. 

• The consequences of honest or dishonest responses 

should be clarified with the offender. 

• Counselors should use available collateral information, 

such as drug testing results, to verify the accuracy of the 

information. 

Key Issues Related to 

Screening and

Assessment 

The distinctions between screening and assessment are defined above. This section highlights 

key issues relevant to both. 

Accuracy of Information

Accuracy of screening and assessment information is clearly dependent on the honesty of 

the offender. It is critical to administer 

screening and assessment instruments in a 

way that encourages honest answers. The 

consequences of honest and dishonest 

responses should be clarified, and the setting 

for the screening can be important in this 

regard (Knight et al. 2002). Some factors that 

contribute to greater accuracy of responses 

include using collateral information, using 

concurrent drug testing, and reviewing with 

the offender the purposes of information 

obtained during screening and assessment. 

In some contexts (e.g., pretrial and presentence settings), offenders are often concerned 

that screening and assessment results will be 

used against them; for example to coerce 

them into a long-term treatment program. 

The individual may also want to avoid being 

labeled as having an addiction problem. 

Conversely, an offender may purposely try to 

skew the results to influence the 

outcome of trial, sentencing, or 

placement in custody and/or 

treatment settings. It is important for those administering 

screening and assessment to recognize the factors that may influence the accurate disclosure of 

information, and to craft their 

findings accordingly. 

Unless potential concerns related

to the screening and assessment

process are addressed directly, it 

is unlikely that screening and

assessment results will provide an 

offender. In this case, in addition to police, 

corrections, and medical records, an assessment should include family and other collateral sources for historical information. 

The following guidelines pertain to assessment 

protocols: 

•Purpose—In pretrial or diversion settings, 

assess for linkage to the community and 

placement to different types of services. 

•Content—In all settings, deepen the information obtained from previous screenings 

(psychopathy, antisocial). 

•Source—In pretrial or diversion settings, 

seek more expansive collateral information 

from family and social service staff. In jails, 

prisons, or community supervision settings, 

correctional officers and/or collateral 

offenders may be additional sources of 

information. 

Once a screening has identified the need for 

treatment, assessments should be conducted 

before offenders are given permanent placements. Assessments feed into treatment planning, decisions about treatment intensity and 

services needed (e.g., treatment planning and 

matching), and re-entry and continuing care 

plans. 

Screening and Assessment 13 
accurate picture of the offender’s substance 

abuse problems and treatment needs. 

Offenders should be briefed in advance 

regarding who will have access to screening 

and assessment information and how the 

information will be used. Counselors and 

criminal justice professionals should also 

clearly indicate their own role in the information gathering process. It may also help to 

address myths regarding court-ordered or 

other mandated treatment and treatment program requirements, and to describe the benefits of participating in treatment. Counselors 

working in criminal justice settings should 

also be aware of issues related to confidentiality and informed consent in the context of 

screening and assessment (see CSAT 2004). 

Continuity of Information

Screening and assessment are not single 

events but continuous processes that can be 

repeated by a variety of professionals in a 

variety of settings (CSAT 1994a). Efforts 

should be made to ensure the continuity of 

the information and to preserve the rights of 

the client. Ongoing communication and data 

sharing are important aspects of the screening 

and assessment process. Substance abuse 

treatment and criminal justice system staff, at 

all points in the process, need to pass on 

information obtained from substance abuse 

screening and assessment. Key information 

can be summarized and consolidated using a 

brief format, but this information should be 

maintained in a case file—even if a client does 

not go on to criminal prosecution—so that it 

can be used in case of subsequent arrest. It is 

helpful to standardize the format used to document screening and assessment information 

so that staff can be trained to more readily 

access, interpret, and communicate this information (CSAT 1994a). 

Effective treatment programs require assessment and coordination between substance 

abuse treatment and criminal justice programs and an understanding of the goals of 

both systems. Coordination also leverages the 

scarce resources for substance abuse treatment (CSAT 1994a). To encourage a team 

approach to treatment, assessment, referral, 

and case management, the consensus panel 

recommends that the two systems develop or 

strengthen arrangements that support linkages at the institutional and procedural levels. In addition, cross-training can promote 

the use of screening and assessment results 

and can reduce duplication of efforts (CSAT 

1994a). 

Systemwide Information

Sharing 

Frequently, those in the criminal justice system who conduct initial substance abuse 

screening and assessment maintain the information, while others who have contact with 

the offender later in the course of criminal 

justice processing have to rescreen or reassess 

the individual. (See CSAT 2004 for information 

about confidentiality and certain restrictions 

regarding sharing of information.) The use of 

multilevel agreements to share information is 

one approach that can minimize duplication 

of screening and assessment activities. One 

way to achieve this is to convene stakeholder 

meetings with representatives from all of the 

involved agencies in the system to develop 

these agreements. The benefits of multilevel 

agreements tend to be quite persuasive. 

Following are two examples: 

•Agency A is spending $15 per drug screen in 

addition to staff time. If that agency works 

out an implementation plan with Agency B, 

both agencies can share the information, 

avoiding the unnecessary costs of duplicating tests. 

•Hospitals that have laboratory test results 

can add them to a database to confirm or 

refute self-report information. 

At each stage of the criminal justice process 

there can be individuals or agencies that do 

not support sharing of substance abuse 

14 Chapter 2 
screening and assessment information. These 

groups have legitimate concerns that need to 

be expressed, and they need to be brought 

into the decisionmaking process as full stakeholders. Jurisdictions that establish interagency agreements can preserve limited staff 

time and resources and help avoid unexpected resistance to systemwide sharing of screening and assessment information at any stage 

in the criminal justice process. See the text 

box below for examples of programs that have 

developed multilevel agreements for sharing 

information systemwide. 

Examples of Multilevel Agreements for Systemwide 

Sharing of Information

Developing multilevel agreements is a difficult task and can take years to complete. Large criminal justice systems will clearly benefit from having an intermediary case management or placement system to 

increase communication and coordination between in-custody programs, community-based providers, 

and parole offices. Below are several working models of multilevel agreements for systemwide sharing of 

information. 

Lane County, Oregon

Lane County uses client consent and a multilevel agreement between agencies to facilitate sharing of 

information. In this model, the client and agencies must agree up front if someone wants shared access 

to information. A correctional/mental health official developed a screening and reporting system where 

every person in jail is screened for drugs, risk, and mental health with a brief instrument. The screening 

information is available systemwide (i.e., jail, diversion, and community programs), including a tear-off 

copy for mental health information (National GAINS Center 2000). 

High Intensity Drug Trafficking Areas Automated Tracking System

The University of Maryland developed a nonproprietary Management Information System (MIS) called 

HATS, the HIDTA [High Intensity Drug Trafficking Areas] Automated Tracking System, that links substance abuse treatment, mental health, juvenile, and community information. HIDTA is a program within the Office of National Drug Control Policy that coordinates drug control efforts in 28 regions around 

the country. A layered set of informed consent agreements is used to provide different access levels to 

different stakeholders (e.g., judges, parole, treatment programs). Users gain HATS access by signing an 

agreement to share any improvements made to the system, to benefit all stakeholders. The MIS is in use 

from coast to coast as a seamless care screening, assessment, case matching, and monitoring database 

(Taxman and Sherman 1998). For more information, go to the Washington/Baltimore HIDTA HATS site 

at http://www.hidta.org. 

Maricopa County, Arizona 

Maricopa County has a data-link feed between the jail and behavioral health authority to determine 

whether offenders entering jail have a previous record of mental health services or substance abuse 

treatment (National GAINS Center 1999c). (See also chapter 8.) 

Screening and Assessment 15 
Examples of Multilevel Agreements for Systemwide 

Sharing of Information (continued) 

Orange County Probation Department 

As part of the implementation of Proposition 36, the Orange County (California) Probation Department 

developed an MIS that links the Drug and Alcohol Division of the County Health Care Agency (HCA) 

with myriad treatment providers in the county. The law requires that the offender have an assessment 

and be referred to treatment within 7 days of sentencing. In processing offenders, the Probation 

Department conducts an initial assessment, while the HCA conducts a clinical assessment to determine 

the appropriate treatment level. On receiving the case from the court, the Probation Department sends 

a referral through the system to HCA, who then completes the assessment, selects a provider, and sends 

a notice through the system to the selected provider. The system then allows the provider to send periodic progress reports to the Probation Department, including when release of information forms have been 

signed, assessment levels, drug test results, and progress in treatment (Orange County Probation 

Department 2002). 

The Need To Rescreen and

Reassess

There are many reasons to rescreen and 

reassess. Offenders who may fear the consequences of self-disclosing substance abuse 

problems in one setting (e.g., pretrial detention) may be more open to discussing their 

need for treatment at a later stage (e.g., community supervision or prison). 

Offenders’ motivation for treatment may 

change over time; for example, as they 

become more familiar with peer mentors, 

counseling staff, program expectations, and 

their own self-defeating behaviors 

may reflect a gradual process of uncovering 

reasons to quit their substance use, and identifying strengths that can be built on during 

treatment. Another key reason for conducting 

multiple screenings and assessments over time 

is that previous information obtained may 

become outdated and may not include recent 

events that are relevant to treatment, such as 

relapse episodes, undetected mental disorders, or domestic violence. 

from the past. Another example 

is participants in drug courts who 

initially appear resistant to treatment during status hearings and 

who are unresponsive to early 

efforts by the judge and/or treatment counselors to instill motivation (e.g., through praise, use of 

sanctions, and engagement in 

more intensive treatment), but 

who later surprise program staff 

by their progress toward recovery over the course of a year or 

more of program participation. 

For these individuals, assessment 

Advice to the Counselor: 

The Need To Rescreen

• An offender’s motivation and willingness to enter treatment may change over time. Those who fear the consequences of self-disclosing substance abuse in a pretrial 

setting may be more open to discussing their need for 

treatment while under community supervision or in 

prison. Others who initially appear resistant to treatment 

may later surprise program staff by their progress 

toward recovery. 

• Multiple assessments may uncover an offender’s reason 

to quit substance use and identify strengths that can be 

built on during treatment. 

16 Chapter 2 
Timing of Screening and

Assessment 

In some criminal justice settings only a single 

screening is needed, due to limited treatment 

options available or to the fact that assessment will be provided at a later stage. This 

screening is typically focused on issues related 

to eligibility criteria and suitability for treatment. In cases in which several treatment 

options and sufficient time are available, 

screening is often followed by a more comprehensive assessment. 

Although screening is usually conducted as 

early as possible after the offender’s entrance 

into the criminal justice system, assessment 

may be delayed due to the offender’s sentence 

length, anticipated date of enrollment in substance abuse treatment services, and other 

factors. For example, most prison treatment 

programs provide services for inmates who 

are serving the last 24 months of their sentence, and routinely wait to provide a comprehensive assessment until the inmate is 

nearing the enrollment date for treatment services. 

When Is a Formal Diagnosis

Necessary? 

When identified with a 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 recent drug or alcohol use, 

or withdrawal from these substances, it is 

particularly important to defer diagnosis until 

an adequate assessment period is provided 

under conditions of abstinence. A “people 

first” description such as “offender who uses 

drugs” is preferable to the label “drug user.” 

Moreover, diagnostic classification can sometimes preclude offenders from receiving needed services. For example, a mental disorder 

diagnosis can preclude access to substance 

abuse 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 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 

drug-induced, organic, or psychiatric). 

• The counselor needs to clarify co-occurring 

disorders that affect treatment decisions. 

• The information is for research or evaluation 

purposes. 

Drug Testing 

Drug testing is frequently used as a screening 

device in community-based and institutional 

settings. For example, in pretrial settings 

drug testing is used to identify and monitor 

drug use and to reduce the number of rearrests among defendants (Bureau of Justice 

Assistance 1999). A major objective of pretrial drug testing is to offer courts alternatives to either detention or unsupervised 

release during the pretrial period. In community settings drug testing provides a powerful 

tool for treatment staff, the courts, and community supervision staff to monitor and 

address relapse episodes and treatment 

progress. In institutional settings, drug testing 

is helpful in monitoring abstinence and can 

serve as an “early warning” device in detecting problems among therapeutic residential 

programs. In all settings, drug testing serves 

both as a deterrent to use and as a strong 

incentive for offenders to remain abstinent. 

Screening and Assessment 17 
 

Because of advancements in drug testing technologies, drug testing can easily be incorporated into the pretrial risk assessment process. For instance, using hand-held devices, 

commercial laboratories can conduct analyses 

of urine, perspiration, and hair to identify 

the presence of a variety of drugs. Pretrial 

screening for five drugs can cost anywhere 

from $5 to $120 (Henry and Clark 1999). 

However, protocols for collecting, testing, and 

disposing of specimens must be carefully 

observed to preserve the chain of evidence in 

the pretrial setting. Counselors should ensure 

that the rights of detainees and offenders are 

not violated (see chapter 7). 

Areas To Address in

Screening and

Assessment 

This section describes the key areas that the 

consensus panel felt were important for effective screening and assessment. 

Substance Abuse History

Key areas addressed during substance abuse 

screening and assessment are reviewed in several published TIPs, including numbers 7, 

Screening and Assessment for Alcohol and 

Other Drug Abuse Among Adults in the 

Criminal Justice System (CSAT 1994d); 11, 

Simple Screening Instruments for Outreach 

for Alcohol and Other Drug Abuse and 

Infectious Diseases (CSAT 1994e); 31, 

Screening and Assessing Adolescents for 

Substance Use Disorders (CSAT 1999c); and 

42, Substance Abuse Treatment for Persons 

With Co-Occurring Disorders (CSAT 2005c). 

Major topics covered during screening and 

assessment include observable signs and 

symptoms of alcohol or drug use, signs of 

acute drug or alcohol intoxication and withdrawal effects, drug tolerance effects, negative consequences associated with substance 

abuse, the self-reported history of substance 

abuse, age and pattern of first substance 

abuse, recent patterns of use, drug(s) of 

choice, and motivation for using substances. 

A full examination is made of the prior 

involvement in treatment, both in criminal 

justice and non–criminal-justice settings. 

Family history of substance abuse is also 

important, including current patterns of 

abuse by family members who have contact 

with the offender. 

Screening instruments 

The effectiveness of substance abuse assessment and screening instruments may vary 

according to the criminal justice setting and 

the goals of gathering information in that setting. For example, in one study (Peters et al. 

2000), 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 

(the extent to which the scores are the same 

on two administrations of the instrument with 

the same people), although the validity of the 

instruments varied, as described later in this 

section. The screening instruments examined 

in the study included the following: 

• Alcohol Dependence Scale (ADS) 

• Addiction Severity Index (ASI)–Alcohol Use 

subscale (ASI-Alcohol) 

• ASI–Drug Use subscale (ASI-Drug) 

• Drug Abuse Screening Test (DAST-20) 

• Michigan Alcoholism Screening Test (MAST 

short version) 

• Substance Abuse Subtle Screening 

Inventory-2 (SASSI-2) 

• Simple Screening Instrument for Substance 

Abuse (SSI-SA) 

• TCU Drug Screen (TCUDS) (Knight et al. 

2002) 

However, these instruments varied considerably in sensitivity, specificity, and positive 

predictive value with different subpopulations 

(see appendix B for definitions of terms). For 

example, the SASSI-2 had significantly lower 

positive predictive value for African Americans than for Caucasians and Hispanics/ 

Latinos (Peters et al. 2000). Figure 2-3 lists 

18 Chapter 2 
Figure 2-3 

Recommended Substance Abuse Screening Instruments 

Instrument Purpose Description 

Alcohol Dependence A 25-item instrument The ADS (Skinner and Horn 1984) can be coupled with the 

Scale (ADS) developed to screen for 

alcohol dependence 

symptoms; performs adequately in community 

and institutional settings 

ASI-Drug Use section to provide an effective screen for 

alcohol and drug use problems among offenders. For more 

information on the ADS, contact the Center for Addiction 

and Mental Health (formerly the Addiction Research 

Foundation) at (800) 661-1111. The ASI is reprinted in 

TIP 7, Screening and Assessment for Alcohol and Other 

Drug Abuse Among Adults in the Criminal Justice System 

(CSAT 1994e). 

Simple Screening A 16-item screening 

instrument that examines 

symptoms of both alcohol and drug dependence 

An expert panel developed the SSI-SA as a tool for outreach workers. The SSI-SA, which can be administered 

without training, includes items related to alcohol and drug 

use, preoccupation and loss of control, adverse consequences of use, problem recognition, and tolerance and 

withdrawal effects. The SSI-SA is fully described in TIP 

11, Simple Screening Instruments for Outreach for Alcohol 

and Other Drug Abuse and Infectious Diseases (CSAT 

1994f) and is reproduced along with instructions in TIP 

42, Substance Abuse Treatment for Persons With CoOccurring Disorders (CSAT 2005c). 

Instrument for 

Substance Abuse 

(SSI-SA) 

TCU Drug Screen 

(TCUDS) 

A 15-item substance 

abuse diagnostic screen 

The TCU Drug Screen is completed by the offender and 

serves to quickly identify individuals who report heavy 

drug use or dependency (based on the DSM-IV-TR and the 

National Institute of Mental Health Diagnostic Interview 

Schedule) and who therefore might be eligible for treatment. For more information regarding the TCUDS and 

other related instruments go to http://www.ibr.tcu.edu. 

Source: Peters et al. 2000. 

recommendations for brief screening instruments based on this research (refer also to 

appendix C for the administration time and 

uses of specific instruments). 

Findings indicated that either the TCUDS or 

a combination of the ADS and ASI-Drug 

screen should be used in situations in which it 

is important to reduce inappropriate referrals 

to substance abuse treatment. These instruments may be particularly useful for treatment programs that have limited “slots” 

available and significant consequences for 

mismatching offenders to the program (e.g., 

therapeutic communities or other residential 

programs). The SSI-SA is recommended for 

use in situations in which it is desirable to 

identify the largest number of offenders who 

need treatment (Peters et al. 2000). Some correctional systems have begun to use the SSISA for initial screening at the time of prison 

admission, with conducting additional assessment later to verify the need for treatment 

and to determine the specific level of services 

needed. 

In conducting screening and assessment with 

female offenders, counselors may want to 

Screening and Assessment 19 
consider use of the Alcohol Use Disorders 

Identification Test (AUDIT) and the 

Tolerance, Worried, Eye Openers, Amnesia, 

Kut Down test (TWEAK), both of which were 

developed for women and are more sensitive 

than the CAGE. The AUDIT and TWEAK 

also provide equivalent sensitivity in African 

Americans and Caucasians. For screening of 

alcohol problems among female offenders, 

counselors may also want to consider use of 

the Rapid Alcohol Problems Screen (RAPS), 

which has been shown to be more sensitive 

than other measures with African-American, 

Hispanic, and Caucasian women (Cherpitel 

1997). See appendix C for information on 

how to obtain these instruments. 

Assessment instruments 

A wide variety of substance abuse assessment 

instruments is available for use in the criminal justice system. The most commonly used 

assessment instrument is the ASI (McLellan et 

al. 1980, 1992), which is used for screening, 

assessment, and treatment planning. The ASI 

was supported by the National Institute on 

Drug Abuse and is reproduced in TIP 7, 

Screening and Assessment for Alcohol and 

Other Drug Abuse Among Adults in the 

Criminal Justice System (CSAT 1994e), and 

TIP 38, Integrating Substance Abuse 

Treatment and Vocational Services (CSAT 

2000c). The instrument 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, and mental health status. Many 

agencies, including those in criminal justice 

settings, have adapted modified versions of 

the ASI for use as a substance abuse screening instrument. Two separate sections of the 

ASI that examine drug and alcohol use are 

frequently used as screening instruments. 

A positive feature of the ASI is that it has 

been validated for use in criminal justice populations (McLellan et al. 1985, 1992; Peters et 

al. 2000). For example, the ASI is highly correlated with objective indicators of addiction 

severity. The ASI is also one of the few instruments that measure several different functional aspects of psychosocial functioning 

related to substance abuse and provide a concise estimate of the history of substance abuse 

as well as recent use. The instrument provides severity ratings in each functional area 

assessed, which are useful both clinically and 

for research purposes. In using the ASI for 

assessment, 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. A self-report version of the ASI was 

developed that has been shown to be a reliable and accurate alternative to the counselor-administered instrument (Butler et al. 

1998, 2001). 

Detoxification Needs

Screening should address current evidence of 

intoxication, dependence, overdose, and withdrawal. This is particularly relevant in community corrections and jail settings, in which 

there may be significant periods of substance 

abuse that precede contact with the criminal 

justice system. Criminal justice and treatment 

staff should be trained to detect signs and 

symptoms of substance abuse and to refer 

clients to medical staff to assist in cases of 

acute intoxication. Once an individual is 

referred for detoxification, medical staff 

should perform a comprehensive assessment 

to determine the level of prior and recent use, 

and the level of substance abuse or dependence. 

Safe withdrawal from substances such as 

stimulants, cocaine, hallucinogens, and 

inhalants can be achieved with psychological 

support, symptomatic treatment, and periodic reassessments by healthcare providers. 

Frequent clinical assessments, along with 

appropriate treatment adjustments, are also 

important since the intensity of withdrawal 

cannot always be predicted accurately 

(Federal Bureau of Prisons 2000). Some substances, such as alcohol, sedative-hypnotics, 

20 Chapter 2 
Readiness for Treatment 

In addition to examining the severity of substance abuse problems, it is helpful to know

whether a client is receptive to treatment and

is committed to recovery goals. Readiness for

treatment provides an important indicator

regarding where the substance abuse treatment should begin.

Readiness for treatment is not always clearly

defined or apparent at the onset of treatment. 

Most clients do not volunteer for treatment

and experience significant ambivalence about

the process and level of commitment

required. For years, treatment professionals

and paraprofessionals believed that a person

needed to “hit bottom” to be ready for

change. Today, it is recognized that people 

can be ready for treatment without “hitting

bottom” and that many people can receive

benefits from treatment even if they are not

completely ready. For example, motivational 

interviewing (MI) techniques (discussed in 

detail in TIP 35, Enhancing Motivation for 

Change in Substance Abuse Treatment [CSAT 

1999b]) can be used to help clients resolve 

their ambivalence toward treatment and 

toward making changes in their lives. MI provides an empathic, supportive, and directive 

counseling style that attempts to persuade 

and anxiolytics, can produce dangerous withdrawal syndromes once physiological dependence has developed. Offenders who have

severe and life-threatening symptoms of 

intoxication or withdrawal should be placed 

immediately under medical supervision. The 

Federal Bureau of Prisons (2000) recommends that “inmates presenting with alcohol 

intoxication should be presumed to have 

alcohol dependence until proven otherwise” 

(p. 8).

Not all substances of abuse produce clinically 

significant withdrawal syndromes, but abstinence generally results in some psychological 

changes. Offenders should thus be reassessed 

often. Substance abuse may mask co-occurring mental disorders, such as depression, or 

symptoms of mental illness may disappear

when the offender is not using. In some cases, 

withdrawal may cause symptoms of mental 

disorders that can be identified and treated. 

For more information on the signs and symptoms of intoxication and withdrawal and the 

treatment of individuals undergoing detoxification, see the forthcoming TIP 

Detoxification and Substance Abuse 

Treatment (CSAT in development a). The 

Federal Bureau of Prisons Clinical Practice 

Guidelines: Detoxification of Chemically 

Dependent Inmates, December, 

2000 can be accessed online at 

http://www.hawaii.edu/hivandaids/

Physical Health 

Conditions

Besides the potential need for 

detoxification services, screening should also address significant medical conditions that 

may affect the offender’s 

involvement in treatment, such 

as physical disabilities, tuberculosis, hepatitis, HIV/AIDS, and 

other debilitating diseases. 

Advice to the Counselor: 

Screening for Detoxification

• Screening forms should note evidence of intoxication,

dependence, overdose, and withdrawal. This is particularly important in community corrections and jail settings, in which there may be significant periods of sub

stance abuse that precede contact with the criminal justice system.

• Besides the potential need for detoxification services,

screening should address conditions that may affect the

offender’s involvement in treatment, such as physical dis

abilities.

• It is helpful to note whether a client is receptive to treatment and may be committed to recovery (readiness to

change).

Screening and Assessment 21 
and guide the client toward change rather 

than to create motivation through confrontation of the client’s substance abuse problems 

and labeling the client as an “addict.” 

Many individuals who successfully recovered 

from substance abuse problems were coerced 

into treatment, either by family, employers, 

or the criminal justice system. Coerced treatment by the criminal justice system has been 

shown to be at least as effective as noncoerced treatment, when time in treatment is 

held constant (CSAT 1994a; De Leon 1988; 

Hubbard et al. 1988). Coercion can come 

from multiple sources. Many offenders 

reported that pressures from “psychological, 

financial, social, familial, and medical 

domains” had more influence in their decision 

to enter treatment than did the legal system 

(Marlowe et al. 1996, p. 81). However, their 

decision to stay in treatment is more often 

based on motivational readiness (Knight et al. 

2000) and external leverage. Thus, for clients 

with low internal motivation, coercive interventions may help to increase their readiness 

for treatment. Excluding people as “unready” 

or “unmotivated” would exclude the vast 

majority of clients and would mean that treatment and recovery would never begin for 

many (CSAT 1994a). For example, Alcoholics 

Anonymous counsels people who abuse alcohol to “bring the body, and the mind will follow,” believing that motivational readiness 

will grow as the program takes hold. 

An individual’s readiness for change is one of 

the most important factors that substance 

abuse counselors and clinicians should examine during the screening and assessment process, and has been found to be predictive of 

treatment retention and other outcomes. 

Studies have shown that initial motivation for 

treatment influences enrollment in postrelease treatment services (DeLeon et al. 

2000; Simpson and Joe 1993). Several treatment interventions (e.g., MI, motivational 

enhancement therapy) (Miller and Rollnick 

2002) have been developed to explore and 

enhance readiness for treatment. Many substance abuse programs in the criminal justice 

system include a “pre-treatment,” or “readiness” phase designed to address the needs of 

offenders not yet committed to recovery goals 

and ongoing involvement in treatment. This 

initial phase of treatment addresses offenders’ goals, expectations, and motivation for 

change. This intervention helps identify 

offenders who are ready for more intensive 

treatment services that require full participation in activities designed to encourage 

changes in attitudes and behaviors. 

Assessing readiness includes obtaining information about clients’ awareness of a substance problem, their ability to acknowledge 

their need for help, their willingness to accept 

help, their perception of how others feel 

about their need for help, and whether they 

have taken steps to change on their own 

(Wanberg and Milkman 1998). Generally, 

clients can be considered “ready” for treatment if they want to abstain from substance 

abuse, see treatment as a means to become 

drug- or alcohol-free, and recognize the difficulty in abstaining from substance abuse 

without professional assistance (CSAT 

1994a). Figure 2-4 describes several brief 

instruments that can be used to assess readiness for treatment. For more detailed information on this topic, see TIP 35, Enhancing 

Motivation for Change in Substance Abuse 

Treatment (CSAT 1999b). See also chapter 3 

for a discussion of the stages of change model. 

Co-Occurring Disorders

A substantial percentage of those under criminal justice supervision have one or more cooccurring mental disorders in addition to 

their substance use disorder. There were an 

estimated 283,800 incarcerated individuals in 

1998 who had a major mental disorder, 

including 16 percent of State prison inmates, 

7 percent of Federal prison inmates, and 16 

percent of jail inmates (Ditton 1999). Of all of 

these individuals, 49–65 percent were under 

the influence of drugs or alcohol at the time 

of their offense, and 24–38 percent had a history of alcohol dependence. Because individuals often require therapeutic intervention for 

22 Chapter 2 
Figure 2-4 

Instruments for Evaluating Readiness for Treatment 

Instrument Description

The University of URICA was developed to assess stage of change. The instrument is known to be valid 

Rhode Island with different populations in a variety of settings. El-Bassel and colleagues have deterChange Assessment mined that URICA is useful, reliable, and valid among incarcerated women who use 

Scale (URICA) drugs (el-Bassel et al. 1998). The URICA and other similar instruments are reprinted 

in TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 

1999b). 

The TCU Treatment 

Motivation Scales 

The TCU Treatment Motivation Scales can be used to track the stages of change in 

treatment motivation. For further information, go to http://www.ibr.tcu.edu. 

The Circumstances, 

Motivation, 

Readiness, and 

Suitability Scales 

(CMRS) 

The CMRS scales were designed to predict retention based on dynamic client factors 

related to seeking and remaining in treatment (DeLeon et al. 1994). The 

Circumstances scale is defined as the external pressure to engage and remain in treatment. The Motivation scale is defined as the internal pressure to change; the 

Readiness scale is defined as the perceived need for treatment; and the Suitability 

scale is defined as the individual’s perception of the treatment modality or setting as 

appropriate for himself. A prison version has been developed. A revised version of 

the CMRS, the CMR, is also available. The CMR is copyrighted and can be obtained 

by contacting the National Development and Research Institute, Inc., 71 W. 23rd 

Street, 8th Floor, New York, New York 10010, or mail@ndri.org. 

Stages of Change, SOCRATES includes items specifically focused on alcohol abuse and can be used as a 

Readiness, and starting point for discussion. A Spanish translation is available. The SOCRATES and 

Treatment Eagerness other similar instruments are reprinted in TIP 35, Enhancing Motivation for Change 

Scale (SOCRATES) in Substance Abuse Treatment (CSAT 1999b). 

co-occurring disorders, accurate screening 

and assessment are of particular importance. 

Much of the literature related to co-occurring 

disorders in the criminal justice system has 

focused on the most severe mental disorders 

(e.g., schizophrenia, bipolar disorder, and 

major depression) (Broner et al. 2002). 

However, less severe disorders (e.g., anxiety, 

phobia disorders, and posttraumatic stress 

disorder [PTSD], along with less severe 

depression, attention deficit disorders, and 

various types of personality disorders) are 

also common among offenders with substance 

use and mental disorders, and can affect 

treatment outcomes (Broner et al. 2002; 

Haywood et al. 2000; Henderson 1998; Peters 

and Hills 1997, 1999; Teplin et al. 1996). 

An important first step in treating offenders 

with co-occurring disorders is to develop a 

systematic approach to screen and assess for 

these disorders. Relatively few jurisdictions 

systematically screen for mental health problems or co-occurring disorders upon arrest, 

prior to or following the arraignment process, 

or upon entrance into the jails. Despite the 

high prevalence of co-occurring disorders, 

these disorders are not always detected from 

the individual’s arrest charge or mental status 

during booking. Unless the screening process 

is systematic, the target population may not 

be identified. As a result, many individuals 

are not diverted into specialized programs or 

provided effective discharge planning— 

strategies that are likely to reduce recidivism 

(Broner et al. 2001a). 

Screening and Assessment 23 
Steps for Assessing the Interactive Effects of 

Co-Occurring Disorders 

1. Assess the significance of the substance use disorder. Obtain a chronological history describing the onset 

of mental disorder and substance abuse symptoms. 

•Determine whether mental disorder symptoms occur only in the context of substance abuse. 

•Determine whether ongoing abstinence leads to rapid and full resolution of mental disorder 

symptoms. 

2. Determine the duration of the current period of abstinence. 

•If there has not been a 4–6 week period of abstinence, repeat assessment and diagnosis after such a 

period, depending on clinical judgment about the particular drug abuse history and the offender’s 

physical status. 

3. Reassess mental disorder symptoms at the end of 4–6 weeks of abstinence or at any time such symptoms 

appear or change. 

4. If mental disorder symptoms are fully resolved, consider referral for traditional substance abuse treatment; if not, consider referral for mental health or specialized co-occurring disorders services. 

5. Provide ongoing reevaluation of the offender’s mental disorder symptoms and progress in treatment. 

Screening and assessment for co-occurring 

disorders should occur soon after entry into 

involvement in the criminal justice system. 

Many individuals who are screened or 

assessed in court, community corrections, or 

jail settings may be under the influence of 

alcohol or drugs and may need to be detoxified before determining whether they have cooccurring disorders. Acute symptoms of alcohol or drug use and residual effects of detoxification can mimic a wide variety of mental 

disorders, including anxiety, bipolar disorder, depression, and schizophrenia. Most 

prison inmates screened for co-occurring disorders will have been detoxified by the time 

of admission to treatment, although chronic 

residual side effects of drug use may cloud the 

initial symptom picture. It is therefore important to identify patterns of recent substance 

abuse and to observe mental health symptoms 

over time to see if they resolve as the individual detoxifies. It is often useful to defer diagnosis (or to provide a provisional diagnosis, if 

needed) until the interactive effects of cooccurring disorders can be determined. 

No single instrument can adequately screen 

for all mental and substance use disorders, 

particularly given the constraints of length, 

cost, and required training—but a combination of instruments can be used (Peters and 

Hills 1999). The choice of substance abuse 

screening instruments should be based on the 

purpose of the screening, ethnic or racial 

characteristics, language spoken, and gender 

(Broner et al. 2002). Figure 2-5 provides a list 

and description of instruments used to screen 

and assess for mental disorders. 

Broner and colleagues recommend the MiniInternational Neuropsychiatric Interview for 

mental disorder screening in court-based 

diversion programs (without the Antisocial 

Personality Disorder and Substance and 

Alcohol Abuse modules and with a substance 

use rule-out question added to reduce falsepositives). Several sources recommend the 

TCUDS, SSI, or ADS/ASI combination for 

substance abuse screening among offenders 

with mental health problems (Broner et al. 

2001a; Peters and Bartoi 1997). For assessment of psychiatric disorders, Broner and 

24 Chapter 2 
 

 

Figure 2-5 

Instruments for Screening and Assessing Mental Disorders 

Instrument Description 

Beck Depression •A 21-item self-report of symptoms that screens for symptoms of depression. 

Inventory II (BDI-II) • Requires no significant training to administer. 

(Beck et al. 1996) • Found to be the most effective instrument in detecting depression among individuals who abuse alcohol (Weiss and Mirin 1989). 

• Should not be used as a sole indicator of depression but in conjunction with other 

instruments (Weiss and Mirin 1989; Willenbring 1986). 

Brief Symptom •A short form of the Symptom Checklist 90 - Revised (SCL-90-R). 

Inventory (BSI) • Comprising 53 items, including three global indices of psychopathology (General 

(Derogatis 1975a) Severity Index, Positive Symptom Total, Positive Symptom Distress Index) and 

nine primary psychiatric symptom dimensions. 

• Quick to administer and requires no significant training to administer. 

• Only a 6th grade reading level is required. 

• May be most useful as a general indicator of psychopathology (Boulet and Boss 

1991). 

General Behavior • A 73-item self-report instrument that examines mood disorders. 

Inventory (GBI) • Requires no significant training to administer. 

(Depue and Klein • Differentiates between unipolar and bipolar depression. 

1988) 

Hamilton Depression • A 17-item scale completed by an interviewer based on self-report information. 

Scale (HAM-D) • Examines several key elements of depression, including sleep disturbance, somati­

(Hamilton 1960) zation, anxiety-depression, and apathy. 

• Requires training to administer. 

Mental Health • Eighteen simple questions designed to screen for present or past symptoms of most 

Screening Form-III of the main mental disorders. 

(MHSF-III) •A “rough” screening device and asks only one question for each disorder for 

(Carroll and which it attempts to screen. 

McGinley 2001) •Reproduced in TIP 42, Substance Abuse Treatment for Persons With CoOccurring Disorders (CSAT 2005c). 

Millon Clinical • A self-report measure with several subscales. 

Multiaxial Inventory • Useful in assessing Axis II (personality) disorders that may affect involvement in (MCMI-III) treatment. 

(Millon 1983; Millon • Includes the Drug Abuse Scale (DAS), an instrument designed to measure personet al. 1994) ality characteristics often associated with drug abuse (Calsyn and Saxon 1989). 

Screening and Assessment 25 
Figure 2-5 (continued) 

Instruments for Screening and Assessing Mental Disorders 

Instrument Description 

Minnesota Multiphasic • A self-report measure with 567 items, 10 main clinical scales, and 10 supplementary 

Personality Inventory scales. 

(MMPI-2) • A restandardized version of the MMPI. 

(Butcher et al. 2001) • Frequently used in correctional settings for classification and assignment to housing 

or inmate programs, and to predict an inmate’s response to placement in a correctional setting. 

• Useful in identifying characteristics of antisocial personality disorder. 

• Designed to identify psychopathology and not to identify substance use disorders. 

Personality • A self-report measure with 344 items and 22 scales. 

Assessment Inventory • Eleven clinical scales include separate measures of alcohol problems and drug (PAI) problems. 

(Morey 1991) • Five treatment scales are also provided in the PAI. 

Referral Decision • A 14-item measure of mental disorder symptoms developed to identify mental health 

Scale (RDS) problems. 

(Teplin and Swartz • Developed and validated in a criminal justice setting. 

1989) • Found to be useful in detecting the presence of major mental illness among jail 

inmates. 

• Requires no training to administer. 

• Self-administered. 

• Examines only a few mental disorders (depression, bipolar disorder, schizophrenia). 

Symptom Checklist •A 90-item, multidimensional self-report inventory designed to assess recently experi90 - Revised enced physical and psychological distress. 

(SCL-90-R) • Requires no training to administer. 

(Derogatis 1975b) • Self-administered. 

• Short amount of time to administer. 

• Frequently used in criminal justice settings. 

• Covers a wide range of symptom dimensions that include somatization, obsessivecompulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, 

paranoid ideation, and psychoticism. 

colleagues recommend the Structured Clinical 

Interview for DSM-IV (SCID) (Broner et al. 

2001a). Refer to appendix C for these and 

other examples of instruments that are recommended for use with specific populations. 

For more information on screening for cooccurring disorders see chapter 4 of TIP 42, 

Substance Abuse Treatment for Persons With 

Co-Occurring Disorders (CSAT 2005c). 

History of Trauma 

Rates of trauma in men and women entering 

the criminal justice system are higher than 

are rates found in community samples. For 

26 Chapter 2 
Advice to the Counselor: 

Screening for Co-Occurring Disorders

• Screening and assessment for co-occurring disorders 

should occur on entry into the criminal justice system, 

given the high prevalence of co-occurring disorders in 

this population. 

• Individuals in community corrections or jail settings may 

need to be detoxified before screening for co-occurring 

disorders. The acute symptoms of alcohol or drug use 

and the residual effects of detoxification can mimic a 

wide variety of mental disorders, including anxiety, bipolar disorder, depression, and schizophrenia. 

example, Teplin et al. (1996) found that 34 

percent of female jail inmates had PTSD. 

According to the DSM-IV-TR, trauma is 

defined by two characteristics: 

1. A person experiences, witnesses, or is 

threatened by physical harm. 

2. The person’s response to the event includes 

“intense fear, helplessness or horror” (APA 

2000a, p. 463). 

This definition highlights that trauma is not 

simply an event of a particular type but 

includes a subjective dimension in that the person’s response to the event is powerfully negative. For example, one person may survive a 

car accident and not react with “fear, helplessness, or horror,” while another person does 

experience such feelings. 

Among female State prisoners, 40–80 percent 

report a history of emotional, physical, or 

sexual abuse (Bloom et al. 1994; Snell 1994). 

Female prison inmates are three times more 

likely to report a history of any abuse and six 

times more likely to report a history of sexual 

abuse in comparison to male inmates. A history of physical or sexual abuse has been linked 

to many types of mental disorders, including 

PTSD, depression and suicidal behavior, and 

borderline personality disorder and other 

personality disorders (Spielvogel and Floyd 

1997). 

Despite high rates of physical 

and sexual abuse among offenders, screening and assessment in 

the criminal justice system has 

not historically addressed these 

issues, nor have treatment services been provided in jail, 

prison, or community settings. 

There are many compelling reasons to address abuse and trauma issues during screening and 

assessment in the criminal justice 

system. For many offenders, the 

guilt, shame, and low self-esteem 

related to their trauma history 

may lead to social isolation and 

may reduce participation in treatment activities. For example, given the close relationship 

between past physical or sexual abuse and 

substance abuse, treatment that does not 

address one of the “root” contributors to substance abuse may be perceived as unimportant or irrelevant and may not provide sufficient incentives for the offender to change his 

or her attitudes and behavior. The offender’s 

resulting lack of engagement in program services may be misinterpreted as resistance to 

treatment or lack of motivation rather than to 

psychological issues related to abuse and 

trauma. Forced abstinence during jail or 

prison may also deprive offenders of their 

primary means of coping with negative emotions related to past abuse and trauma (i.e., 

use of drugs and alcohol). When this coping 

mechanism is no longer available, many 

offenders are left vulnerable and may begin 

to exhibit symptoms of depression and other 

mental disorders that can interfere with treatment. If unaddressed, past trauma can also 

trigger substance abuse relapse (during or 

after treatment), through emotional, physical, 

or situational cues associated with prior 

abuse experiences. 

Only trained counselors should inquire about 

abuse and trauma issues. The counselor 

should be prepared for how to respond to 

self-disclosed experiences related to physical 

and sexual abuse and how to provide referral 

for services. In most substance abuse settings, 

Screening and Assessment 27 
the goal of screening or an intake interview is 

not to compile detailed and comprehensive 

information regarding past trauma, but to 

identify that the offender has a history of 

trauma for purposes of treatment planning, 

triage, and referral for more intensive services. As a result, counselors should be familiar with and have ready access to resources 

(e.g., counselors with mental health training, 

liaisons from women’s shelters and treatment 

programs) to refer persons who wish to discuss their histories of trauma in more detail. 

Although clinicians are sometimes concerned 

about addressing material that is potentially 

uncomfortable or even overwhelming for 

either the client or themselves, these adverse 

consequences are rarely experienced when 

these issues are raised by well-trained staff. 

In fact, offenders are typically relieved to 

talk frankly about their abuse and trauma 

experience, albeit in an appropriately limited 

fashion. Indepth discussion of the specific 

events surrounding traumatic experiences is 

typically conducted in followup individual or 

Screening and Assessment of Abuse and Trauma History 

Structured interview assessments

•Trauma Assessment & Treatment Resource Book 

New York State Office of Mental Health’s Trauma Initiative 

Design Center 

44 Holland Ave 

Albany, NY 12229 

Fax requests: (518) 473-2684 

•The Integrated Biopsychosocial Assessment that includes trauma history questions in an assessment form 

appropriate for a mental health or substance abuse setting. Available from: 

Colleen Clark, Ph.D. 

Louis de la Parte Florida Mental Health Institute 

13301 Bruce B. Downs Blvd./ MHC 1345 

Tampa, FL 33612-3899 

Requests by e-mail: Cclark@ fmhi.usf.edu 

Self-report instruments

•The Traumatic Antecedent Questionnaire (TAQ) (van der Kolk 1992). A widely used measure of lifetime 

experiences of trauma in 10 domains, i.e., physical, sexual, witnessing trauma, etc. 

•The Dissociative Experiences Scale (DES) (Bernstein and Putnam 1986). A self-report measure examining 

several domains of dissociative phenomena, often sequelae of trauma, i.e., amnesia, identity alterations, 

spontaneous trance states, etc. 

•The Clinician Administered PTSD Scale (CAPS) (Blake et al. 1998). A clinician-administered scale that 

provides an accurate diagnosis of PTSD. 

•The Trauma Symptom Inventory (TSI) (Briere 1995). A 100-item self-report instrument that evaluates 

symptoms in adults that may have arisen from childhood or adult traumatic experiences. Includes 10 clinical scales and 3 validity scales. An alternate version (TSI-A) includes no references to sexual issues. The 

companion Trauma Symptom Checklist 40 (Briere 1995; Briere and Runtz 1989) is a 40-item instrument 

that contains 6 sub-scales. Items are rated on a 4-point scale covering frequency over the past 2 months. 

•Posttraumatic Disorder Scale (PTDS) (Foa et al. 1993). Measures trauma history and specific symptoms 

associated with posttraumatic stress disorder. 

28 Chapter 2 
group treatment sessions that specifically 

address this topic area. Treatment for trauma 

issues progresses in stages, with early treatment goals focused on issues of ensuring safety in relationships, the place of residence, 

and in the workplace. Later work explores 

issues of recovery and reconciliation, if 

appropriate. This later work is frequently 

conducted by therapists with advanced 

degrees and in most cases is not appropriately 

addressed by paraprofessional staff. 

Most commonly, assessment of trauma has 

been conducted through a clinical interview. 

In these settings, it is preferable to use standardized questions that avoid the use of terms 

such as “abuse,” “trauma,” or “perpetrator” 

and that instead focus on description of specific events or experiences. 

Sample interview questions could include: 

•Were you ever hit or punished in ways that 

left bruises, burns, or cuts? Were you ever 

threatened with knives or guns? Were you 

ever made to go without eating? Did you ever 

witness anyone else getting hurt? Did you 

ever have to be taken from your parents’ 

care? 

•As a child, did you have any sexual experiences? With whom and for how long did this 

go on? Were you ever threatened about it? 

Were any photos taken? Did any of these 

experiences lead to medical or other problems? Do you have any recurrent memories of these events 

now? 

•Are you safe in your current 

relationship? Has your safety 

ever been threatened in any of 

your adult relationships? Have 

you been punched, shoved, or 

hit? Did you ever seek any 

medical help as a result? Have 

you talked to people about 

these experiences? (Spielvogel 

and Floyd 1997). 

For more information on this 

topic see also TIP 25, Substance 

Abuse Treatment and Domestic 

Violence (CSAT 1997b), TIP 36, Substance 

Abuse Treatment for Persons With Child 

Abuse and Neglect Issues (CSAT 2000d), and 

the forthcoming TIP Substance Abuse and 

Trauma (CSAT in development f). 

Psychopathy and Risk for

Violence and Recidivism

A number of criminogenic “risk factors” are 

often assessed in justice settings to determine 

eligibility for admission to substance abuse 

treatment programs and community release 

(e.g., parole), and for placement in institutional housing or in different levels of supervision (Borum 1996; Douglas and Webster 

1999; Otto 2000). This information is particularly helpful to identify offenders likely to be 

disruptive in treatment programs, to be rearrested, or to commit violent crimes after 

release from institutions. Risk factors can be 

categorized as static or dynamic. Static risk 

factors are those that cannot change, such as 

gender and race, or are relatively enduring 

traits such as the diagnosis of a mental disorder, criminal history, family history, and the 

characteristics of the offender’s victims. 

Dynamic risk factors are those likely to 

change over time and that change according 

to the client’s environment, social situation, 

or experiences, such as drug use or homelessness. Following is a discussion of the risk facAdvice to the Counselor: 

Screening for Trauma 

• Trained counselors are best equipped to inquire about 

abuse and trauma issues. Offenders who have experi 

enced abuse or trauma and who are undergoing forced 

abstinence while in jail or prison may be deprived of 

their primary means of coping with the negative emo 

tions related to past trauma. These offenders may begin 

to exhibit signs of depression or other mental disorders 

that can interfere with treatment. 

• Counselors should be familiar with and have ready access 

to resources to refer persons who wish to discuss their 

histories of trauma in more detail. 

Screening and Assessment 29 
tors for psychopathy and for violence and 

recidivism. 

Psychopathy 

One stable risk factor often found among 

offenders with substance use disorders is psychopathy and the closely related antisocial 

personality disorder defined in the DSM-IV 

classification system. Personality disorders 

are persistent and pervasive patterns of maladaptive behavior that are usually exhibited 

early in life. Historically, many terms have 

been used to describe personality disorders 

that involve criminogenic characteristics. 

Four closely linked terms are “sociopath” 

(and the trait of sociopathy), “antisocial personality” (and antisocial traits), “dissocial 

personality” (dissocial behavioral traits), and 

“psychopathic personality disorder” (psychopathy or psychopathic traits). Whereas 

the first three formulations of criminogenic 

personality types focus on social deficits and 

mild emotional and cognitive problems resulting in impulsivity and poor school achievement, psychopathy focuses on primary and 

severe deficits in attachment and interpersonal bonding, lack of empathy for others’ experiences, lack of remorse, and shallow emotional functioning. These relatively stable 

traits are thought to have a biological basis. 

As previously indicated, psychopathy is related to the DSM-IV antisocial personality disorder but represents a more extreme version of 

that disorder. Some would argue that psychopathy represents a distinct diagnostic 

group. From 40 to 60 percent of male prison 

Advice to the Counselor: 

Screening for Psychopathy

inmates meet the criteria for antisocial personality disorder, whereas only 10 to 20 percent of male prison inmates meet the criteria 

for psychopathy (Hare et al. 1991). 

Psychopathy is an important predictor of 

treatment dropout, level of involvement in 

violence, and criminal justice recidivism 

(Hart et al. 1994; Hemphill et al. 1998; Ogloff 

et al. 1990; Rice et al. 1992). Offenders identified as having a high degree of psychopathy 

may require specialized, more structured 

treatment approaches, although there is not a 

large body of evidence describing effective 

therapeutic interventions that have been 

applied to this population. Assessment for 

psychopathy is often used in criminal justice 

settings to rule out individuals for treatment 

involvement, particularly if there are not sufficiently structured treatment programs available. 

Few short screening instruments exist for psychopathy because of the complexity of dimensions that need to be examined. The most 

widely used instrument to identify psychopathy is the Hare Psychopathy ChecklistRevised (PCL-R) (Hare 1998b; Hare et al. 

1991; Hart et al. 1994). The PCL-R is considered the “gold standard” for measuring psychopathy. It requires a significant amount of 

time to review archival information and to 

conduct an interview. A shorter screening 

version of this instrument—the PCL-SV—has 

also been developed for use with this population and validated in substance abuse treatment settings (Hart et al. 1995). Another 

shorter (60-item) measure, the Self-Report 

Psychopathy (SRP) instrument, 

has been developed for use in 

criminal justice settings by the 

author of the PCL-R. 

• Psychopathy is an important predictor of treatment 

dropout, level of involvement in violence, and criminal 

justice recidivism. Offenders identified as having a high 

degree of psychopathy may require specialized, more 

structured treatment approaches, although there is not a 

large body of evidence describing effective therapeutic 

interventions for this population. 

Several other short self-report 

screening instruments for psychopathy have been developed 

but have yet to be fully validated 

with criminal justice populations. These include the 

Psychopathic Personality 

30 Chapter 2 
Inventory (Lilienfeld and Andrews 1996), the 

Psychopathy Q-Sort (Reise and Oliver 1994; 

Reise and Wink 1995), and the Levenson SelfReport Psychopathy Scale (Brinkley et al. 

2001; Levenson et al. 1995). A number of 

other screening and assessment instruments 

examine personality features related, but not 

identical, to psychopathy (Zimmerman 2000), 

as described in Figure 2-6 on the next page. 

Violence and recidivism 

Although psychopathy may be the single most 

important risk factor for criminal recidivism, 

other risk factors are important to assess 

among offenders with substance abuse problems. Even offenders determined to have low 

levels of psychopathy may still be at high risk 

for violence or recidivism due to other risk 

factors. Other major risk factors for violence 

and criminal recidivism include 

•Antisocial attitudes 

•Criminal peers 

•Prior history of crime and violence, and early 

age at time of first offense/violent act 

•Active symptoms of severe mental illness 

•Impulsivity 

•Environmental stress 

•Treatment nonadherence 

•Personality disorders (generally) 

A number of environmental stressors can lead 

to renewed substance use and risk for recidivism when offenders are released from custody or when their daily structure and level 

of supervision is reduced (Peters 1993; 

Wanberg and Milkman 1998). During these 

transitions, many offenders face employment 

and financial problems, and few have family 

or social supports. Meanwhile, there are 

immediate demands to organize daily activities, develop and maintain constructive relationships, manage personal or household 

finances and problems, and participate in 

community supervision. Many offenders 

involved with drugs have never learned the 

requisite skills to accomplish these tasks, and 

some rapidly return to substance abuse in the 

absence of opportunities to learn and 

rehearse those skills. 

Many offenders have long histories of psychosocial problems that have contributed to 

their substance abuse and criminal involvement. These include interpersonal difficulties 

with family members, difficulties in sustaining 

long-term relationships, emotional and psychological difficulties, difficulties in managing 

anger and stress, educational and vocational 

skills deficits, and employment problems 

(Belenko and Peugh 1998; Peters 1993). 

Offenders do not typically plan or seek out 

addictive lifestyles or relapse. Rather, it is 

their lack of planning, personal objectives, 

and self-monitoring that leads to substance 

abuse or dependence or relapse. The lack of 

basic coping skills to manage life and social 

pressures further contributes to the risk for 

relapse and recidivism. 

Reunification with family members is often 

accompanied by stress related to the family’s 

distrust and anger over offenders’ past drug 

use, unresolved conflicts with the partner or 

spouse, shifting parental roles, and added 

financial obligations, as well as drug use in 

the family or neighborhood. Elements of community supervision can also increase an 

offender’s stress during re-entry to the community. These include drug testing, use of 

house arrest, and other surveillance or 

reporting activities, as well as the offender’s 

recognition of the significant level of effort 

and adherence required by community supervision programs. The community’s ongoing 

leverage to maintain the offender’s involvement in treatment following release from custody or other secure settings can be a further 

stressor (U.S. Department of Justice 1991). 

Figure 2-6 (next page) provides descriptions 

of three general assessment instruments related to the risk for violence and recidivism. 

Screening and Assessment 31 
Instruments Description 

Psychopathy 

assessment 

instruments 

Psychopathy 

Checklist – 

Revised (PCL-R) 

•A 20-item assessment measure that requires use of a semi-structured 

interview and review of archival records. 

•Requires 90–120 minutes for the interview section and 60 minutes for the 

collateral records review. 

•Measures the extent to which individuals exhibit psychopathic features 

on a 40-point scale, with a cutoff score of approximately 30 indicating 

psychopathy. 

•Has considerable validation for use with offenders and is highly predictive of violence and criminal recidivism. 

Psychopathy 

Checklist – 

Screening Version 

(PCL-SV) 

•A 12-item measure examining the same construct of psychopathy as the 

PCL-R. 

•Requires 45 minutes for the interview section and 30 minutes for the collateral records review. 

•Scored on a 24-point scale with a cutoff of approximately 18 indicating 

psychopathy. 

Other instruments related 

to psychopathy 

Carlton 

Psychological 

Survey 

•Used as an intake screening in correctional settings. 

•Contains scale scores for five categories: antisocial tendencies, chemical 

abuse, self-depreciation, thought disturbance, and validity. 

•Especially useful for those with low education and literacy as it requires 

only a 4th-grade reading level. 

Jesness Inventory • Examines moral development throughout the life span. 

Paulus Deception 

Scales 

• Gauges the extent of deception provided through offenders’ self-report. 

Millon Clinical 

Multi-Axial 

Inventory-III 

(MCMI-III) 

• Provides an assessment of personality disorders and psychopathy. 

• Correctional version of the MCMI-III provides early identification of 

substance abuse and mental health problems.

• The 175-question test takes 25 minutes to complete. 

• Spanish versions available (Millon et al. 2002). 

Minnesota 

Multiphasic 

Personality 

Inventory 

(MMPI-2) 

• A self-report objective assessment measure with 567 items, 10 main clinical scales, and 10 supplementary scales (Hathaway and McKinley 1989). 

• The Psychopathic Deviate Scale on the MMPI identifies individuals with 

psychopathic and antisocial features.

• Frequently used in criminal justice settings (particularly in prisons) for 

classification and assignment to housing or offender programs and to 

predict an offender’s response to placement in prison setting. 

• MMPI subtypes described by Megargee et al. (1979) are often used to 

identify offenders who require more intensive supervision and structured program activities. 

Figure 2-6 

Instruments Examining Psychopathy and Risk for 

Violence and Recidivism 

32 Chapter 2 
Figure 2-6 (continued) 

Instruments Examining Psychopathy and Risk for 

Violence and Recidivism 

Instruments Description 

Other instruments related 

to psychopathy 

Personality 

Assessment 

Instrument (PAI) 

• Self-report instrument for assessing traits associated with psychopathy. 

• Includes 344 items and requires 50–60 minutes to administer. 

• Contains scales for Negative Impression Management, Malingering, and 

Defensiveness (Morey and Lanier 1998). 

• The Antisocial Features (ANT) scale is the most highly correlated with 

psychopathy and focuses on antisocial behaviors, egocentricity, and 

stimulation-seeking. 

General 

assessment 

instruments 

related to the 

risk for violence and 

recidivism 

Level of Service 

Inventory (LSI) ­

Revised 

•A 54-point scale used to predict the chances of criminal recidivism or 

supervision failure among offenders. 

•Useful for identifying those in need of more intensive levels of treatment, 

placement in halfway houses, and level of supervision and security classification (Andrews and Bonta 1995). 

•Used by jurisdictions to support an increase or decrease in the level of 

community supervision. 

•Includes assessment of drug use and is sometimes used in tandem with 

substance abuse treatment decisions. 

Historical, 

Clinical, Risk 

Management 

(HCR-20) 

•Provides a comprehensive risk assessment based on historical, clinical, 

and risk management assessments. 

•Composed of static and dynamic factors with information derived from 

clinical interview, standardized assessment (e.g., the PCL-R or PCLSV), and collateral sources. 

• Includes three sections—10 historical items, 5 clinical items, and 5 risk 

management items—with a final risk rating of low, medium, or high 

(Webster et al. 1997, 2000). 

The Violence Risk 

Appraisal Guide 

(VRAG) (Harris et 

al. 1993) 

•An assessment tool for predicting violent recidivism. 

•Is an actuarial measure based on 12 objective variables that are linked to

recidivism. 

•Requires interview and archival review, and incorporates results of diagnostic testing, IQ testing, the PCL-R, criminal history, and indicators of 

adult adjustment. 

Selection and

Implementation of 

Instruments

Using well-accepted and standardized instruments can bring uniformity, quality control, 

and structure to the process. Some instruments may be more appropriate than others 

for particular purposes (CSAT 1994a), 

depending on the information needed for 

treatment decisions. For example, some 

instruments focus on drug dependence and 

not abuse, some identify those for whom specific treatment options are appropriate, and 

Screening and Assessment 33 
some are validated for use with criminal justice populations. 

The appropriateness of particular instruments depends on the type of client being 

referred to a specific criminal justice program 

and the goals related to program admission. 

For instance, drug education programs are 

generally provided to a wide number of 

offenders, and a substance abuse screen that 

tends to be overly inclusive for this intervention might be preferred to a more exclusive 

screen. On the other hand, because of the 

limited access to treatment for offenders with 

co-occurring substance use and mental disorders, screening for mental disorders as well as 

for drug use problems may need to be conservative to avoid referring someone who does 

not need services. Therefore, flexibility in 

developing screening and assessment 

approaches is needed, depending on specific 

program parameters (e.g., type of staff, client 

goals and needs). 

This section describes the various factors that 

the consensus panel thinks are important in 

the selection of screening and assessment 

instruments, including length, cost, window of 

detection, interview versus self-administered 

instruments, staff training required, literacy, 

language, and computerization. 

What Guidelines Are Available 

Regarding the Effectiveness

of Instruments? 

Screening and assessment instruments vary 

considerably in their ability to detect substance use disorders and in the coverage of 

related areas such as mental health and other 

health issues, family and social functioning, 

and employment. The consensus panel 

believes that several guidelines should be considered when selecting substance abuse 

instruments for a particular criminal justice 

setting, in addition to the time and cost of 

administration. These guidelines, also known 

as “psychometric properties,” are often 

described in research reports examining a 

particular instrument or in manuals that 

accompany the instruments. Five major statistical guidelines are used to gauge an instrument’s accuracy for use with client populations: 

•Overall accuracy—the extent to which the 

instrument classifies respondents correctly. 

•Sensitivity—the extent to which the instrument accurately identifies those with substance use disorders (true positives). 

•Specificity—the extent to which the instrument accurately identifies those without 

substance use disorders (true negatives). 

•Positive predictive value—the proportion of 

offenders identified by the instrument as 

having substance abuse problems, compared to the total number having substance 

abuse problems. 

•Negative predictive value—the proportion 

of offenders identified by the instrument as 

not having substance abuse problems, compared to the total number not having substance abuse problems. 

Psychometric information helps counselors 

decide the usefulness of a screening instrument 

in a specific criminal justice setting. Questions 

counselors should ask include 

•Are there normative scores for the population? 

•Does the research show the instrument is 

valid for use with offenders and for relevant ethnic/cultural groups represented? 

•Is it better to err on the side of falsepositive or false-negative results? In other 

words, a decision must be made about 

whether to err on the side of sending someone to treatment who does not need it or 

not sending someone who does need it. 

Length

Another critical factor that enters into the 

choice of a substance abuse screening instrument is how long it takes to administer. 

Although many drug use assessments are well 

designed and serve as broad sorting tools for 

treatment and intervention, they tend to take 

longer to administer than correctional agen34 Chapter 2 
cies can afford (Knight et al. 2002). Rather, 

correctional systems usually have a short 

period of time to determine which of a large 

number of offenders need treatment. For 

example, the Program and Services Division 

of the Texas Department of Criminal Justice 

coordinates a drug abuse screening and treatment referral process for several hundred 

inmates monthly. The division lacks the staff, 

time, or financial resources to administer 

lengthy individual interviews for each new 

admission. Therefore, simple logic dictates 

that an instrument should not be used if it 

takes longer to administer than the staff time 

available. 

Cost 

The cost of instruments varies according to 

whether they are publicly or commercially 

available, whether the instrument is computerized, and the unit costs per administration that 

are assigned by the publisher. There are several screening and assessment instruments available at no cost in the public domain. Other 

commercially available instruments are available that can often be administered for $1 to $5 

per unit. (See appendix C.) 

Window of Detection

Questions phrased to ask about a relatively 

short window of detection—focusing on current 

rather than lifetime alcohol and drug problems—are recommended for screening 

(Cherpitel 1997; Knight et al. 2002) because 

there is a greater chance of obtaining valid 

responses. However, shorter detection windows 

could be too restrictive, and some who need 

treatment could be overlooked (e.g., offenders 

who abstained from substances while awaiting 

trial). 

Interview Versus SelfAdministered Instruments

The method used to administer an assessment 

instrument has implications for staffing, language, literacy, and reading level. A face-toface interview can ensure that the respondent 

understands the items and answers them, but 

it is more time consuming and costly. The 

interview, which may be broken into several 

sessions, might be more appropriate for those 

with physical or cognitive disabilities. If cost 

is a concern, self-administered instruments 

could be used. Use of small-group interviews 

is another less costly alternative to individual 

interviews (Broome 

et al. 1996b). 

Research suggests Correctional staff 

members who 

have been trained

to administer an

instrument can, in 

turn, train others 

to use it. 

that the reliability of 

the administration 

method varies by 

setting and the content evaluated 

(Broner et al. 2002; 

Broome et al. 1996b; 

Knight et al. 1998). 

The method chosen 

(e.g., interview or 

self-administered) 

also affects the 

amount of training 

required to administer the screening. 

Staff Training Required

Training will have a major impact on instrument selection. Logically, if resources for 

intensive training are not available, instruments should be selected that do not require 

interpretation. Although most screening 

instruments do not require substantial staff 

training, some, such as the SASSI, may 

require more training than others. Further, 

even when little training is required, such as 

for the CAGE or interview-based instruments, the level of training can influence the 

validity of results. For assessment instruments such as the ASI, training may have a 

significant impact on the interpretation of 

results, administration of the instrument, and 

development of basic counseling techniques 

related to engaging clients, eliciting problems, 

interviewing strategies, and dealing with resistance. 

Screening and Assessment 35 
Even with qualified staff, extensive training 

may be difficult to implement. Choosing a 

brief, easily administered screening instrument that requires little staff training can 

solve these difficulties. In some instances, 

correctional staff members who have been 

trained to administer an instrument can, in 

turn, train others to use it (Knight et al. 

2002). 

Literacy

A brief screening for literacy is recommended 

if it is suspected that a client may not be able 

to complete a paper-and-pencil test. The 

Slosson Oral Reading Test–Revised 

(http://www.slosson.com) may be useful if a 

counselor wants to know whether a client can 

read at a particular grade level. It is important to note, however, that a client’s inability 

to read or write does not mean he or she cannot take an active part in the assessment. 

Rather, the counselor can substitute an interview for a paper-and-pencil assessment and a 

thumbprint for a signature. 

Language 

Optimally, the instrument chosen should be 

written in the individual’s language of choice, 

whether English or another language. 

However, it should not be assumed that individuals who can speak a particular language 

can also read that language, or any other. To 

that end, the client may need to communicate 

in “street language.” In this case, the counselor should mirror and leverage whatever 

vocabulary the client uses. Professional or 

clinical jargon should be avoided (CSAT 

1994a). 

Translating an instrument on the fly, such as 

for the Hispanic/Latino population, will 

greatly reduce the reliability and validity of 

screening results. Each population has 

differ­ent usages of language; 

misunderstandings and inaccuracies can 

impact engagement in treatment and client 

motivation for change. 

Computerization

Some instruments allow screening through 

computerization (e.g., ASI). Computerization 

can reduce the personnel time needed to conduct screening and assessment but can also 

reduce the comprehensiveness of information 

gathered compared to clinical interviews. 

Research indicates that a computerized version of the ASI provides good reliability and 

validity for use with substance-involved 

clients (Butler et al. 1998, 2001). One report 

(Budman 2002) concluded that the computerized ASI is “more reliable, faster to administer, more accepted by patients, and more 

cost-effective” in comparison to the interview 

version of the ASI. While computerization 

can decrease the effort and time required for 

scoring, it can be an obstacle for offenders 

who are unfamiliar with computer technology 

and introduces added up-front and ongoing 

costs. 

Screening and

Assessment 

Considerations for

Specific Populations

Within different treatment settings in the 

criminal justice system, screening and assessment instruments and procedures are sometimes altered to address the unique needs of 

specific clinical populations, such as ethnic 

and cultural minorities, women, and offenders with co-occurring disorders. For example, 

there is a growing recognition that instruments vary in their ability to detect substance 

abuse and other problems among these specific populations and that in some cases new 

instruments need to be developed. A related 

concern is that if a screening or assessment 

instrument is substantially modified for use 

with specific populations, research is needed 

to validate the effectiveness of the new instrument in that setting. Another concern is that 

if items are added or deleted, this may affect 

36 Chapter 2 
the overall scoring of the instrument. The following section presents issues to consider 

when screening and assessing specific populations and suggests strategies for modifications 

to instruments and procedures. 

Racial and Ethnic Minorities

When the counselor and the offender are 

from different racial or ethnic groups, the 

potential for misunderstanding is considerable. These differences can affect the staff’s 

ability to assess client needs and/or to recommend culturally competent services for clients 

from other cultures and can jeopardize the 

client’s chances for treatment success. The 

sources of misunderstanding originate in culture, socioeconomic class, and language (Sue 

and Sue 1999), as well as in race, gender 

(Broner et al. 2001a), literacy, and physical 

or cognitive inability to respond to the instrument (CSAT 1994a). 

A general introduction to a screening or 

assessment could include statements about the 

effects of substance abuse on society or on the 

client’s culture, along with information about 

the purpose of the process. Counselors should 

ask clients directly about how they view or 

describe themselves and their preferred usage 

of terms such as black, African American, 

person of color, Hispanic, Latino, Chicana, 

Pacific Islander, gay, homosexual, or lesbian. 

Counselors should also be aware of general 

cultural beliefs and expectations. For example, screening American-Indian populations 

can prove difficult because gaining trust is 

sometimes a challenge. Moreover, some tribal 

cultures dictate silence about substance abuse 

issues. As a result, a screening that detects 

the need for further assessment brings the 

stigma of losing dignity in the tribe. 

American-Indian men and women may also be 

the victims of other types of abuse that can 

impede the screening and assessment process. 

Further barriers of language, literacy, and 

comprehension are also present in this population (Sue and Sue 1999). 

It may be necessary for a counselor to modify 

screening and assessment instruments to be 

sensitive to cultural differences. Individuals 

interested in modifying instruments should 

consult the research literature to identify 

adaptations that have already been developed 

and validated or new scales that have been 

adapted for the instruments. For example, 

several adaptations of the ASI have been 

developed for use with American Indians 

(Carise et al. 1998) and with women (CSAT 

1997c). Also, new 

intake and followup 

scales have been 

developed for the Women respond 

differently to the 

screening process 

than men, and a 

longer, more 

flexible format is

often useful.

ASI (Alterman et al. 

1998). Counselors 

are encouraged to 

determine whether 

norms for an instrument make sense 

with the population 

they are testing. If 

the recognized criterion score results in 

too many individuals 

being excluded from 

treatment, perhaps 

the counselor should 

consider lowering it. 

(See also the forthcoming TIP Improving 

Cultural Competence in Substance Abuse 

Treatment [CSAT in development b].) 

Women

Counselors also need to be aware of special 

issues in screening and assessing female 

offenders. Women respond differently to the 

screening process than men (Kassebaum 

1999), and a longer, more flexible format is 

often useful, particularly to explore unanticipated areas that may arise. Females are more 

likely than males to have a co-occurring mental disorder and trauma-related problems. In 

addition, they are more likely to be affected 

by poverty, abuse histories, unstable social 

supports, and medical problems (el-Bassel et 

al. 1996; Fullilove et al. 1993; Haywood et al. 

Screening and Assessment 37 
2000; Henderson 1998; Jacobson and Herald 

1990; Jordan et al. 1996; Richie and Johnsen 

1996; Teplin et al. 1996). In addition, many 

have lost custody of their children as a result 

of incarceration. Important counseling and 

treatment approaches for women are 

described in CSAT’s Technical Assistance 

Publication (TAP) 23, Substance Abuse 

Treatment for Women Offenders: Guide to 

Promising Practices (Kassebaum 1999), and 

the forthcoming TIP Substance Abuse 

Treatment: Addressing the Specific Needs of 

Women (CSAT in development g). Additional 

guidelines for screening and assessment of 

trauma history among female offenders are 

discussed earlier in this chapter. 

Most substance abuse screening and assessment instruments were developed and tested 

in male populations. Those working with 

female offenders should carefully review 

screening and assessment instruments to 

examine whether they have included content 

that is relevant to female offenders, such as 

information related to custody of children 

and parenting, history of physical and sexual 

abuse, and symptoms of trauma. Test instruments should be examined to determine if 

they were developed and normed using female 

populations, and if not, whether there are 

other instruments that may be more suitable 

Advice to the Counselor: 

Screening Specific Populations

• It may be necessary for a counselor to modify screening 

and assessment instruments to be sensitive to cultural 

and other differences. 

• Women respond differently to the screening process 

than men, and a longer, more flexible form is often useful to explore unanticipated areas that may arise. 

• Many adaptations have already been developed and validated. For instance, new versions of the ASI have been 

developed for use among American Indians and with 

women. 

• Counselors interested in modifying instruments should 

consult the research literature to identify new adapta 

tions or scales for existing instruments. 

for this population. One example of an instrument that has been tested with both male and 

female populations is the TCUDS II, which 

has been found to have good reliability for 

both genders (Knight 2001). Other screening 

instruments such as TWEAK have been 

developed specifically for women. 

Offenders With Co-Occurring 

Mental Disorders

As noted previously, specialized screening 

and assessment approaches are needed for 

offenders with co-occurring disorders. 

Integrated screening and assessment 

approaches should be used to determine the 

scope, symptoms, and consequences (e.g., 

level of cognitive and intellectual functioning) 

of mental and substance use disorders and to 

examine the relationship between these disorders and criminal behavior. Because of the 

high rates of co-occurring disorders among 

offenders in criminal justice settings, identification of a single disorder (i.e., either mental 

health or substance use) should immediately 

trigger screening for the other type of disorder. Somewhat longer periods of screening 

and assessment may be needed for offenders 

with cognitive deficits (e.g., limited attention 

span) related to their mental disorders. 

Counselors may need to allow 

breaks during interview sessions, 

move at a slower pace during the 

interview, and obtain collateral 

information to verify key information related to mental disorder symptoms, treatment and 

medication use, and interactive 

effects of co-occurring disorders. 

Depending on the criminal justice setting, screening may 

include a brief interview, use of 

self-report instruments, and 

review of archival records. A 

number of short self-report 

instruments are also available to 

examine the presence of mental 

disorder symptoms (Peters and 

38 Chapter 2 
Bartoi 1997). A mental status examination is 

also provided during many screenings for cooccurring disorders. In addition to examining 

key symptoms, mental health treatment history, and family history of mental disorder, it is 

helpful to assess the interactive effects of both 

disorders to determine whether there is an 

independent mental disorder, or if mental disorder symptoms are present only when the 

offender uses drugs or alcohol. 

Screening for suicidal thoughts and behavior 

should occur on an ongoing basis for all 

offenders with co-occurring disorders in the 

criminal justice system. This screening is particularly important for offenders with severe 

depression or schizophrenia and individuals 

who are experiencing stimulant withdrawal. 

Suicide screening should be conducted at the 

time of transfer to new institutions, or at different stages in the justice system (e.g., 

arrest, pretrial diversion, probation). All suicidal behavior should be taken seriously and 

assessed promptly to identify the types of services needed. For more information see TIP 

42, Substance Abuse Treatment for Persons 

With Co-Occurring Disorders (CSAT 2005c). 

Integrated Screening 

and Assessment— 

Sample Approaches

Programs often integrate a variety of screening 

and assessment instruments to place clients in 

the most appropriate treatment program. 

Several sample models of integrated screening 

and assessment implementations are described 

below. 

Colorado Department of 

Corrections (CDOC) 

Colorado has a unique screening and assessment approach applied to offenders in both 

prison and community settings. All inmates 

transferred to CDOC for supervision receive 

a comprehensive screening and assessment for 

substance abuse problems, including the 

Alcohol and Substance Use Screening and the 

Level of Service Inventory–Revised (LSI-R). 

Based on the instruments, an extensive treatment matching approach places offenders in 

correctional settings where intensity varies 

from no treatment to therapeutic communities. The treatment matching approach 

defines key criteria for admission to each 

level of correctional treatment services based 

on the history of involvement in correctional 

treatment, individual motivation, social support, living arrangements (if in noninstitutional settings), level of mental disorder and 

substance abuse symptoms, substance dependence symptoms, and other factors (O’Keefe 

2000). 

Florida Department of 

Corrections (FDOC) 

Florida has developed an integrated screening 

and assessment system for all inmates entering its reception centers. The system uses the 

SSI-SA coupled with a records review (e.g., 

referrals from drug courts, history of DUI or 

drug offenses, FDOC treatment history) and a 

self-report gathered from interviews during 

the reception process. Responses from the 

various sources are weighted and then used to 

determine the offender’s needed intensity of 

treatment and placement. Those inmates 

placed in services are administered a further 

assessment on transfer to a permanent institution, including the ASI and other psychosocial information. Key screening and assessment information is computerized and available to treatment, classification, and probation and parole staff (U.S. Department of 

Justice 1991). 

Jacksonville, Florida, Adult 

Drug Court Programs

This jurisdiction takes an integrated 

approach to screening and assessment that 

blends information from screening instruments, interviews, and archived records. For 

example, in the Jacksonville Adult Drug 

Court program, offenders are first interScreening and Assessment 39 
viewed and offered treatment by their attorneys and the public defender. After that, several steps are followed: 

1. Treatment Accountability for Safer 

Communities (TASC) screens every offender in the program (either in jail or in the 

TASC office) for the likelihood of substance abuse or dependency, using the 

agency’s screening form, coupled with a 

commercially available screen. 

2. For offenders with substance use disorders, the need for treatment is evaluated 

using section 1 of the American Society of 

Addiction Medicine (ASAM) Patient 

Placement Criteria, Second Edition, 

Revised (PPC-2R) (ASAM 2001). 

3. For offenders who need treatment, placement criteria are assessed with the other 

sections of the ASAM PPC-2R, which 

include prior treatment history; biomedical, emotional, and behavioral conditions 

and complications; treatment acceptance/ 

resistance; relapse and continued use 

potential, and recovery environment. 

4. For offenders placed in treatment, a DSMIV diagnosis is provided. 

All screening and assessment information, the 

offender’s treatment progress, and program 

evaluation and monitoring data are stored in 

an MIS that is available to drug court staff, 

including the drug court judge who can access 

key information such as recent drug test 

results during drug court status hearings. The 

MIS was developed by the drug court staff, 

court technology staff, and the City of 

Jacksonville. A juvenile MIS is being developed (Cooper 2002). 

Orange County, California, 

Drug Court Program

Orange County targets nonviolent offenders 

charged with possession or being under the 

influence of illicit drugs, first determining the 

offender’s eligibility and suitability for the 

Drug Court Program. To determine eligibility 

for the Drug Court Program, the district 

attorney’s office flags offenders charged with 

possession or being under the influence. 

Then, probation staff reviews prior arrest 

history and interviews the offender about 

substance abuse history and willingness and 

ability to comply with program requirements. 

Finally, clinical staff from the program’s 

treatment providers complete a screening 

interview. 

Eligible candidates are given a predetermined 

period of time in which to either plead guilty 

or opt into the treatment program. When 

candidates opt for treatment, suitability is 

then determined. This entails a full assessment, including a complete review of criminal 

history, the circumstances surrounding the 

charged offense, the results of any prior 

interactions with the criminal justice system, 

and a risk/needs assessment (with the 

National Institute of Corrections’ version of 

the LSI) to assess treatment needs and risk of 

reoffense. Finally, clinical staff conducts an 

ASI and a full psychosocial history to determine the offender’s motivation for treatment, 

desire for change, emotional stability, and 

ability to comply with program requirements. 

The program runs for 18 months, with 

reassessments every 6 months to re-evaluate 

risk/needs scores (again using the LSI). The 

new scores are then used by the Drug Court 

Team (e.g., clinical staff, judge) to adjust 

supervision and treatment strategies. 

Conclusions and

Recommendations

The consensus panel believes that the following are important points and recommendations about screening and assessment for 

criminal justice populations: 

•An effective screening and assessment 

approach will encourage appropriate referral of offenders to different levels of treatment and will reduce the likelihood that 

offenders are released to the community 

without treatment (see chapter 3 for related 

discussion). 

40 Chapter 2 
•Appropriate assessment for substance abuse 

treatment in criminal justice settings examines the substance abuse history, psychopathy and related risk factors, history of mental health problems, and other psychosocial 

areas that are affected by substance abuse. 

•Intensive treatment should clearly be 

reserved for offenders who have at least 

moderate substance abuse problems and at 

least moderate risk for criminal recidivism. 

Intensive treatment for low-risk offenders 

will have only a minor impact on reincarceration rates. However, there is still considerable work to be done to determine the 

most effective procedures for treatment 

matching with offenders. 

•Failure to identify incarcerated offenders 

who need postrelease treatment reduces the 

impact of positive change that occurred 

during correctional treatment. 

•Improved instruments and procedures for 

substance abuse screening and assessment 

will assist in matching offenders to appropriate postrelease treatment services. 

•Matching has not been consistently demonstrated to be effective, and only limited 

alternative approaches are available. 

•Because reports of offenders’ drug problems are incomplete or contain contradictory information, other collateral sources of 

information need to be obtained (e.g., drug 

test results, correctional records) that can 

be combined with self-report information to 

make referral decisions. For example, in 

many correctional facilities, drug tests are 

used to flag the need for treatment—even 

when an offender denies recent substance 

abuse. Similarly, criminal records may indicate substance abuse problems, based on a 

history of drug-related or DUI/DWI 

arrests, or presentence investigation 

results. 

•While most staff may conduct screenings, 

staff with appropriate training should provide assessments and related diagnoses and 

treatment plan recommendations. 

•Screening and assessment instruments vary 

considerably in their ability to detect substance use disorders and to provide information regarding other areas related to 

substance abuse. A range of substance 

abuse screening and assessment instruments 

have been validated for use with offenders, 

and some are available at relatively little 

expense. 

•The psychometric 

properties of A range of

substance abuse

screening and 

assessment instruments have been 

validated for use 

with offenders,

and some are 

available at

relatively little

expense.

screening and 

assessment instruments should be 

carefully reviewed, 

and choice of 

instruments based 

on demonstrated 

reliability and 

validity within 

substance abuse 

populations, and 

optimally, the utility of instruments 

in criminal justice 

settings. 

•A tiered screening 

and assessment 

approach could be 

developed in set-

tings in which several types of treat-

ment services are 

available. The initial screening 

includes a broad filter to detect those who 

have substance abuse problems, while the 

more intensive assessment reviews specific 

treatment needs and risk levels so that the 

offender can be assigned to an appropriate 

level of treatment. 

•Screening and assessment information 

should be obtained at each major point of 

transition within the criminal justice system 

(e.g., booking to jail, placement on probation). In some cases, relevant information 

can be obtained from previous stages in the 

system, for example through transfer of 

records from probation to institutional settings. 

Screening and Assessment 41 
•Offenders initially assessed with symptoms 

of co-occurring disorders should be evaluated over an extended period of time to examine whether these symptoms resolve in the 

absence of substance abuse. This reassessment should be conducted by staff members 

who understand patterns of symptom interaction among co-occurring disorders. 

•Screening and assessment for a prior history of physical and sexual abuse should be 

conducted routinely, particularly in settings 

that include large numbers of female 

offenders. Staff training is needed to develop effective interviewing approaches related 

to the prior history of abuse, counseling 

approaches in dealing with abuse and trauma issues, and in making referral to mental 

health services. 

•Memoranda of understanding and other 

formal agreements can be developed across 

different agencies working within the criminal justice system to promote sharing of 

screening and assessment information. Key 

information related to treatment progress, 

outcomes, diagnoses, and ancillary services 

needs should be communicated across different points in the criminal justice system. 

42 Chapter 2 
 

 

In This
 

Chapter... 

Treatment Levels and 

Components 

Potential Barriers to 

Triage and Placement 

Creating a Triage and 

Placement System 

Compiling Information To 

Guide Triage and 

Placement Decisions 

Conclusions and 

Recommendations 

3 Triage and

Placement in

Treatment Services

Overview 

Identifying offenders in need of substance abuse treatment is only the 

first step in providing help to these individuals. Because no single treatment has been shown to be effective for all offenders, effective matching 

to individual needs such as vocational or employment skills, family 

counseling, and mental health services improves the likelihood that the 

client will successfully complete treatment. Matching to specific treatment interventions also is cost-effective and improves the quality of services within existing programs. For example, offenders appropriately 

matched to either a high-structure, behaviorally oriented program or a 

low-structure counseling program consistently have significantly less 

severe problems and lower rates of substance abuse than those not 

appropriately matched to treatment programs. Finally, with only a limited number of available intensive treatment slots (e.g., residential services) in many criminal justice settings, offenders placed in these programs who do not need or desire intensive treatment may be disruptive 

or drop out of treatment prematurely, preventing others from benefiting 

from them. 

This chapter provides detailed information on how to best use the information obtained through screening and assessment in order to match 

the offender to appropriate treatment services. It begins by discussing 

three major treatment categories and outlines barriers to placement. A 

detailed discussion of triage and placement follows. 

Treatment Levels and Components
 The consensus panel believes that treatment matching in the criminal 

justice system is most effective when there is a continuum of services— 

ranging from low to high intensity. This section provides a brief description of treatment levels that may be available in criminal justice settings. The continuum of treatment levels includes three major treatment 

categories: pretreatment services, outpatient treatment, and inpatient 

treatment (including residential care). Several types of program services 

43 
Effectiveness of Treatment Levels—Results From the 

DATOS Study 

Results from the federally funded Drug Abuse Treatment Outcome Studies (DATOS) (Hubbard et al. 1997; 

Simpson et al. 2002) indicate that all major treatment levels (including long-term residential, short-term 

inpatient, outpatient, and outpatient methadone) are effective in reducing substance abuse and criminal 

activity. For example, reductions in weekly cocaine use from pretreatment to 1 year posttreatment followup 

ranged from 46 percent among short-term residential clients to 20 percent among outpatient methadone 

clients. Reductions in criminal activity from pretreatment to 1 year posttreatment followup ranged from 25 

percent among long-term residential clients to 8 percent among outpatient clients. 

Key findings and implications from the DATOS studies include the following: 

•All substance abuse treatment modalities are effective in reducing substance abuse and criminal activity. 

•Residential treatment programs of at least 3 months’ duration are particularly cost-effective for use with 

criminal justice clients. 

•Client readiness for and commitment to change and engagement and retention in treatment are important 

predictors of treatment outcomes. These factors, when routinely assessed by criminal justice programs, 

may be useful in targeting offenders who need more intensive services (e.g., intensive case management). 

•Measures of client engagement and treatment progress are good predictors of dropout from treatment. 

When routinely assessed, these predictors can help identify clients who require specialized interventions 

(e.g., peer mentors, motivational enhancement therapies, individual counseling) to sustain their involvement in treatment. 

•Involvement in posttreatment peer support activities is helpful in preventing relapse. Clients are more 

likely to engage in ongoing peer support groups if they begin these activities during treatment. 

•Among clients with prior treatment experience, outcomes are more dependent on the quality of relationships with treatment counselors than are outcomes for first-time clients (Franey and Ashton 2002). 

often are available within each treatment 

level. As the text box above indicates, 

research suggests that all major treatment 

levels are effective. Nonetheless, the consensus panel believes that clients should be 

matched not only on the intensity of services 

they need, but also on the particular components that are responsive to their individual 

needs. 

Pretreatment Services

Pretreatment services, which are not part of 

primary treatment, include primary prevention, early intervention, and detoxification. 

Primary prevention and early intervention are 

not typically used in criminal justice settings. 

•Primary prevention. These are services for 

people who have not used substances. Most 

primary prevention programs are in schools 

or the community. 

•Early intervention. This includes psychoeducational programs for those who have used 

substances and are considered to be at high 

risk for substance-related problems or have 

a history of substance abuse. Other interventions include screening and assessment 

to identify substance abuse problems. Brief 

interventions also are appropriate for 

offenders who use substances but who do 

not meet the diagnosis of having a substance 

use disorder. For example, ongoing evaluation can help determine if referral to a 

more intensive level of care is needed. In 

some instances, early intervention can be 

used as short-term treatment for individuals with low-severity substance abuse problems. 

44 Chapter 3 
•Detoxification. Medically supervised detoxification services are required for offenders 

whose alcohol or drug abuse has caused 

severe and life-threatening symptoms (e.g., 

acute intoxication, blackouts). Although 

detoxification typically is conducted prior 

to the onset of substance abuse treatment, it 

is important to provide a thorough assessment during detoxification and to provide 

orientation to the recovery and treatment 

process. For more information, see chapter 

2 of this TIP and the forthcoming TIP 

Detoxification and Substance Abuse 

Treatment (Center for Substance Abuse 

Treatment [CSAT] in development a). 

Outpatient Treatment 

Also referred to as ambulatory care, outpatient 

treatment provides a broad range of services 

without overnight accommodation and includes 

nonintensive and intensive outpatient treatment, methadone treatment, and day treatment 

or partial hospitalization. Some of these services can be provided following inpatient or 

residential treatment, or as followup care after 

involvement in a residential program. 

•Nonintensive outpatient treatment. This is 

substance abuse treatment that includes 

professional assessment and treatment 

involving less than 9 hours per week in regularly scheduled sessions. Nonintensive outpatient treatment often addresses related 

psychiatric, emotional, and social issues, 

and offers a forum to explore issues such as 

the relationship between violence and mental disorders. Nonintensive outpatient treatment also can accommodate clients with job 

or family responsibilities, as treatment services may be offered on weekends or 

evenings. 

•Intensive outpatient treatment. This is substance abuse treatment with professional 

assessment and treatment from 9 to 20 

hours per week in a structured program. 

These programs can be held on evenings or 

weekends. (For more information see the 

forthcoming TIPs Substance Abuse: 

Clinical Issues in Intensive Outpatient 

Treatment [CSAT in development d] and 

Substance Abuse: Administrative Issues in 

Intensive Outpatient Treatment [CSAT in 

development c].) 

•Methadone treatment. This is a medically 

supervised outpatient treatment that provides counseling while maintaining the 

client on the drug methadone. This regimen 

is used primarily for heroin or other opioid 

addiction and provides a legitimate, closely 

monitored substitute for illicit drugs. The 

client must be able to document at least a 2­

year history of addiction to qualify for a 

methadone treatment program. It is rarely 

used with those who are incarcerated. (For 

more information see TIP 43, MedicationAssisted Treatment for Opioid Addiction 

in Opioid Treatment Programs 

[CSAT 2005a]). 

•Day treatment or partial hospitalization. 

This is substance abuse treatment with professional assessment and treatment of more 

than 20 hours per week in a structured program. This is the most intensive of the outpatient treatment options and can be used 

for treating clients who demonstrate the 

greatest degree of dysfunction but who do 

not require inpatient or residential treatment. Evening and weekend programming 

often is included. 

Inpatient Treatment and

Residential Care 

Inpatient treatment options include intensive 

medical, psychiatric, and psychosocial treatment provided on a 24-hour basis. The continuum of residential care includes psychosocial 

care at the most intensive end and group living 

with no professional supervision at the least 

intensive end. It is unlikely that the full range 

of services will be available in any one community. 

•Intensive residential treatment. This longterm treatment can be directed by a substance abuse treatment professional or 

could be medically directed. Intensive residential treatment is appropriate for people 

Triage and Placement in Treatment Services 45 
with multiple problems, especially those 

with co-occurring mental and substance use 

disorders (COD). Psychosocial rehabilitation is always a goal of treatment. The 

duration of treatment in this setting varies 

considerably, from 3 months to as long as 2 

years. 

•Therapeutic community (TC). The traditional TC is a long-term (15 to 24 months) 

rehabilitative model that is often staffed by 

recovering professionals, treatment and 

mental health professionals, and vocational 

and educational counselors. Therapeutic 

help from the residential community 

paves the way for 

residents to recover 

Accurate 

screening and 

assessment are 

necessary for 

effective 

placement. 

from their substance abuse problems and to develop 

the vocational, educational, and social 

skills they need to 

become productive 

members of society. 

Most TC residents

have been involved 

with the criminal

justice system. The 

theory and practice 

of the TC have been 

detailed in the literature (De Leon 2000), and the effectiveness 

of these programs has been documented 

both in prisons and in community-based 

settings (Melnick et al. 2001). A 2-day training course offered by the Mid-America 

Addiction Technology Transfer Center in 

Kansas City, Missouri, is available. This 

course consists of lectures, small groups, 

and instructional materials on the TC 

model and how it works. For more information go to http://www.attcNETWORK.org/. 

•Psychosocial residential care. This longterm (6 to 24 months) psychosocial care 

model has elements similar to the therapeutic community model in that it relies heavily 

on peer pressure as well as formal treatment to shape behavior. It is appropriate 

for people with substance abuse problems 

and concomitant disorders that do not 

require acute medical or psychiatric intervention. People compliant with psychiatric 

and other prescription medications are 

appropriate for this level of care. The focus 

of care is on psychosocial rehabilitation. 

•Medically monitored intensive inpatient 

treatment. This level of care involves 

around-the-clock medical monitoring, 

assessment, and treatment in an inpatient 

setting, usually by a nurse or nurse practitioner. It is used for clients who have acute 

and severe substance use disorders and who 

may also have a coexisting medical or psychiatric disorder. Such treatment generally 

involves a short to intermediate length of 

stay (7 to 45 days) and may include nonmedical or social model programs with variable lengths of stay. 

•Medically managed intensive inpatient 

treatment. This level of care involves 

around-the-clock, medically directed evaluation and treatment in an acute-care inpatient setting, usually by a medical doctor. 

This level of care is appropriate for the 

treatment of medical and psychiatric problems that may require biomedical treatment 

(such as life support) or secure services 

(such as locked units). Such treatment generally involves a short to intermediate 

length of stay (7 to 45 days). 

•Short-term nonhospital intensive residential 

treatment. This treatment is generally 21 to 

45 days in length and is designed to teach 

the client how to live a substance-free life 

and to provide motivation for the maintenance of such a lifestyle. Follow-up care on 

an outpatient basis and continued participation in peer support groups is recommended to maintain the recovery process 

begun in the residential setting. 

•Halfway house. Residents are expected to 

follow house rules and share house responsibilities in a residential setting under staff 

supervision. Residents generally find their 

46 Chapter 3 
 

own way to outside activities (e.g., work, 

court, counseling, vocational training, and 

schooling). The house sometimes offers 

treatment services. Length of stay is limited 

or unlimited depending on the attainment of 

specific progress goals. 

•Group home. This refers to a residential, 

transitional living situation without any specific treatment plan and minimal staff 

supervision. It is sometimes known as a 

three-quarter-way house. Residents may 

work and receive education, training, or 

treatment in the community. House residents generally decide on admission of new 

residents. House responsibilities are 

shared, and the house is governed and run 

by its residents. The length of stay is 

generally unlimited as long as abstinence 

from substances is maintained; the Oxford 

House model includes complete resident 

self-governance and self-sufficiency. The 

key to success in all such models is that the 

living situation is substance free, which supports abstinence among residents. 

Potential Barriers to 

Triage and Placement 

Inadequate Screening and

Assessment 

Accurate screening and assessment are necessary for effective placement. However, 

resources, adequate time to conduct comprehensive assessments, and trained staff are not 

always available in criminal justice settings. As 

a result, substance abuse treatment in criminal 

justice settings often is based on sparse and 

inadequate information (Knight et al. 2002). 

Competing Demands in

Institutional Settings

A challenge for substance abuse treatment 

programs in institutional settings is the competing demands on offenders’ time. For example, a prison’s need for labor to fulfill its contracts and maintain itself can compete with an 

offender’s needs for treatment. Or, inmates 

could be assigned to institutional education 

programs. In addition, there are also competing demands for treatment. Treatment service 

options often are limited and waiting lists 

exist for most services in community-based 

programs. The community-based system of 

care across the country largely is funded to 

provide services to a nonoffender population. 

In some cases, prioritization of community 

treatment services for offenders has placed a 

strain on the limited number of available 

treatment slots. 

Information Flow 

Issues regarding the transfer of information 

across different settings in the criminal justice 

system present a major barrier to effective 

placement in offender treatment services. For 

example, this might include a need for a centralized database that can be accessed by various providers as offenders move through the 

system. 

Creating a Triage and

Placement System

The consensus panel believes that to ensure 

appropriate treatment for offenders who 

abuse substances, the offender’s needs and 

available resources must be balanced. 

Coordination of treatment matching within 

the criminal justice system can reduce the 

long-term costs of incarceration and other 

criminal justice functions only if adequate 

personnel and funding are available for case 

management. Ongoing planning and coordination among criminal justice staff, substance 

abuse treatment staff, and policymakers and 

other stakeholders is important to establish 

an effective treatment matching system. 

Based on the experiences of consensus panel 

members, the optimal approach would be to 

assemble a team consisting of correctional/ 

supervision and clinical staff to develop a 

triage and placement system and to assume 

Triage and Placement in Treatment Services 47 
responsibility for compiling and processing 

treatment matching information. Once the 

triage and placement system has been developed, the team can review cases referred to 

treatment, transfers, and placement in high 

intensity or specialized treatment programs 

(e.g., co-occurring disorders services). 

This coordinated approach also can ensure 

that ongoing troubleshooting occurs to adjust 

eligibility criteria, to check admission and 

transfer procedures, and to monitor reentry 

to the community. Although triage and placement teams do not necessarily meet on a daily 

basis, they are regularly involved in reviewing 

offenders’ placement status and decisions to 

place or transfer offenders to different program settings. Scoring criteria for assigning 

offenders to different levels of treatment often 

are developed by clinical staff with significant 

involvement and review by criminal justice 

staff (e.g., classification officers). Use of scoring criteria and development of a triage and 

placement database are useful for document 

standardization and treatment provision 

across different groups of offenders. 

Following are key triage and placement activities that the consensus panel believes 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 (for more

information on confidentiality, go to

http://www.hhs.gov/ocr/privacy/ and see CSAT 

2004) 

•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

•Determining offenders’ eligibility for and

access to health, mental health, and social

services in the community

Triage and Placement 

Strategies

Triage and placement strategies for offender 

treatment programs depend on the range and 

type of services available, specific eligibility 

requirements attached to various programs, 

and the resources available to manage this 

process. In some criminal justice settings 

(e.g., jails) only limited types of services are 

available, such as 12-Step groups or a more 

intensive treatment program. In these settings, 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 for the program. This 

often is accomplished by a single staff member and through a combination of self-administered tests, brief interview, and records 

review. 

In settings that feature a range of treatment 

services, triage and placement are usually 

lengthier, often involving 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. The consensus panel recommends 

that in general, the sophistication of a treatment matching system should reflect the 

48 Chapter 3 
•Range of different levels of treatment intensity available 

•Scope of information needed to determine eligibility for admission to the various levels of 

treatment 

•Consequences for “mismatching” offenders to 

the different levels of treatment 

Under most conditions, triage and placement 

decisions are guided by the need to reserve 

program slots for offenders with more severe 

substance abuse problems and who present at 

least moderate risk for criminal recidivism 

(see Figure 3-1, next page). Research indicates that treatment programs targeting 

offenders with moderate to high risk for 

recidivism produce the greatest posttreatment 

reductions in recidivism and are more costeffective (Andrews et al. 1990; Bonta 1997; 

Gendreau 1996). 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. In summary, offenders with more severe addiction problems and 

more significant risks for criminal recidivism 

do not experience positive treatment outcomes unless they are placed in highly structured and intensive treatment programs. 

Conversely, assigning low-severity offenders 

to these high-intensity programs often is inefficient and counterproductive for people who 

use drugs casually, who are then 

exposed to the corrosive effects 

of more seasoned offenders with 

pronounced criminal attitudes, 

beliefs, and lifestyles. 

Compiling Information

To Guide Triage and

Placement Decisions

Screening and assessment are discussed comprehensively in chapter 2. This section outlines 

how to use information derived from screening 

and assessment to make triage and placement 

decisions. 

As described in Figure 3-1, placement and 

triage strategies in criminal justice settings 

often use a tiered approach. In the first stage 

of this process (screening and assessment), 

attempts are made to identify major mental 

health problems or psychopathy that would 

interfere with involvement in substance abuse 

treatment. If one of these problems is identified, the offender can be directly routed to a 

specialized treatment or management unit/ 

program. This tiered approach enables criminal justice staff to quickly identify offenders 

who are not good candidates for substance 

abuse treatment and prevents unnecessary 

substance abuse screening and assessment for 

offenders who would perform poorly in existing substance abuse programs. 

If a range of offender treatment options is 

available, placement in services usually is 

determined by the following factors: 

• Risk for criminal recidivism 

Advice to the Counselor: 

Triage and Placement 

• Measurements of client readiness for change, commit 

ment to change, and engagement in treatment are 

important predictors of treatment outcomes. 

• In settings with limited services available, elaborate 

triage systems are unnecessary and placement often can 

be determined with a brief interview of the offender, 

some self-administered tests, and a records review. 

• Accurate screening and assessment are necessary for 

effective triage and placement in the face of competing 

demands for resources. 

Triage and Placement in Treatment Services 49 
Figure 3-1 

Placement and Triage Strategies 

Source: Zimmerman 2000. 

•Level of offender needs for substance abuse, 

mental health and other psychosocial or medical services, and employment 

•Offender motivation and readiness for treatment 

•Other offender characteristics including cognitive and intellectual abilities, abilities to 

read and write, and related abilities to communicate in individual and group settings 

and to withstand stress in highly intensive 

therapeutic communities 

Research indicates that treatment programs 

that place individuals in services according to 

these areas are likely to enhance outcomes for 

offenders (Andrews et al. 1990; Gendreau 

1996). The following sections discuss each of 

50 Chapter 3 
these areas in relation to triage and placement services, identify information sources 

necessary for placement, and list instruments 

that can be used to compile the information. 

For more information on the instruments listed, see chapter 2 and appendix C. 

Risk for Criminal Recidivism

Assessment of the risk for future criminal 

and/or violent behavior is of vital importance 

in the process of assigning offenders to treatment programs within the criminal justice 

system. Offender characteristics and environmental factors used to estimate the likelihood 

of future criminal behavior are termed “risk 

factors.” (See chapter 2 for information on 

identifying risk factors.) 

Once criminal risk factors are identified, 

research indicates that structured and intensive cognitive–behavioral approaches can 

address offenders’ “criminogenic needs” 

related to their dynamic risk factors (those 

that are likely to change over time) (Andrews 

and Bonta 1998; Wanberg and Milkman 

1998). Andrews and Bonta (1998) have identified several promising targets for treatment 

intervention based on dynamic risk factors: 

•Developing and improving life management, 

problemsolving, and self-control skills 

•Developing associations or relationships and 

bonding with prosocial and anticriminal 

peers and with prosocial and anticriminal 

role models 

•Enhancing closer family feelings and communication 

•Improving positive family structures to promote monitoring 

•Managing and changing antisocial thoughts, 

attitudes, and feelings 

In general, offenders who are at high risk for 

criminal recidivism require more structured 

and intensive treatment interventions such as 

intensive outpatient treatment, day treatment, residential treatment, or TCs, while 

low-risk offenders are better suited for lowintensity interventions such as outpatient 

treatment, drug education, and peer support 

or 12-Step programs (see Figure 3-1) (Falkin 

et al. 1999). 

Information needed for 

triage and placement 

•Criminal history, including age at first 

arrest, number and type of prior arrests, 

history of violence and aggressive behavior, 

history of incarceration, probation and/or 

parole revocations 

•Age, education, marital status, employment 

history 

•Characteristics of psychopathy, including 

entitlement, impulsivity, superficial interpersonal relationships, lack of empathy, 

sensation seeking, poorly controlled anger 

•Nature of offender’s family and social network (prosocial versus procriminal) 

•Other personality disorders, including 

paranoia 

Instruments used to compile 

this information 

Use of some of these instruments is described in 

chapter 2. 

•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 

•Personality Assessment Instrument (PAI) 

•Novaco Anger Inventory 

•Jesness Inventory 

•Paulus Deception Scale 

•Inventory of Sensation Seeking 

Triage and Placement in Treatment Services 51 
Level of Substance Abuse 

Problems

Offenders with current alcohol or drug 

dependence and a history of chronic substance use generally require more structured 

and intensive levels of treatment (Knight et 

al. 1999b; Simpson et al. 1999a). There is 

some evidence that highly structured treatment approaches that use a cognitive–behavioral orientation are more effective for 

offenders with pronounced substance abuse 

problems, in comparison to less structured 

client-centered approaches that use nondirective, supportive counseling strategies 

(Thornton et al. 1998). Offenders who have 

less serious substance abuse problems are 

likely to benefit from a variety of treatment 

options across a range of modalities and levels 

of intensity (Knight et al. 1999b; Simpson et 

al. 1999b). 

Information needed for 

triage and placement 

•Substance dependence symptoms 

•Substance abuse-related arrests (e.g., driving 

under the influence [DUI]/driving while 

intoxicated [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 used to compile 

this information 

Use of these instruments is described in 

chapter 2. 

• Addiction Severity Index (ASI) 

• Simple Screening Instrument for Substance 

Abuse (SSI-SA) 

•Texas Christian University Drug Screen 

(TCUDS) 

•Alcohol Dependency Scale (ADS) 

Level of Mental Health

Problems

Offenders with co-occurring mental disorders 

have participated successfully in many substance abuse treatment programs in criminal 

justice settings, although they generally have 

more pronounced difficulties in employment, 

family relationships, and physical health 

(Peters et al. 1992) and sometimes have cognitive deficits related to their mental disorders. 

Although offenders with co-occurring substance use and mental disorders present 

unique challenges, their ability to participate 

in treatment programs varies according to 

their functioning level in several key areas, 

including the ability to sustain attention and 

to participate in individual and group interactions, their vulnerability to emotional conflict, and the presence of acute symptoms 

(e.g., paranoia, delusions). As a result, triage 

should include a mental health assessment to 

examine the potential effects of mental health 

problems on their participation in available 

treatment programs. Even moderate to high 

levels of mental disorders can be accommodated in many criminal justice treatment programs, particularly those with mental health 

and other health services staff available, and 

that feature specialized treatment services for 

people with co-occurring disorders (Edens et 

al. 1997). 

Information needed for 

triage and placement 

• Acute mental disorder symptoms that can 

influence the offender’s ability to participate in individual or group treatment settings 

•Suicidal or other violent behaviors 

•Cognitive and interpersonal or social 

impairment caused by current mental disorder symptoms, specifically related to atten52 Chapter 3 
tion and concentration, problemsolving 

skills, interpersonal skills, and frustration 

tolerance 

•Effects of stress and other environmental 

influences on mental disorder symptoms 

and related behavioral problems 

•Likelihood of recurrence of mental disorder 

symptoms and behavioral problems given 

environmental conditions in available treatment programs 

•Accommodations available in existing treatment programs to address mental disorder 

symptoms and behavioral problems 

Instruments used to compile 

this information 

Use of these instruments is described in chapter 2. 

• Minnesota Multiphasic Personality 

Inventory (MMPI) 

• Millon Clinical Multiaxial Inventory—III 

(MCMI-III) 

• Symptom Checklist 90-Revised (SCL90-R) 

• Brief Symptom Inventory (BSI) 

Offender Motivation and

Readiness for Change 

The offender’s motivation and readiness for 

treatment is another key factor in triage for 

placement in substance abuse treatment. 

Motivation and readiness for change are 

important predictors of treatment compliance, dropout, and outcome, and this information is vital (Ries and Ellingson 1990). 

Treatment is likely to be ineffective until individuals accept the need for treatment of their 

substance abuse as well as other related 

problems. 

An offender’s motivation to participate in 

treatment is influenced by justice system 

sanctions and incentives, including court 

orders to complete treatment, probation revocation, more intensive mandatory treatment, 

“good time” credit for involvement in correctional treatment, and incarceration in jail or 

prison. Offenders also may be motivated by 

negative consequences outside the justice system, including threats to stable housing, 

employment, family, and marriage (Ziedonis 

and Fisher 1994). 

However, the consensus panel cautions that 

assessments of motivation and readiness for 

change that occur outside clinical settings can 

misidentify significant numbers of 

offenders who could The offender’s 

motivation and

readiness for 

treatment is a key 

factor in triage for

placement in

substance abuse

treatment.

benefit from 

involvement in substance abuse treatment. Many offenders who initially 

appear unmotivated 

can quickly become 

engaged in treatment through peers 

who are committed 

to recovery and who 

are actively involved 

in treatment. 

Involvement in 

group counseling 

and contact with 

program participants and staff can 

stimulate motivation for change in the previously unmotivated offender. 

Motivation for treatment changes over time, 

and offenders often cycle through several predictable stages of change during the treatment 

and recovery process. The stages of change 

model has been developed to describe recovery from various types of addictive disorders 

(Prochaska et al. 1992), and includes the following stages: 

• Precontemplation (unawareness of substance 

abuse problems) 

• Contemplation (awareness of substance abuse 

problems) 

Triage and Placement in Treatment Services 53 
• Preparation (decision point) 

• Action (active behavior change) 

• Maintenance (ongoing preventive behaviors) 

Offenders who are in the precontemplation 

stage of change have little awareness of substance abuse (or other) problems and have 

few intentions of changing their behavior. 

Awareness of problems increases in later 

stages, as the individual begins to consider 

the goal of abstinence. However, due to the 

chronic relapsing 

nature of substance 

use disorders, Matching 

offenders to 

treatment services 

that are 

appropriate to the 

current stage of 

change is likely to 

enhance treatment 

compliance and 

outcomes. 

movement through 

stages of change is

not a linear process, 

and offenders often 

return to earlier 

stages of change 

before achieving 

sustained abstinence. 

Assessments of

offenders’ motivation for treatment

and their current 

stage of change are

useful in matching 

to different types of 

treatment and to 

developing treatment plans. For 

example, matching 

offenders to treatment services that 

are appropriate to the current stage of change 

is likely to enhance treatment compliance and 

outcomes. Conversely, for offenders who are 

in the early stages of change, placement in 

treatment that is too advanced and that does 

not address ambivalence regarding behavior 

change may lead to unsuccessful termination 

from treatment. For individuals in the later 

stages of change, placement in services that 

focus primarily on early recovery issues also 

may lead to unsuccessful termination from 

treatment. Several considerations are provided in chapter 5 regarding matching treatment 

services to the offender’s stage of recovery. 

For more information, see TIP 35, Enhancing 

Motivation for Change in Substance Abuse 

Treatment (CSAT 1999b). 

Information needed for 

triage and placement 

• Perceived severity of drug and alcohol 

problems 

• Interest in making changes in drug and 

alcohol use 

• Steps that have been taken by the offender 

toward abstinence from alcohol or drugs 

• Perceived importance of receiving substance abuse treatment 

Instruments used to compile 

this information 

• Circumstances, Motivation, Readiness, and 

Suitability Scale (CMRS) (De Leon and 

Jainchill 1986; DeLeon et al. 1994) 

• Stages of Change Readiness and Treatment 

Eagerness Scale (SOCRATES) 

• University of Rhode Island Change 

Assessment Scale (URICA) (DiClemente and 

Hughes 1990) 

Examples of Triage and

Placement Approaches

The consensus panel thought that the following 

three examples demonstrated effective use of 

triage and placement strategies. 

Florida Department of 

Corrections 

The Florida Department of Corrections has 

operationalized a multilevel triage process to 

refer inmates to substance abuse treatment 

programs. This process involves the following 

steps: 

54 Chapter 3 
• Review by classification staff to examine 

sentence structure, prior arrests, and correctional history. 

• Brief screening for substance abuse problems and dependence symptoms using a 

modified version of the SSI-SA. 

• Personal interview. 

• Determination of the need for treatment 

based on the substance abuse screening, the 

history of drug or alcohol offenses, prior 

history in correctional treatment, recommendations by drug courts or other sentencing courts, and staff or self-reported 

referral for treatment. 

• Assignment of a “priority score” for substance abuse treatment, based on the substance abuse screening score, the number of 

prior substance abuse offenses, number of 

prior correctional treatment episodes, positive drug test results, and counselor interview results. 

• Routine identification of inmates prioritized 

for substance abuse treatment through 

“flags” initiated within the computerized 

database. 

Several of the components contributing to the 

priority score are weighted, including recommendations for treatment from drug courts or 

other sentencing courts, DUI manslaughter 

convictions, and unsuccessful termination 

from community corrections residential treatment programs. The inmate priority score is 

entered on a computerized database. Inmates 

with high priority scores are then transferred 

to facilities with substance abuse treatment 

programs, where an additional substance 

abuse screening and interview is conducted. 

Priority placement in intensive treatment services is provided for inmates with at least 12 

to 18 months remaining on their sentence. 

Megargee and Case 

Management Classification 

Systems 

Correctional systems have long used a variety 

of typologies to match clients to treatment 

and supervision approaches in institutional 

and community settings. These typologies 

usually are based on a combination of criminal history variables and psychosocial characteristics. One example of a multidimensional treatment matching system is the Megargee 

System, which is based on an extensive analysis of Minnesota Multiphasic Personality 

Inventory (MMPI) responses given by a large 

sample of Federal prison inmates. Ten distinctive profile types have been identified, 

each with varying treatment implications that 

range from recommended placement in the 

least restrictive setting to placement in specialized mental health facilities (Vigdal and 

Stadler 1996). 

The Case Management Classification (CMC) 

system was developed by the Wisconsin 

Department of Corrections. Based on an 

offender’s responses to a 45-minute 

semistructured interview, four categories are 

used to determine treatment assignment within the correctional system: 

1. Selective intervention for offenders who 

have led relatively stable, prosocial lives. 

The current offense resulted from an isolated stressful event and represents a temporary lapse. 

2. Environmental structure for offenders lacking social and vocational skills who are typically led by others into criminal activity. 

3. Casework control for offenders with very 

unstable lives who are actively involved with 

drugs or alcohol and have a number of 

prior arrests. 

4. Limited setting for offenders with long-term 

criminal involvement and who are comfortable with their criminal lifestyle and strive 

for success through criminal activity. 

Triage and Placement in Treatment Services 55 
ASAM Patient Placement 

Criteria 

One approach that has been developed to 

assist in triage and placement decisions for 

substance abuse treatment services is the 

revised version of the American Society of 

Addiction Medicine (ASAM) Patient 

Placement Criteria (PPC-2R) for the 

Treatment of Substance-Related Disorders, 

Second Edition, Revised (ASAM 2001). These 

criteria provide guidance for substance abuse 

counselors and other treatment staff in determining the best “match” between client characteristics and several levels of treatment services. An interview format of the ASAM PPC2R is under development for use in clinical 

settings. Within the ASAM approach, treatment matching is facilitated for several different levels of treatment, including the following: 

•Level 0.5—Early intervention 

•Level 1—Outpatient treatment 

•Level 2—Intensive outpatient treatment/partial hospitalization 

•Level 3—Residential/inpatient treatment 

•Level 4—Medically managed intensive inpatient treatment 

Client characteristics are described across six 

dimensions for each level of treatment. Within 

each of these dimensions, the client characteristics described are intended to reflect a good 

“match” between client needs and the treatment setting. Dimensions of client characteristics in the ASAM-PPC-2R system are 

1. Alcohol intoxication and/or withdrawal 

potential 

2. Biomedical conditions and complications 

3. Emotional, behavioral, or cognitive conditions and complications 

4. Readiness to change 

5. Relapse, continued use, or continued problem potential 

6. Recovery environment 

The ASAM approach, or similar dimensional 

matching strategies, may be useful for substance abuse treatment staff within criminal 

justice settings. Although the ASAM criteria 

have not yet been formally adapted for 

offender populations, the PPC-2R could 

prove helpful in providing a structured vehicle for determining which offenders would 

benefit from different levels of treatment 

intensity, structure, and supervision. One 

additional dimension that could be useful to 

incorporate in criminal justice adaptations of 

the ASAM PPC-2R is the risk for criminal 

recidivism. Levels of treatment services specified within the ASAM criteria would also need 

to be tailored to specific types of criminal justice settings (e.g., drug courts, restitution or 

day treatment centers, in-jail and in-prison 

settings), with additional client–offender 

dimensional criteria developed for each of 

these new settings. Although this adaptation 

process would require some attention, there is 

likely to be significant overlap between 

client–offender dimensional criteria for these 

new settings (e.g., drug courts), and existing 

ASAM criteria for various settings (e.g., 

intensive outpatient treatment, therapeutic 

communities). 

Conclusions and

Recommendations

The consensus panel recommends that several 

key points be considered when developing a 

triage and placement system for substance 

abuse treatment in the criminal justice system: 

• An effective triage and placement system 

should be developed to ensure adequate 

training and availability of staff to conduct 

assessments. 

• In general, offenders who have significant 

risk for substance abuse and criminal 

recidivism should be prioritized for initial 

placement in substance abuse treatment 

services, rather than in other institutional 

programs (e.g., educational or 

vocational/employment services). These 

offenders should be referred to intensive 

56 Chapter 3 
treatment programs (e.g., day treatment, 

intensive outpatient, residential services). 

• Mental disorder symptoms and impairment 

should be carefully considered in determining placement in substance abuse treatment 

services. The functional ability of inmates 

should be the central concern in triage and 

placement decisions, rather than mental 

disorder diagnoses. 

• A centralized substance abuse treatment 

database should be created to organize 

results from screening and assessment, to 

help coordinate the triage and placement 

process, and to track offender progress in 

treatment. 

• In addition to key information regarding 

substance abuse problems, risk for criminal 

recidivism, and mental health problems, 

triage and placement decisions also should 

consider the offender’s motivation and 

readiness for treatment, the length of sentence/incarceration, prior history in treatment, violence potential, and other related 

security and management issues. 

• A centralized database that provides timely 

information on offenders as well as the 

availability of services should be developed 

to improve triage and placement. 

Triage and Placement in Treatment Services 57 
In This
 Chapter... 

Assessing the Severity of 

Substance Use Disorders 

Assessing the Severity of 

Co-Occurring Disorders 

Criminality and 

Psychopathy 

Client Motivation and 

Readiness for Change 

Implementing an Effective 

Treatment Planning 

Process 

Conclusions and 

Recommendations 

4 Substance Abuse 

Treatment Planning 

The good treatment plan is a comprehensive set of tools and strategies 

that address the client’s identifiable strengths as well as her or his problems and deficits. It presents an approach for sequencing resources and 

activities, and identifies benchmarks of progress to guide evaluation. 

—Center for Substance Abuse Treatment (CSAT) 1994d, p. 21 

Overview 

While screening and assessment identify the offender’s need for substance abuse and other treatment services, and triage and placement 

services match the offender to the proper treatment, the treatment plan 

is where the information gathered is used to put treatment into practice. 

A treatment plan is a map specifying where clients are in recovery from 

substance use and criminality, where they need to be, and how they can 

best use available resources (personal, program-based, or criminal justice) to get there. At a minimum, the treatment plan serves as a basis of 

shared understanding between the client and treatment providers. 

Clients learn what is expected of them in program commitments and 

attendance. 

There are many approaches to treatment planning, but they possess 

some basic commonalities; this chapter discusses each in further detail. 

The severity of substance abuse-related problems must be determined, 

since this is the basis for appropriate placement in a treatment program. In addition, the presence of co-occurring mental disorders must 

be assessed because these may limit the type of treatment approach and 

identify the need for psychiatric care. Also important is assessing factors such as procriminal attitudes and psychopathy that may suggest 

persistent criminality unrelated to substance abuse. The degree to 

which the individual is motivated to change behavior and lifestyle is 

another critical factor that has a bearing on whether motivational 

enhancement interventions, sanctions, or more self-directed treatments 

are appropriate. Finally, offender-clients should be involved in developing their treatment plan so that they can be referred to appropriate services in the community. 

59 
 

Assessing the Severity

of Substance Use 

Disorders

Treatment planning within the criminal justice system requires a comprehensive assessment of an offender’s substance abuse history 

and patterns of use, including drug(s) of 

abuse, chronological patterns of use, specific 

reasons for use, consequences of use, and 

family history of drug and alcohol abuse. 

Often treatment involvement within the criminal justice system is based primarily on a conviction or plea to a drug-related offense. 

Although the number and type of substancerelated charges is sometimes a fairly good 

indicator of substance abuse and related 

problems, the offense category alone is not a 

foolproof indicator of treatment need or of 

appropriateness of referral to a specific program. The presence of intoxicants in blood or 

urine at the time of arrest is a better, albeit 

imperfect, indicator. 

Using multiple indicators for assessing the 

severity of a substance use disorder is important because individuals with few substancerelated problems typically do not respond 

favorably to intensive treatment and fail to 

identify with the process of recovery. Close 

association with more severely affected 

offenders can result in the less-severe offender becoming socialized into a criminal and 

drug-oriented lifestyle through contagion of 

attitudes and introduction to a criminal social 

network. Minimally, an assessment of severity 

should focus on determining the impact of use 

on the individual’s community adjustment. 

Usually this also entails taking a drug history 

that inquires about the frequency, dosage, 

and types of drugs used. A drug history may 

also inquire about the times at which, or settings in which, an offender uses. 

Assessment of the severity of a substance use 

disorder may lead to an actual diagnosis of a 

substance use or dependence disorder. 

However, most offender treatment programs 

consider routine use of illicit drugs without a 

diagnosable disorder to be a legitimate focus 

for treatment, since any use is illegal and may 

result in arrest or violations of community 

supervision guidelines. Also, most settings 

lack the qualified staff and time required to 

make formal diagnoses, and clients are sometimes in the setting for too short a time to 

delay treatment while awaiting formal diagnosis of a substance use disorder. In these settings, clinical impressions are more feasible 

than are formal diagnoses, and common 

sense, assisted where possible by standardized assessment instruments, should prevail 

in deciding whether and how to provide treatment services. Fortunately, several standardized instruments with good psychometric 

properties are available in the public domain, 

or at low cost, for the purpose of screening 

and assessment of substance use severity (see 

chapter 2). 

Assessing the Severity

of Co-Occurring 

Disorders

Another important area to assess in developing a treatment plan is the presence and 

impact of psychological and emotional problems, particularly those that are not the 

direct result of substance abuse. Offenders 

with severe substance use disorders have relatively high rates of affective disorders, anxiety disorders, and personality disorders. 

These disorders can contribute to the development of substance use problems, or the 

emotional disorders may develop as a consequence of the physiological effects of longstanding drug use and the stressful or traumatic life events that are often experienced as 

part of a lifestyle in which drug use plays a 

central role. Some individuals have mental 

health problems prior to intake; others develop them during adjudication, incarceration, 

or community supervision. Commonly 

encountered disorders include anxiety, 

depression, and posttraumatic stress disorder 

(PTSD) (Teplin et al. 1996). Developing programs to assist those with co-occurring mental 

and substance use disorders requires integrating treatments and modifying commonly 

60 Chapter 4
 

used interventions to take into account possible cognitive disabilities and increased need 

for support among these individuals. In addition, system-level barriers in funding, 

staffing, and training must be overcome 

(Drake et al. 2001). (See also TIP 42, 

Substance Abuse Treatment for Persons With 

Co-Occurring Disorders [CSAT 2005c].) 

Although the treatment of co-occurring severe 

mental disorders and substance use disorders 

sometimes is provided in specialized, more 

intensive programs, less severe mental disorders that do not cause major functional 

impairment can be treated and managed 

effectively within mainstream programs. 

Moreover, not addressing these underlying 

problems can increase the likelihood of 

relapse. It is important to note, however, that 

the early stages of recovery often are marked 

by increases in depression and anxiety, due, 

in part, to residual effects of substance withdrawal and also to the individual’s recognition of consequences related to his substance 

abuse, including incarceration or other 

restrictions to his liberty. Likewise, substance 

abuse may mask an underlying mental disorder that may not become apparent until the 

offender is no longer using drugs or alcohol. 

Thus, assessments should be repeated regularly during the treatment process. 

Advice to the Counselor: 

Mental Health Issues

Posttraumatic Stress Disorder

and Depression

Problematic early life experiences, physical 

and sexual abuse, witnessing violence among 

family and friends, and other traumatic life 

events often emerge as key issues in substance 

abuse treatment. Whether identified initially 

or after a period of treatment, it is important 

that these issues be reflected in the treatment 

plan, matched with interventions likely to be 

effective, and tracked with regard to 

progress. For example, while most clients will 

find that negative mood will decrease over the 

first few months of abstinence and treatment, 

an individual’s depression, nightmares, and 

other trauma-related symptoms might persist 

after several months. If symptoms do not 

require transfer to a mental health services 

program, this individual should be referred 

to mental health professionals for further 

assessment and treatment. The referral could 

result in recommendations for antidepressants and/or antianxiety medications and/or 

involvement in cognitive–behavioral therapy 

related to trauma and substance abuse issues. 

These interventions may be instrumental in 

preventing substance abuse relapse and 

allowing the client to continue making 

progress within her substance abuse treatment program. 

Serious Mental Disorders

Although they occur less frequently 

than PTSD and mild anxiety or 

• After a few months of abstinence, most clients will show 

a decrease in negative mood related to their substance 

use. However, abstinence may reveal the presence of 

other, more serious mental disorders (such as posttraumatic stress disorder, depression, schizophrenia, intermittent explosive disorder, or borderline personality disorder) that will require collaboration with a mental health 

professional. Some individuals will achieve a level of 

adjustment that will allow them to continue in main 

stream substance abuse treatment, but others will 

require more intensive intervention for their co-occurring disorders. 

depression, serious mental disorders 

(including schizophrenia, delusional 

disorder, bipolar disorder, and major 

depression) can adversely affect the 

ability of treatment programs to manage an offender’s behavior. Behavioral disorders that involve self-harm 

(e.g., cutting or burning oneself, suicidal threats or attempts), and impulsive and uncontrollable aggression are 

particularly problematic to manage in 

a treatment setting. These more severe 

Substance Abuse Treatment Planning 61 
 

behaviors require involvement of mental 

health professionals for diagnostic workup 

and treatment interventions. 

In the case of serious mental disorders and 

threatening behavioral disorders, an 

assertive, psychiatrically based treatment 

approach is needed during the most intensive 

phases of the disorder. After the more severe 

symptoms have abated (usually through medication and behavioral management on a specialized unit or in a hospital), collaboration 

between mental health and substance abuse 

professionals is needed to determine the best 

approach to manage and treat the individual. 

Some individuals will achieve a level of 

adjustment that will allow mainstreaming 

within substance abuse programs, with medication monitoring in collaboration with medical staff. Other individuals will require more 

intensively integrated care and intervention 

for their co-occurring disorders. 

Intermittent Explosive 

Disorder

Treatment planning for individuals who present with an intermittent threatening behavioral disorder is complex. If these behaviors 

are fairly frequent, it will be impractical to 

manage the individual in a mainstream program. If these behaviors occur infrequently, 

the individual may be manageable in the 

mainstream setting, but only with additional 

assessment as to the causal antecedents 

(immediate situation and circumstances) of 

the outbursts or self-harm behaviors and an 

analysis of the incentives and perpetuating 

factors that fuel the behavior. With this 

assessment in hand, the treatment plan can 

be used to alert and guide the individual and 

staff regarding triggers for the unwanted 

behaviors and ways to defuse their appearance, or ways to limit the threat they present 

to the client and others. 

The treatment plan in such cases will often 

involve the client’s committing to a behavior 

contract that requires reporting strong temptations or urges to the staff, specifies self-control strategies, and clarifies the consequences 

of the behavior, which may include sanctions 

for misconduct, intensification of treatment, 

or removal from the mainstream program 

with referral to a specialized behavioral unit. 

In many cases psychiatric consultations and 

medication management can be helpful. 

Borderline Personality

Disorder

Individuals diagnosed with borderline personality disorder (BPD) sometimes engage in 

severely disruptive behaviors. Individuals 

with this disorder typically experience many 

specific negative emotions (vulnerability, hostility, sadness, anxiety, etc.) or a nonspecific 

but intense sense of distress or “feeling bad.” 

This is combined with an inability to monitor 

and control emotions, alternating chaotic or 

contradictory ways of relating to self and others, and self-harm or dramatically selfdestructive behaviors. 

Dialectical Behavior Therapy (DBT) (Linehan 

1993) has been developed specifically 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, and agree to attend 

skills training sessions and to work on reducing suicidal or self-injurious behavior and 

other behaviors that interfere with treatment. 

Core DBT interventions involve careful examination of clients’ problems and emotional 

difficulties, as well as a recognition that these 

problems make sense within the context of 

current life situations. Problemsolving skills 

are used throughout DBT, as are contingency 

management, cognitive–behavioral treatment 

approaches, supervised “exposure” to past 

trauma events, and use of psychotropic medication. 

62 Chapter 4
The DBT approach typically consists of at 

least 1 year of treatment, comprising weekly 

individual psychotherapy and group therapy 

sessions. Individual sessions explore problematic behaviors and chains of events leading up 

to the behaviors, while therapy sessions focus 

on interpersonal effectiveness skills, tolerance 

of distress, emotional regulation, and selfawareness or “mindfulness” skills. The pretreatment phase of DBT is dedicated to 

assessment, orientation, and developing commitment to the treatment process. 

Three subsequent stages of treatment emphasize self-examination and development of 

skills. Stage 1 of DBT involves examination of 

suicidal and other problem behaviors that 

interfere with treatment and the client’s quality of life, and development of related skills to 

address these issues. Stage 2 of DBT addresses problems related to PTSD, and Stage 3 is 

focused on developing self-esteem and 

addressing individual treatment goals. 

Advice to the Counselor: 

Borderline Personality Disorder

• Severely disruptive clients may have borderline personali 

ty disorder. Dialectical Behavior Therapy has been developed specifically for treatment of this disorder and can 

be successfully integrated with substance abuse treat 

ment programs. 

psychopathology, is one of the most important 

predictors of treatment outcome. Although 

substance abuse treatment has become 

increasingly integral to the criminal justice 

system, it should not be assumed that crimes 

committed by drug-involved offenders are 

solely the result of drug-acquiring behavior 

or are attributable to intoxication and 

impaired brain functioning. The majority of 

drug-involved offenders show a dramatically 

reduced pattern of criminal activity while 

they are abstinent and involved in treatment, 

as compared with periods of active substance 

abuse (De Leon et al. 1982; Deschenes et al. 

1991). Nonetheless, some offenders persist in 

committing a high frequency of property and 

violent crimes, even in the absence of substance abuse. 

Sources of Criminality

Many offenders begin their criminal careers 

before the onset of substance use, with drugs 

and alcohol being more symptomatic of 

a broader pattern of delinquency, acting-out, and social deviance. Three 

sources of criminal behavior that are 

closely associated with drug use can be 

identified: procriminal values, procriminal associates, and psychopathy. 

Criminality and
 

Psychopathy
 In developing treatment plans for substanceinvolved offenders, it is important to assess 

whether criminal attitudes and behaviors predated drug and alcohol abuse and whether 

criminogenic personality features will impede 

involvement in treatment. This assessment is 

useful in constructing a balance between risk 

containment and rehabilitative activities prescribed for the offender, and, along with substance use disorder severity and presence of 

Procriminal values 

Procriminal values in adults are most 

often the result of the combination of 

early involvement with delinquent peers, the 

experience of parental neglect or abuse, the 

absence of prosocial resources and strengths 

(such as literacy, employability, and social 

skills), and exposure to an overly permissive 

or procriminal environment, such as an 

unsafe school or crime-ridden neighborhood. 

Examples of procriminal values include intolerance for personal distress and unwillingness 

to accept responsibility for behaviors that 

adversely affect others. Procriminal values 

and attitudes, coupled with a longstanding 

pattern of antisocial and criminal behaviors, 

are the key elements of psychopathy. 

Substance Abuse Treatment Planning 63 
 

Procriminal associates 

Procriminal associates can develop from life 

in proximity to high-frequency crime areas, 

but more often the choice of criminal associates is the logical result of “criminal thinking” 

and procriminal values. Procriminal associations are also formed during incarceration or 

involvement in criminal justice programming. 

Often these are not balanced by prosocial 

friendships because of the person’s inability 

to overcome the stigma of having a criminal 

record or attract and maintain relationships 

with individuals who are socially less 

“marginal.” 

Procriminal values and thinking, as well as 

criminal associates, are rooted in normal cognitive, emotional, and social processes, such 

as the need for belonging and approval, the 

need to feel that one has gotten a “fair deal” 

in life, and the need to feel a sense of self-efficacy and security. Because the origin and 

perpetuation of these factors are based primarily in normal psychosocial aspects of the 

person—that is, they are based on thoughts, 

emotions, and ways of relating that are within 

normal limits—they are fairly susceptible to 

being modified using the psychosocial methods common to the major substance abuse 

treatment modalities. Individuals whose criminality results primarily from these two factors can learn new ways of thinking and valuing, as well as new ways of feeling and how to 

manage their feelings, especially in the context of developing new prosocial and prorecovery relationships. Treatment approaches 

that address criminal thinking are discussed 

in chapter 5. 

Psychopathy

Psychopathy is distinguished from both procriminal values and procriminal associates in 

that it is most often conceptualized as a personality trait with primarily biological underpinnings. When this trait becomes extreme it 

can be described as a personality disorder. 

Personality disorders are distinctive, longstanding, pervasive patterns of behavior, 

which usually begin early in life. Personality 

disorders tend to affect almost every aspect of 

a person, such as thinking, feeling, perceiving, and relating to others, with worsening 

cycles of self-defeating and maladaptive 

behavior. Most theorists and researchers view 

psychopathy as the result of interactions 

between biological differences—primarily 

located in the brain (Anderson et al. 1999; 

Laakso et al. 2001)—and the most early and 

basic experiences that shape the personality, 

such as the experience of bonding, attachment, and concern for others (Hare 1996). 

Psychopathy is expressed in ways of thinking 

(impulsive, irresponsible, and grandiose) and 

feeling (without empathy and shallow) that 

typically result in behaviors that seriously 

infringe on the rights of others. 

In contrast to the BPD, the most notable 

characteristic of individuals with severe psychopathy (other than persistent criminality 

and exploitation of others) is the lack of normal attachment to and value for other people. 

Although they can be glib and charming, people with psychopathy have a shallow and 

fleeting ability to experience, express, and 

understand social emotions such as embarrassment, self-consciousness, shame, guilt, 

pity, and remorse. This affective-interpersonal deficit often is expressed in the form of 

cold and callous use of other people without 

regard for their feelings or well-being. This 

lack of empathy is usually the basis for a lack 

of remorse for criminal behavior and is supported by the belief that society and the victim are at fault, rather than the perpetrator, 

or that the damage done by one’s crimes is of 

little consequence (Hare 1998a). 

The Psychopathy Checklist–Screening 

Version (PCL–SV) can provide an important 

screening mechanism for identifying those 

offenders who may require a more extensive 

evaluation. The PCL-SV and other instruments for examining psychopathy are discussed in more detail in chapter 2. All other 

things being equal, individuals who are low in 

psychopathy can be expected to respond 

favorably to substance abuse treatment in the 

64 Chapter 4
criminal justice system and to significantly 

reduce their criminal behavior as the result of 

this treatment. Individuals who are in the 

moderate range of psychopathy will benefit 

from treatment but will require more intensive monitoring, an emphasis on consequences 

and potential sanctions versus personal aspirations and goals, and vigilance for deception 

and manipulation of treatment and criminal 

justice supervisors. 

Individuals high in psychopathy require the 

most intensive in-prison and community 

supervision and monitoring. Intensive treatments that engage the client in deep emotional 

processing, that require “working through” 

life experiences to develop insight, or that 

stress the development of social skills for 

their own sake should be avoided for this 

group. Treatments should be limited to practical relapse prevention activities, including 

relapse to illegal or seriously self-defeating 

forms of manipulation and exploitation of 

others, with increased monitoring for drug 

use. All self-reported aspects of community 

adjustment must be carefully corroborated by 

first-hand observation or reported by an 

independent third party, including, for example, attendance at required programming, 

status of living conditions, type and hours of 

work, criminal background of close associates, and use of leisure time. 

Offenders with severe psychopathy tend to do 

poorly in treatments of all types, when compared to those without severe psychopathy. 

Of great importance is the surprising and paradoxical finding 

Client Motivation and
 

Readiness for Change 

The successful implementation of a treatment 

plan depends, to a great extent, on the 

client’s motivation and readiness for change. 

Motivation level has been found to be an 

important predictor of treatment compliance, 

dropout, and outcome, and is useful in making referrals to treatment services and in 

determining prognosis (Ries and Ellingson 

1990). Motivation is sometimes thought of as 

an emotional commitment to voluntary 

engagement in treatment. However, this view 

is overly simplistic, since motivation can be 

influenced by many factors including the 

threat of sanctions or the promise of rewards 

for treatment engagement (such as reduced 

jail time, access to needed services, or transfer to a desired correctional facility where the 

treatment will take place). Motivation and 

readiness for treatment are expected to 

change over time, and individuals often cycle 

through several predictable “stages of 

change” during the treatment and recovery 

process. Due to the chronic relapsing nature 

of substance abuse problems, offenders frequently return to previous stages of change 

before achieving recovery goals and sustained 

periods of abstinence. (See chapter 3 for a 

discussion of the stages.) 

A number of attempts have been made to link 

the readiness to change approach to a 

substance abuse-specific model that involves 

(now replicated) that offenders 

with severe psychopathy who 

are given intensive treatment 

re-offend more frequently and 

more seriously than offenders 

with psychopathy who go 

untreated (Hobson et al. 2000; 

Reiss et al. 1999, 2000). In 

other words, treatment may be 

contraindicated for offenders 

with severe psychopathy. 

Advice to the Counselor: 

Psychopathy

• Individuals high in psychopathy require the most intensive in-prison and community supervision and monitoring. Treatment should be limited to practical relapse pre 

vention activities, including relapse to illegal or seriously 

self-defeating forms of manipulation and exploitation of 

others, with increased monitoring for drug use. 

• All self-reported aspects of community adjustment must 

be carefully corroborated by first-hand observation or an 

independent third party. 

Substance Abuse Treatment Planning 65 
“phases” of recovery. Each phase of recovery 

is typified by a characteristic level of motivation, often reflected in engagement with treatment and with specific recovery-related activities. These models have considerable value 

for both treatment planning and research as 

ways of describing and communicating about 

where a client is in regard to readiness 

(McHugo et al. 1995). 

Assessment of treatment readiness and stage 

of change is useful in treatment planning and 

in matching the offender to different types of 

treatment. For example, matching offenders 

to treatment that is appropriate to their current stage of change is likely to enhance treatment compliance and outcomes. For individuals in the early stages of change, placement in 

treatment that is too advanced and that does 

not address ambivalence regarding behavior 

change may lead to early termination from 

the program. For offenders who are in later 

stages of change, placement in services that 

focus primarily on early recovery issues may 

also lead to premature termination from 

treatment. Staff involved in treatment planning should be careful to assess the offender’s 

stage of change and readiness for substance 

abuse treatment and to consider this information when developing treatment plan goals. 

Ongoing review of readiness for treatment can 

be provided through use of self-report instruments, focused discussion with the client, 

observation of the client within a treatment 

program, and review of collateral reports 

Advice to the Counselor: 

Motivation for Change 

• Treatment plans should contain a section addressing 

motivation for change. Clients may have only a vague 

sense of their own motivation for treatment. However, 

staying focused on the positive consequences of recovery 

is an essential aspect of the recovery process. 

• From the first point of intake to the final community 

supervision session, promoting and utilizing motivation 

should be an upfront aspect of substance abuse 

treatment. 

from treatment staff, criminal justice staff, 

and family members. Several techniques for 

screening and assessment of readiness for 

change are discussed in chapter 3. 

Motivation for change is so often an issue for 

criminal justice clients that perhaps most 

treatment plans should contain a section 

addressing motivation and readiness for 

change. Surprisingly, individuals who verbalize the greatest desire for treatment may not 

have more than a vague sense of their own 

motivation to escape the negative consequences they are currently experiencing, such 

as incarceration, debt, or ill health. However, 

staying focused on the positive consequences 

and rewards of recovery is an essential aspect 

of the recovery process. From the first point 

of intake to the final community supervision 

session, promoting and utilizing motivation 

should be an upfront aspect of criminal justice management of substance abuse treatment. Motivational interviewing methods, 

providing feedback to clients on key aspects 

of assessment findings and progress toward 

treatment plan goals and intimate involvement of the client in the construction and 

revision of the treatment plan are important 

ways of enhancing client engagement in treatment. (For more information, see TIP 35, 

Enhancing Motivation for Change in 

Substance Abuse Treatment [CSAT 1999b].) 

Focus on Personal Strengths

The strengths-based approach to 

treatment planning in juvenile 

justice and adult criminal justice 

settings has been received with 

enthusiasm in many quarters.

This contrasts with the traditional deficit-based approach to

treatment planning for adults

involved in the criminal justice

system. Strengths can be recognized and used in treatment 

planning without neglecting

deficits or decreasing the necessary emphasis on accountability 

and responsibility. Offenders 

66 Chapter 4
tend to exaggerate or minimize their 

strengths. Assisting clients in identifying and 

getting an accurate estimate of their personal 

strengths should emphasize, but not be limited to, those that are relevant to recovery. 

Strengths assessment often begins by determining what interests or inspires the client or 

by identifying those things in which the client 

has a sense of pride. Therapeutic community 

settings often identify specific roles within the 

treatment environment that clients can take 

on as their strengths and work to develop 

them further. Other modes of intervention 

perhaps need to create roles or activities for 

clients that use their strengths or identify 

opportunities outside of the program itself. 

Women’s programs often emphasize the 

strengths that enabled survival during periods of abuse or neglect. Identifying and working with strengths in the treatment planning 

process allows the client to be less defensive 

about the identified deficits and problem 

areas in the same plan. It is important, however, that the perception of the strengths as 

legitimate and of value be shared among the 

members of the planning team and with the 

client. 

Implementing an

Effective Treatment 

Planning Process

Offender Involvement in the 

Development of the 

Treatment Plan

The consensus panel believes that it is essential for clients to be involved in setting case 

management goals that are in their own best 

interests. Success of the treatment plan can 

be greatly aided by the client’s involvement in 

the development of specific objectives and 

interventions. An example of this process is 

the Client’s Recovery Plan (CRP), in use at 

the Walden House program in San Francisco 

(see Figure 4-1, next page). The client documents his perception of his circumstances, 

needs, and tendencies, and these are incorporated into the program treatment plan. The 

CRP opens the dialog between the client and 

the staff on a more equal footing. 

Coordination of Treatment 

Planning and Sharing of 

Treatment Information

Treatment planning activities in criminal justice settings should include the full range of 

professionals involved in supervising, monitoring, and providing therapeutic services. In 

noncustody settings, it is useful to have probation or parole officers involved in this process, in addition to staff from halfway houses, 

employment/vocational services, and family 

members. In custody settings, treatment planning could involve case management or transition staff who may be responsible for coordinating prerelease plans and making 

arrangements for treatment appointments following release from custody. The consensus 

panel recommends that treatment plans be 

updated at different transition points in the 

criminal justice system (e.g., following release 

from custody, transfer to less intensive supervision status, or departure from a halfway 

house setting), as the offender’s motivation, 

response to environmental stressors, and level 

of involvement in treatment may significantly 

change. Signed releases of confidential information and interagency memorandums of 

agreement can help to ensure that treatment 

plans and other key information are transferred to appropriate staff during these transition points. 

Relapse prevention plans often are used within community-based treatment programs in 

the criminal justice system to develop a coordinated approach to supervision, treatment, 

and judicial supervision that recognizes the 

importance of substance abuse relapse. 

Relapse prevention plans often describe highrisk situations for the offender which increase 

the likelihood of relapse, relapse “triggers” or 

cues (e.g., interpersonal conflict, negative or 

Substance Abuse Treatment Planning 67 
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Figure 4-1 

Client’s Recovery Plan (CRP) 

Name ________________________________________ Date ____________________ WH # ______________________ 

Note to client 

This form is provided to you, as a Walden House client, in order to obtain your input into your treatment plan. 

Your counselors will be evaluating you and your treatment needs based on the Psycho-Social History and 

Assessment that you provided them. This form is your opportunity to do your own self-evaluations on the same categories. 

Instructions 

Please describe your own preferences or ideas of what you feel you need in the following categories (if the category 

does not apply, please put “N/A”). 

Drug and Alcohol 

Childhood/Family 

Relationship/Marital/Sexual 

Friendship/Recreation and Leisure/Religious/Spiritual 

Parenting/Child Protective Services (CPS) 

Criminal Justice 

Education 

Employment 

68 Chapter 4
___________________________________________________________________________________________________ 

___________________________________________________________________________________________________ 

___________________________________________________________________________________________________ 

___________________________________________________________________________________________________ 

___________________________________________________________________________________________________ 

___________________________________________________________________________________________________ 

___________________________________________________________________________________________________ 

___________________________________________________________________________________________________ 

Housing 

Mental Health 

Overall, is there anything else you feel you need that is not covered in the above areas that is related to your substance abuse recovery? 

In your opinion, how much treatment time do you feel you need? Be specific. 

Your signature: _______________________________________________________________________________ 

Thank you. Your input is appreciated and will be taken into consideration in the development of your treatment 

plan. You are to bring this completed form with you to your clinical assessment meeting. 

positive emotions, drug paraphernalia, old 

drinking or drug associates), skills to be 

developed to address problems related to 

relapse, and specific strategies to deal with 

relapse urges, “triggers,” and high-risk situations. Relapse prevention plans are used in a 

number of drug courts, and help develop consensus among court, supervision, and treatment staff about an offender’s current “risk” 

level for relapse and in organizing responses 

to critical incidents and problem behaviors. 

Linkages With Community

Treatment 

For criminal justice clients who will not 

remain long in a jail setting, linkages to the 

appropriate community services are an essential part the treatment plan. The shorter the 

jail detention, the more important these links 

become, especially if a client needs a range of 

services, including educational, vocational, 

legal, medical, and mental health. For these 

links to work most effectively, the treatment 

plan must include all relevant information 

Substance Abuse Treatment Planning 

about the client that may be needed by the 

community providers involved. This will 

allow all the different parties to agree on their 

own responsibilities to the client as well as the 

conditions for reporting back to the case 

manager as needed for the client’s welfare. In 

some cases an interagency audit, however 

informal, can be useful to identify gaps in the 

treatment plan and barriers to the client’s 

progress, as well as the strengths present in 

the client’s situation. 

Successful links with community agencies 

require careful planning and considerable 

resources to develop. Treatment planning and 

case management as a whole will be easier for 

treatment professionals if these relationships 

already exist and can be called upon quickly. 

Case managers can cultivate these relationships by being involved whenever possible in 

activities of the agencies they work with, such 

as by attending committee or planning meetings, in helping staff members of these organizations to develop offender programs and 

policies, and by contributing to resource 

materials and manuals. (See TIP 30, 

69 
 

Continuity of Offender Treatment for 

Substance Use Disorders From Institution to 

Community [CSAT 1998b].) 

Conclusions and

Recommendations

The consensus panel recommends that several 

key points be considered when developing a 

substance abuse treatment plan for clients in 

the criminal justice system: 

•Sufficient resources are needed for comprehensive assessment and treatment planning, 

including adequate staffing, clerical support, and access to computers and management information systems. 

•When sharing information is not feasible 

(e.g., routinely providing detailed information to a drug court judge regarding offender disclosures in treatment), consultation, 

training, and written agreements are needed to define the types of information that 

will be shared, with whom, and under what 

circumstances. 

•Procedures should be developed to control 

the flow of relevant information to the various staff involved in an offender’s treatment and supervision. These procedures 

are required to protect the privacy and 

confidentiality rights of offenders. (For 

more information on confidentiality, SEE

CSAT 2004.) 

•The offender should be involved in all 

major aspects of the treatment planning 

process. 

•Procedures should be adopted for in-prison 

treatment programs regarding information 

sharing and flow of treatment records from 

one institution to another. Such procedures 

should control access to treatment 

providers and provide protection against 

rerelease of information related to self-disclosures of previous unreported criminal 

behavior or the intent to commit future 

crimes and psychiatric and medical histories, except when required by law. (For 

more information on confidentiality, 

see CSAT 2004.) 

•Treatment plans should assess the severity 

of the substance use disorder as well as any 

COD in order to place the offender in an 

appropriate treatment setting. 

•Treatment plans should address motivation 

and readiness for change. 

•Treatment plans should incorporate a 

strengths-based approach. 

•Offenders possessing some degree of psychopathy may respond less well to traditional substance abuse treatment but benefit from intensive in-prison and community 

supervision that emphasizes consequences 

and sanctions for relapses. 

•Correctional therapeutic community (TC) 

programs should consider use of instruments to measure client progress in treatment, as defined by the TC’s goals for social 

and psychological change. 

70 Chapter 4
In This
 Chapter... 

Clinical Strategies 

Program Components 

and Strategies 

Conclusions and 

Recommendations 

5 Major Treatment 

Issues and

Approaches

Overview 

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 

71 
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. 

Clinical Strategies

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. 

Addressing Basic Needs

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. 

Detoxification 

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 

72 Chapter 5 
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). 

Homelessness 

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. 

Life skills 

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. 

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 

Advice to the Counselor: 

Homelessness

• Offenders should be asked where they lived in the 

month prior to arrest.

• If offenders anticipate being homeless when they leave 

the prison, a plan to provide offenders with housing 

should be in place before their release.

• Addressing deficits in basic life skills as well as housing 

issues can help prevent recidivism. 

Major Treatment Issues and Approaches 73 
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. 

Addressing Criminality

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. 

Criminal thinking 

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 cogniAdvice to the Counselor: 

Criminal Thinking 

• Criminal thinking should be viewed as an outcome of

maladaptive coping strategies rather than as a permanent fixture of the offender’s personality.

• Criminal thinking can be addressed using the same tools

as in substance abuse relapse prevention. This includes

identifying offenders’ primary thinking errors, instructing clients to self-monitor when these errors occur, and

providing regular feedback from peers to prevent rever

sion to criminal behavior.

tive distortions or “thinking errors” (see 

Figure 5-1). 

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)

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

74 Chapter 5 
Figure 5-1 

Common Thinking Errors 

Power thrust Putting people down, dominating 

Closed channel Seeing things only one way 

Victim stance Blaming other people 

Pride Feeling superior to other people 

Don’t care Feeling unconcerned about how other people are affected 

Want it now Demanding gratification now 

Don’t need anybody Refusing to be dependent on others for anything 

Rigid thinking Thinking in black and white terms 

They deserve it Believing that people have it coming 

Screwed Feeling mistreated 

Source: Wanberg and Milkman 1998. 

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. 

Client manipulativeness 

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 

Criminal code 

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 

Major Treatment Issues and Approaches 75 
Thinking for a Change 

NIC’s Thinking for a Change helps offenders learn to change criminal behaviors using three basic techniques: 

•Cognitive self-change. Offenders learn how to examine their thinking, feelings, beliefs, and attitudes in

order to understand how these factors contribute to criminal behaviors.

•Social skills development. Participants explore alternatives to antisocial and criminal behaviors. 

•Problemsolving skills development. Offenders integrate the skills they learn and use them to work 

through difficult situations without engaging in criminal behavior. 

Thinking for a Change is designed to work in a variety of criminal justice settings, and is ideally implemented in groups of 8 to 12. The curriculum is available online, along with more information (at 

http://nicic.gov/t4c). 

require careful confrontation, limit-setting, 

and clear expectations with consequences by 

treatment staff. 

Addressing Anger and

Hostility

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 

1. Identifying the feeling(s). Maybe other

feelings are involved, such as embarrassment or guilt.

2. Understanding clearly where the feeling is

coming from. What is the real source of

the anger?

3. Identifying the goals the anger is serving

(e.g., deflecting attention).

76 Chapter 5 
 

4. Identifying the goals the anger is undermining (e.g., staying out of jail or keeping 

a job). 

5. 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). 

Addressing Identity Issues

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. 

Criminal identity 

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. 

Cultural identity 

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. 

Role as a family member 

and/or parent 

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 

Major Treatment Issues and Approaches 77 
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. 

Confronting the guilt associated with their 

drug abuse can be important in treating parents involved in the criminal justice system. 

Advice to the Counselor: 

Family Involvement 

• Involving the family in an offender’s treatment can be a

positive source of support. Unfortunately, however, some 

family members may provide offenders with drugs and 

be involved in criminal activity. Inmates can develop a 

false sense of “healing” of family problems from having 

reduced and controlled contact with family. 

• Extended family visitation can be used as a reward for

good behavior.

• On release, inmates often find that preexisting family

problems are still present and often worse.

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-justiceprogram

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 treat­ment 

programs also can use family involve­ment 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 a number of factors in reduced and controlled contact cluding 

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 

78 Chapter 5 
involved in criminal activity and be expected 

to carry on criminal activities such as drug 

dealing while one member is incarcerated. 

Role as a person of status 

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. 

Addressing Denial

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. 

Addressing Resistance 

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. 

Major Treatment Issues and Approaches 79 
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 

• Approach coerced clients with understanding and honesty, paying careful attention to body language, eye contact, and tone of voice. 

• When dealing one-on-one with the coerced client, focus 

on the client’s role in forcing the consequence, with 

statements such as “You sort of forced the judge into 

giving you this consequence for using again.” 

• Focus the client on the future and the difference treat- 

ment can make. 

Addressing Guilt, Shame, and

Stigma 

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. 

80 Chapter 5 
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. 

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. 

Establishing Boundaries

Counselors’ methods for establishing a relationship with clients vary according to the setting. It is much more difficult to develop a 

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 

Advice to the Counselor: 

Establishing Boundaries

• No matter how much empathy they feel for offenders, 

counselors need to remember that they represent the 

criminal justice system. 

• Counselors’ self-disclosures can be helpful when balanced 

by appropriate boundaries. 

• Offenders are often deft at conning a counselor into 

doing small and seemingly meaningless things for them, 

but this is often a first step in an unhealthy alliance that 

can be used against the counselor at a later date. A welltrained counselor can confront the offender and turn 

the attempted manipulation into a step for developing a 

stronger treatment alliance. 

Sealed Records 

A criminal record follows offenders long after they serve their time in prison. Many recovering individuals 

find that, despite their best efforts, the stigma of their criminal records limits their options. A 2001 CSAT 

initiative, Rehabilitation and Restitution, contains a component to help recovering offenders get their criminal records sealed. Additionally, participating programs may offer 

•Comprehensive assessments 

•Individualized service plans 

•Case management 

•Continuum of substance abuse treatment services 

•Support in obtaining a GED or other necessary education 

•Job training, placement, and retention programs 

•Continuum of supervision, aftercare, and continuing care programs 

CSAT’s cooperative agreement initiative is aimed at improving the likelihood of successful reintegration. 

Programs funded through the initiative will compare the success rates of those who receive additional 

assistance with those who receive whatever help is usually offered to recovering offenders. 

Major Treatment Issues and Approaches 81 
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. 

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. 

Creating a Therapeutic 

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. 

Striving for counselor 

credibility 

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 

82 Chapter 5 
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. 

Striving for cultural 

competence 

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

• Avoid making promises that you foresee being unable to 

keep. If you are unable to keep a promise, be clear as to 

why you cannot do so and accept the consequences. 

• Demonstrate the attitudes and behaviors you are trying 

to get clients to implement (credible staff are those who 

do as they say). 

• Show a positive attitude toward colleagues, the program, one’s family, and so on. 

• Work to have the client respect who you are, even if he 

does not like what you represent. 

• Ensure that you maintain the respect of your supervisor 

and other staff (including corrections officers and proba 

tion officers). Credibility with offenders is affected by 

their observations of the counselors’ interactions with 

other staff, and clients do watch staff closely. 

• Clearly articulate roles and boundaries. Inmates often see 

treatment staff as potential inroads into all areas ranging from personal property issues, to job assignments, to 

case management concerns. Treatment staff need to 

clearly define their role and limits or they quickly find 

their credibility lost because inmates interpret the staff’s 

inability to correct a nontreatment issue as a lack of concern or caring. 

Designing Treatment to 

Reflect the Stages of Change 

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. 

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 

Major Treatment Issues and Approaches 83 
State Description Strategies 

Precontemplation Unaware of substance 

abuse problems 

Instill discomfort in a supportive manner. Increase the 

client’s ability to recognize problems with current behavior 

and dissonance with future goals. 

Contemplation Awareness of substance abuse problems Tip the balance. Elicit from the client the reasons to change, 

and the risks of not changing. Support prosocial thinking 

from the client. 

Preparation Decision point Plan the action. Help the client determine the best course of 

action. These plans are individualized as they vary considerably from client to client. 

Action Active behavior 

change 

Help the client take steps toward change. Begin shifting from 

external motivators to internal motivators by supporting the 

client’s self-efficacy for change. 

Maintenance Ongoing preventive 

behaviors 

Relapse prevention focusing on coping mechanisms and 

avoidance of triggers. Monitoring of attitudes and behaviors 

that can lead to relapse. Assisting the client in making 

lifestyle changes and encouraging the client to assist others 

who are in the recovery process. 

Figure 5-2 

Strategies for Working With Offenders Based on Their Stage in Recovery 

that reduces both crime and the number of 

crime victims, in addition to rehabilitating 

offenders. 

Program Components

and Strategies

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. 

Engagement 

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). 

84 Chapter 5 
 

Program incentives and 

sanctions to encourage 

engagement 

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. 

Enhancing motivation 

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. 

Effective Use of Coercion at 

the Program Level

“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. 

Retention in 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 retenMajor Treatment Issues and Approaches 85 
Does Coerced Treatment Work? 

In a review of 11 coerced treatment studies conducted over 20 years, Anglin and colleagues (1998) found 

that, while coercion was generally effective, the results were far from unequivocal, with five studies 

reporting that coerced clients did better, four studies reporting no difference, and two studies reporting 

that the coerced clients did worse. It is important to note, however, that in the 11 coerced treatment 

studies reviewed, none directly assessed the motivation of the clients (Farabee et al. 1998). In most 

cases, involuntary or coerced status of clients was inferred from criminal justice status at intake. Many 

clients whose treatment was coerced say they would have entered treatment without legal pressure to do 

so (Marlowe et al. 1996). Only about a third of those who entered coerced treatment for cocaine abuse 

said that legal coercion was a reason for entering treatment. Rather, psychological, financial, social, 

familial, and medical pressures exerted more influence in the decision to enter treatment (Marlowe et al. 

1996). 

While some critics have argued that treatment will be ineffective unless a client is motivated to change 

his or her substance abuse behavior, treatment itself can alter the client’s motivation. In fact, an important indicator of an effective program is its ability to engage and retain clients who initially join under 

coercive pressures. The major difficulty, then, is often a matter of getting resistant clients to enter treatment, and coercion has been shown to increase the likelihood of an offender’s entering treatment (Anglin 

et al. 1998). 

Coercion such as that from the criminal justice system can play an important role in making sure the 

client enters treatment, but it will be internal motivation that predicts whether the client will stay in 

treatment and have a positive outcome. Knight and colleagues (2000) showed that external legal pressure 

and internal motivation are positively and independently related to retention in treatment. The authors 

recommend targeting those with low internal motivation for an intervention to increase readiness. 

Research also suggests that in the absence of leverage imposed by the criminal justice system, offenders 

have a poor record of retention and graduation from substance abuse treatment programs. Moreover, 

outcomes for offenders who receive coerced treatment are as good as or better than for other participants in treatment (Hubbard et al. 1988a; Miller and Flaherty 2000). Leverage through the criminal justice system also helps retain offenders in treatment over time (Miller and Flaherty 2000), which tends to 

reduce the rate of criminal recidivism. 

tion. 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. 

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 convic86 Chapter 5 
tions, 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. 

Incentives and sanctions to 

improve retention 

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. 

Major Treatment Issues and Approaches 87 
 

•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

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. 

Staff Modeling Accountability

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. 

Peer Support and Feedback 

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. 

Program Phasing 

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. 

Self-Management Skills— 

Relapse Prevention

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). 

88 Chapter 5 
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

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 forAdvice to the Counselor: 

Spiritual Approaches

• Spiritual approaches can provide powerful tools for some

to achieve sustained abstinence. Counselors can refer 

clients to the religious leaders of their choice for addi

tional counseling, or to voluntary 12-Step groups that do

not explicitly endorse any one religion.

• Rituals and ceremonies can be used to mark positive

events.

• Providing a time and a suitable place can promote individual meditation, reflection, or prayer. 

Major Treatment Issues and Approaches 89 
mer 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. 

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. 

Conclusions and

Recommendations

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 nonrecovering staff. 

90 Chapter 5 
•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. 

Major Treatment Issues and Approaches 91 
 

 

In This
 

Chapter... 

Treatment Issues Related 

to Cultural Minorities 

Women’s Treatment 

Issues 

Men’s Treatment Issues 

Working With Violent 

Offenders 

Treatment Issues Based 

on Client’s Sexual 

Orientation 

Treatment Issues Based 

on the Client’s 

Cognitive/Learning, 

Physical, and Sensory 

Disabilities 

Treatment Issues for 

Older Adults 

Treatment Issues For 

Clients From Rural Areas 

Treatment Issues For 

People With Co- 

Occurring Substance Use 

and Mental Disorders 

People With Infectious 

Diseases 

Sex Offenders 

Conclusions and 

Recommendations 

6 Adapting Offender

Treatment for

Specific Populations

Overview 

Certain criminal justice system populations may be recognized as having 

specific needs; the consensus panel recommends that whenever possible, 

treatment be modified to meet those needs. A thorough client assessment 

will enable treatment providers to determine what modifications to treatment are required. However, the panel also recognizes that in order to 

explain different types of treatment modifications and the need for those 

modifications it is necessary to group clients according to certain socially 

defined categories that mark their relationship to a dominant identity. 

This chapter provides a basic overview of treatment needs of offenders 

belonging to subpopulations including women; men; violent offenders; gay, 

lesbian, and bisexual offenders; clients with physical and sensory disabilities; older adults; people with co-occurring mental and substance use disorders; people with infectious diseases; and sex offenders. 

Treatment Issues Related to 

Cultural Minorities

There is no denying that the ethnic and cultural composition of offender 

populations is quite different from that of society as a whole. African 

Americans are disproportionately represented in jails, prisons, and 

community supervision programs in comparison with their numbers in 

the general population. They represented 39.2 percent of the jail population and 44.1 percent of the prison population in 2003, 41 percent of 

those on parole, and 30 percent of those on probation. According to the 

2000 Census, however, those who said they were African American 

alone or in combination with one or more other races represent only 13 

percent of the U.S. population. Hispanics/Latinos, of any race, are also 

somewhat overrepresented, representing 15.4 percent of the jail population and 19.0 percent of the prison population in 2003, but only 13.3 

93 
percent of the U.S. population according to 

2002 Census data (Ramirez and de la Cruz 

2002). Caucasians are underrepresented at 

each stage of the criminal justice process, 

making up only 43.6 percent of the jail population and 35 percent of the prison population 

in 2003, 40 percent of those on parole, and 56 

percent of probationers in 2003, but 77.1 percent of the U.S. population (Glaze and Palla 

2004; Harrison and Beck 2004; Harrison and 

Karberg 2004; U.S. Census Bureau 2001). 

McKean (1994) summarizes four somewhat 

overlapping theoretical perspectives to explain 

why certain racial or ethnic groups are overrepresented among offenders: 

•Social isolation 

•Social disintegration 

•Resource deprivation 

•Violent cultural orientation 

These theoretical stances inform substance 

abuse treatment as well. The social isolation 

model states that the dominant group will 

always choose to maintain a social distance 

between itself and minority groups, and to 

this end may employ discriminatory laws and 

policies. Social disintegration models look at 

how weakened informal and institutional 

social controls lead to increased crime. The 

resource deprivation theory emphasizes that 

economic variables such as unemployment, 

poverty, and income inequality are associated 

with crime. The idea of a subculture of violence implies that violent interactions are 

more accepted among some groups than others, for example in gang culture. 

In a study of Alaska Native men, Glass and 

Bieber (1997) found criminal activity to be 

related to social disintegration caused by 

acculturative stress. This stress develops 

when members of a minority culture are pressured to adapt to a dominant culture. The 

bicultural individuals in their study had the 

highest levels of acculturative stress and violent behavior and seemed more prone to identity issues, unstable interpersonal relationships, and unstable emotions. The authors 

surmise that these individuals are not accepted in either culture and that their efforts to 

walk in both worlds contribute to their stress. 

The forthcoming TIP Improving Cultural 

Competence in Substance Abuse Treatment 

(Center for Substance Abuse Treatment 

[CSAT] in development b) provides detailed 

information on adapting treatment to specific 

cultural populations, and, while it is not oriented toward offenders in criminal justice settings, much of what it has to say will apply 

here as well. There are not, however, many 

culturally specific programs operating in the 

criminal justice system, and there also are 

limited data concerning the benefits of culturally competent services in these settings. This 

is certainly an area that requires more 

research. 

Longshore and colleagues (1998) have studied 

treatment motivation among AfricanAmerican detainees who used drugs and had 

never been in substance abuse treatment. Of 

all the factors they studied, “problem recognition” was most clearly associated with motivation for treatment, and that recognition 

was strongest among those who more strongly 

endorsed Afrocentric values such as community, spirituality, collective self-esteem, and 

conventional family roles. Incorporating these 

values into treatment may therefore improve 

treatment outcomes. For example, it could be 

more beneficial to emphasize the prosocial 

reasons for stopping substance use than the 

negative effects of continuing use, to include 

family counseling in treatment, and to view 

recovery as benefiting the community, not 

just the individual. Compared to clients in 

traditional programs, those in Longshore’s 

culturally congruent treatment were more 

involved in the experience, were more forthcoming in their self-disclosures, and participated more actively. They also reported more 

motivation to seek help (Longshore et al. 

1998). 

The consensus panel recognizes that it is 

extremely difficult, however, to create a culturally specific program within a prison or 

94 Chapter 6 
jail given the variety of populations who enter 

the facility and the need to provide equal levels of treatment for all offenders. Culturally 

specific programs also require from clients a 

certain level of commitment to their culture 

that cannot be assumed for all members of a 

particular group. 

Substance abuse treatment requires two-way 

communication of vital information including 

instructions, treatment expectations, personal 

information, and expressions of emotions. In 

a criminal justice setting, where the counselor 

represents the same institutional forces that 

have convicted and imprisoned the client, the 

levels of distrust and possibilities for misunderstanding are magnified. While all correctional staff members (including counselors) 

are seen, to some extent, as representatives of 

the dominant culture, the possibilities for 

misunderstanding can increase when client 

and counselor are from different ethnic or 

cultural backgrounds. These misunderstandings can jeopardize the client’s chances for 

success in treatment. It is the counselor’s job 

to be aware of and sensitive to the values, 

biases, and assumptions that his or her culture has created in matters of communication, therapeutic style, and interpersonal contact and how they affect his or her ability to 

provide culturally competent services to 

clients. The most common misunderstandings 

in counseling originate in culture, socioeconomic class, and language (Sue and Sue 

1999). (See the forthcoming TIP Improving 

Cultural Competence in Substance Abuse 

Treatment [CSAT in development b].) 

Advice to the Counselor: 

Culture and the Counselor

•The most common misunderstandings in counseling origi 

nate in culture, socioeconomic class, and language. It is 

the counselor’s job to be aware of and sensitive to the 

values, biases, and assumptions of his or her own culture 

and to provide culturally competent services to clients. 

Women’s Treatment 

Issues

In 1998, an estimated 950,000 women were 

under supervision by correctional agencies, 

with 85 percent on probation or parole in the 

community. These women were mothers to 

about 1.3 million children under age 18. 

Forty-four percent of them, across settings, 

reported that they had been physically or sexually assaulted at some time during their lives 

(Greenfeld and Snell 1999). 

The percentage of women in the criminal justice system has increased in the past decade— 

in jails it has risen from 10.2 to 11.9 percent 

(Harrison and Karberg 2002). The average 

annual percentage increase in State and 

Federal prisons for women between 1995 and 

2003 was 5.0 percent, compared to 3.3 percent for men. In 2003 more than 100,000 

women were in State and Federal prisons, 

and women represented 11.1 percent of 

adults on parole under State and Federal 

jurisdiction in 1997 (Harrison and Beck 2004; 

Maguire and Pastore 2001). 

About 60 percent of women in State prisons 

used drugs in the month prior to the offense 

for which they were convicted, and about half 

of these women admitted to daily drug use. 

Drug use at the time the crime was committed 

was higher for female inmates than for males 

(40 percent compared to 32 percent), but 

more male inmates than females were under 

the influence of alcohol at the time the crime 

was committed (Greenfeld and Snell 1999). 

Interviews with incarcerated women in 

California, Connecticut, and Florida State 

prisons indicated that more than 

80 percent had used substances 

regularly during their lifetimes 

while 71 percent reported regular 

substance use during the month

prior to their most recent arrest

(Acoca and Austin 1996). A study

conducted by the Connecticut

Department of Corrections indicated that 45 percent of female 

prisoners compared to 22 percent 

Adapting Offender Treatment for Specific Populations 95 
of male prisoners were in need of substance 

abuse treatment (Acoca 1998). 

Many of the issues discussed in this section 

apply to male offenders as well as to females 

but are discussed here because the issues create greater problems for women offenders. 

(For more on women’s treatment issues in 

general, see the forthcoming TIP Substance 

Abuse Treatment: Addressing the Specific 

Needs of Women [CSAT in development g].) 

Compared to their male counterparts, female 

inmates are more likely to have mental disorders (Ditton 1999), to be HIV positive 

(Maruschak 2004), to have been physically or 

sexually abused (Harlow 1999), and to have 

lived with their children in the month prior to 

their arrest (Mumola 2000). According to 

Peters and colleagues’ (1997) study of women 

in a Tampa, Florida, jail treatment program, 

the most common mental disorders that incarcerated women have are serious depression 

and anxiety disorders. In another study of 

women in jail awaiting trial, 60 percent were 

found to have substance abuse or dependence, 22 percent had posttraumatic stress 

disorder (PTSD), and nearly 14 percent had 

at least one major depressive episode in the 6 

months before entering jail (Teplin et al. 

1996). Varese and colleagues (1998) demonstrated that depression among female inmates 

is greater among women who have deficits in 

social skills (e.g., are less assertive and/or are 

more aggressive), have dysfunctional attitudes, and are less able to provide self-reinforcement. These issues must be dealt with in 

substance abuse treatment programs for 

incarcerated women because they are intertwined with substance abuse and criminal 

behavior (Henderson 1998). 

Few substance abuse treatment programs 

have been developed specifically for female 

offenders, and many of the programs that do 

exist for women in jails and prisons are based 

on treatment models developed for male 

offenders (Peters et al. 1997). However, available research suggests that treatment tailored 

for female offenders is effective. For example, 

an outcome study of Forever Free from Drugs 

and Crime, a California program created 

specifically for women offenders, found that 

the longer an offender remained in Forever 

Free, the more likely she was to stay out of 

jail. Women participating in Forever Free 

come from California State prisons, live in a 

240-bed housing unit, and receive treatment 

four hours per day, five days per week. 

Counseling addresses issues specific to 

women, such as dependency, physical and sexual abuse, and parenting. Information on 

Forever Free is available online at 

http://www.drugstrategies.org/ks1998/p_crimin.html or through the California Department 

of Corrections Office of Substance Abuse 

Programs at (916) 327-3707. 

Women in treatment, particularly those in 

early recovery, need to feel they are in a safe 

environment, but many do not feel, and some 

are not, safe in jail or prison (Covington 

1998). To try and make the treatment experience feel safer, the harsh confrontational 

techniques often used in therapeutic communities (TCs) can be modified for women’s programs. Instead, a more supportive approach 

should be used, emphasizing therapeutic 

sanctions (e.g., participation in treatment 

activities) rather than punitive consequences 

(e.g., work assignments) for breaking rules. 

Nearly all women’s programs consider the use 

of harsh language, expressions of hostility, 

and physical force by staff members as detrimental to their clients’ recovery (Welle et al. 

1998). Indeed, such staff actions can recreate 

abusive interpersonal situations experienced 

by many of the female offenders while they 

were in the community. Also, rather than 

needing help in anger management, women 

are more likely to benefit from learning techniques to reduce “guilt and self-blame, 

improve self-esteem and self-awareness, and 

attempt to create an environment of safety 

and support” (Peugh and Belenko 1999, p. 

31). Women are more likely to complete a 

treatment program designed specifically for 

women (Roberts and Nishimoto 1996), and 

clinical experience suggests that women are 

more likely to disclose personal trauma, such 

96 Chapter 6 
as sexual abuse and domestic violence, in single-sex groups. 

Based on their research with women referred 

to a jail-based substance abuse treatment 

program, Peters and colleagues (1997) recommended that programs for female offenders 

adapt treatment approaches developed for 

clients with co-occurring disorders (COD). In 

part, this is because COD are so common in 

this population, but also because this is one 

area where more sensitive and flexible clinical 

approaches have been developed. They stress 

the need to be flexible in terms of the 

sequence, focus, and intensity of treatment 

and to adapt treatment to individual needs 

wherever possible. They also note that time 

needs to be set aside for the assessment and 

diagnosis of COD and for teaching a range of 

skills (i.e., parenting, nutrition and health 

care, accessing social services and housing) 

that are generally not considered as important in treatment programs for male 

offenders. 

Further information on women’s treatment 

issues in general can be found in the forthcoming TIP Substance Abuse Treatment: 

Addressing the Specific Needs of Women 

(CSAT in development g), and more information about treatment for female offenders can 

be found in Technical Assistance Publication 

23, Substance Abuse Treatment for Women 

Offenders: A Guide to Promising Practices 

(Kassebaum 1999). 

Histories of Physical and

Sexual Abuse 

Histories of abuse are of particThe panel recommends that screening for a 

history of abuse be included as part of the 

intake assessments for women in criminal justice treatment settings; to do this, a psychosocial history should be taken that asks about 

issues such as childhood abuse and domestic 

violence. One difficulty with addressing these 

issues with women who are incarcerated is 

that immediate ongoing counseling is not 

always possible, given that counseling staff 

may not be available every day. The consensus panel feels that programs should have 

aftercare available for clients with histories of 

abuse. These issues can take a long time to 

work through and, depending on the setting 

in which treatment is provided, sufficient 

time may not be available within the program. Treatment providers should be aware 

of the range of aftercare options available for 

clients who are leaving the facility to enter 

either the community or another 

facility. 

Indepth treatment for the trauma related to a 

history of abuse should be provided by professionals specifically trained in this area. 

However, innovative strategies that help 

women address issues of abuse at a level with 

which they are comfortable have been developed. For example, the Empowerment 

through Literacy Project helps women 

address issues of sexual abuse in a supportive 

group atmosphere. Women participate in a 

reading group that facilitates discussions on a 

number of important issues (e.g., sexual 

abuse, substance abuse) at the same time it 

promotes literacy. Readings pertinent to these 

women’s life experiences are selected, including books such as Maya Angelou’s I Know 

ular concern for female offenders and can have a significant 

impact on treatment. (In the 

general population, about one 

third of women and between 3 

and 24 percent of men have 

experienced physical or sexual 

abuse. Among substance using 

populations, the figures are 

higher [Gil-Rivas et al. 1997].) 

Advice to the Counselor: 

Treating Female Offenders

• Nearly all women’s programs consider the use of harsh 

language, expressions of hostility, and physical force by 

staff as detrimental to client recovery as these actions 

recreate abusive interpersonal situations experienced by

many of the female offenders while they were in the 

community. 

Adapting Offender Treatment for Specific Populations 97 
 

Why the Caged Bird Sings, Janet Fitch’s 

White Oleander, and Elena Diaz Bjorkquist’s 

Suffer Smoke. 

Under community supervision, an offender’s 

primary goal needs to be to remain drug free 

and out of trouble, and treatment programs 

may not have sufficient time or resources to 

treat all issues that impact their clients. In 

such cases, however, programs should be prepared to assist clients in finding a suitable 

treatment program where they can receive 

treatment for traumatic effects of abuse. 

Some providers conduct survivors’ groups 

that are geared toward including treatment 

for trauma issues within substance abuse 

treatment for women. 

In addition to substances, women can also 

abuse children or even, occasionally, spouses. 

However, if a cycle of ongoing violence is 

going to be interrupted, the nature of a 

woman’s crime should not disqualify her for 

treatment. For example, a woman who is 

incarcerated for killing an abusive spouse will 

likely be considered a violent offender and 

therefore not qualify for treatment. 

Two other TIPs are valuable sources of information about treating women with histories of 

child abuse (TIP 36, Substance Abuse 

Treatment for Persons With Child Abuse and 

Neglect Issues [CSAT 2000d]) and who have 

been victims of domestic violence (TIP 25, 

Substance Abuse Treatment and Domestic 

Violence [CSAT 1997b]). The forthcoming 

TIP Substance Abuse and Trauma (CSAT in 

development f) also contains useful information. 

Low Self-Esteem

Low self-esteem certainly is not just a 

women’s issue. Many offenders, both male 

and female, experience low self-esteem. Guilt 

and shame over past actions are often contributing factors to a poor self-image and low 

self-esteem, but so is a history of discrimination (whether toward the individual or the 

culture/ethnic group to which he or she 

belongs) that can produce poor self-esteem 

when internalized. Low self-esteem often 

takes years to produce; it can begin early in 

life and be increased by physical and sexual 

abuse, substance abuse, and arrest and incarceration. In order to improve a client’s selfesteem, programs need to address this issue 

continually, affirming at each stage of treatment the client’s ability to change and create 

a positive life. 

The strengths-based approach to treatment is 

widely considered the most effective approach 

for improving women’s self-esteem. The panel 

also recommends that group work be used 

with both women and men as a crucial means 

of building self-esteem. (TIP 41, Substance 

Abuse Treatment: Group Therapy [CSAT 

2004], has extensive information on how to 

conduct a variety of substance abuse treatment groups.) Presenting positive role models 

to clients also is essential for women (even 

women who have not gone through the criminal justice system can be role models). 

For women, the more time spent in treatment 

the more likely self-esteem will increase; this 

increase is most likely if the women are in a 

residential/inpatient setting. A residential TC 

helps women build awareness of their 

strengths and helps them “practice” having 

higher self-esteem (De Leon and Jainchill 

1981). However, if treatment is provided in 

an outpatient setting, women often return to 

unhealthy situations (e.g., domestic abuse, a 

job with low pay and high stress) after their 

treatment session and their self-esteem will 

drop again. It takes an extended period of 

positive reinforcement to raise a client’s selfesteem to a level sustainable in the face of 

oppressive forces. Of course, eventually 

clients will need to leave a treatment program, but to make that difficult transition as 

smooth as possible, programs should help the 

client connect to an appropriate support 

group. 

Parenting and Child Custody

The majority of women imprisoned in jails or 

prisons are parents and some programs in 

98 Chapter 6 
and out of prison are adding parenting workshops to their agendas (see text box below). In 

1999, more than 1.5 million children had a 

parent in prison (Mumola 2000; Petersilia 

2000), and many more children have had a 

parent incarcerated during a period of their 

early lives. At least half of the children of 

imprisoned mothers have not seen or visited 

their mothers since incarceration began. 

Under the Adoption and Safe Families Act of 

1997, parents of children in foster care for 15 

or more of the past 22 months may have their 

parental rights terminated by the State. 

Given that the average prison term for incarcerated women is 15 months (Genty 1998), an 

increasing number of parents are permanently banned from their children’s lives—often a 

devastating blow for mothers and their 

children. 

Parenting is not just a women’s issue, and, in 

fact, the vast majority (93 percent) of incarcerated parents are male. However, mothers 

in State and Federal prisons are often (46 

percent and 51 percent of the time, respectively) the sole parent living with their children at the time of their incarceration; 31 

percent of mothers in prison were the only 

adult caring for their children before incarceration. Only 28 percent of the children of 

women in State prisons reside with their other 

parent and nearly 10 percent live in foster 

care or an agency. The majority of incarcerated mothers rely on grandparents or other 

members of their extended family to care for 

their children while they are incarcerated 

(Mumola 2000). If a woman is in prison and 

has no one else to care for her children, her 

loss of custody could be permanent. 

Innovative community reintegration programs 

for female prisoners may feature eventual 

reunification with their children as a significant motivator for treatment. 

Many incarcerated women feel enormous guilt 

about being away from their children and 

worry about maintaining custody of their 

children (Covington 1998). This guilt may be 

a motivating force, but it can also overwhelm 

the client and be a cause for relapse. In some 

cases, children are used to coerce a parent 

into treatment; family drug courts, for example, may remove children from a mother’s 

custody if she does not successfully complete 

treatment. However, the presence of children 

can be a mother’s only link to a stable life, 

and after losing her children to a Child 

Protective Services agency or another family 

member, she sometimes increases her substance abuse. 

Research does suggest that it is in the best 

interest of both mothers and their children to 

have continued interactions while the woman 

is incarcerated. Early research by Holt and 

Miller (1972) found that maintaining family 

ties and providing parenting training positively affected a parent’s success on parole. 

Stevens and Patton (1998) have found that 

women in a modified TC that enables them to 

have their children with them had better 

treatment outcomes than women who had the 

same treatment unaccompanied by their children. The panel encourages jail and prison 

programs to allow for more interaction 

between incarcerated mothers and their children; the 2–4 hours of supervised visitation 

per week that many institutions allow is not 

A Program for Paroled Women and Their Children 

Walden House opened a residential treatment facility for paroled women and their children in El Monte, 

California, in 1999 as part of the Female Offender Treatment and Employment Programs (FOTEP). The 

program is based on the TC model but includes parenting skills, education and vocational preparation, job 

readiness, job placement, and intensive case management. FOTEP fosters an environment where clients 

learn new ways of meeting their needs without relying on substances. In addition to its emphasis on obtaining employment, the program includes components for children and models parenting behaviors (Smith 

2001). 

Adapting Offender Treatment for Specific Populations 99 
The DWCF Program for Women and Their Children 

DWCF opened in early 1999 to serve the needs of 900 female offenders. In addition to providing treatment 

for substance abuse and mental health problems, DWCF follows recommended treatment principles for 

incarcerated women by addressing gender-specific treatment issues such as improving the relationships of 

mothers and their children and increasing contact between them. All mothers in DWCF participate in a 12­

week Parenting Skills Seminar as well as a 12-week seminar that focuses on family relationships (the Family 

Dynamics Seminar). Among other things, these seminars teach mothers about the importance of regular 

phone contact with their children to discuss things such as homework, report cards, and special school 

events. Additionally, the facility has placed special emphasis on increasing the frequency of phone contacts 

and visits between mothers and children. Visits are encouraged and facilitated by the DWCF staff. Special 

children’s visiting areas have been created; these are painted with motifs from children’s literature and furnished with colorful children’s furniture, games, books, and toys. The environment is attractive and appealing to children and facilitates positive mother–child interactions. The DWCF administration also has established a collaborative relationship with a Quaker volunteer organization, whose members provide weekly 

transportation for children (and their caretakers) who lack other means of transportation to the facility. 

Additionally, the facility has developed several apartments within the prison, permitting weekend visits for 

mothers and their children during the 4 to 6 weeks prior to the mother’s release into the community; these 

visits help to reconnect mothers and their children during the crucial period just prior to discharge or 

parole. Staff monitor these visits and provide support and assistance for mothers and their children when 

needed. 

sufficient for mothers or their children. One 

program that is attempting to increase interactions between incarcerated mothers and 

their children is located at the Denver 

Women’s Correctional Facility (DWCF) and is 

described in the box above. 

Job Skills Training 

As Peugh and Belenko (1999) note, female 

inmates with substance use disorders have 

poorer employment histories than their male 

counterparts, and likely have fewer opportunities for employment (especially at jobs that 

Advice to the Counselor: 

Parent Training 

• Discussions of parenting and the welfare of one’s children often promote strong emotional explorations and 

counseling opportunities. 

• Offenders are sometimes more receptive to treatment 

and more willing to accept prosocial values when the 

appeal is made for the sake of their children. 

pay more than minimum wage) than do men. 

Vocational training would reduce the need for 

women to turn to illegal sources of income to 

support themselves and their families after 

release (Peugh and Belenko 1999). Therefore, 

vocational training should be a priority for 

female offenders in substance abuse treatment; however, this often is not the case. The 

vocational options available for female 

inmates are often extremely limited compared 

to the options available for male offenders. 

Male offenders have more opportunities to 

learn higher-paying job skills (such as carpentry or mechanics) than female offenders, 

and so women too often return 

to jobs in the community that 

pay a low wage, do not enable 

them to support themselves and 

their children, and do not raise 

their self-esteem. 

The panel recommends that in 

prisons and jails, substance 

abuse treatment programs and 

TCs introduce vocational programs for women and expand 

100 Chapter 6 
the range of vocational skills taught. 

Programs for offenders under community 

supervision can obtain access to community 

vocational programs that will accept their 

clients. Because so many incarcerated women 

with substance use disorders have no real 

employment history or work skills, clients will 

benefit from learning prevocational skills, 

earning GEDs, and meeting other educational 

goals. Counselors can assess both women’s 

vocational interests and their existing work 

skills. One innovative program that is targeting women with substance use disorders who 

are serving a prison sentence was developed 

by the Project for Homemakers in Arizona 

Seeking Employment (PHASE). A complete 

description of the program is available online 

at http://www.ag.arizona.edu/impacts/2000/ 

ready3.pdf. 

TIP 38, Integrating Substance Abuse 

Treatment and Vocational Services (CSAT 

2000c), provides information on the importance of vocational services, how to integrate 

them into substance abuse treatment programs, and, in a chapter titled “Working 

With the Ex-Offender,” specific information 

on the vocational training needs of offenders. 

Men’s Treatment 

Issues

Because men make up the vast majority of 

offenders and because gender bias often 

makes people see men’s treatment as the 

norm, it sometimes is difficult to see how certain issues need to be addressed for men in 

substance abuse treatment programs. 

Typically, these are issues that have been 

thought of as women’s issues (e.g., sexual 

abuse, parenting) but also can include issues 

that are significant for men in the general 

population, but often forgotten for offenders 

(e.g., status). Much of the information presented above also applies to men. For more 

information on men’s issues related to substance abuse treatment, see the forthcoming 

TIP Substance Abuse Treatment and Men’s 

Issues (CSAT in development e). 

Fathering 

Male offenders often are very concerned 

about the welfare of their children, although 

socially defined gender roles still put more 

pressure on women to be good parents. Male 

offenders may not talk as much about their 

children or the feelings they have for them, 

but they often keep pictures of them and, if 

asked about them, express concern. 

According to Mumola (2000), 40 percent of 

fathers in State prison had at least weekly 

contact with their children. 

It is particularly difficult for male offenders 

to admit that they failed as fathers. Being a 

good father is not, as some might expect, 

looked down on in prisons as a sign of “weakness,” but rather is generally perceived as an 

important and valuable activity. However, an 

individual perhaps feels a conflict between his 

role as a caring parent and the role of a 

“hardened criminal” that he presents within 

the prison. 

Many male offenders feel inadequate when 

dealing with their children and have never 

had any instruction or assistance in how to be 

a good father. Their own fathers often were 

poor role models, and some were (and may 

still be) incarcerated themselves, even in the 

same prison. This does not mean, however, 

that they are bad fathers—just that they are 

not aware of what they should be doing or 

how well they are doing in that role. 

According to Landreth and Lobaugh (1998), 

at the end of a parent training class a group 

of incarcerated fathers was more accepting of 

their children, perceived fewer problems with 

their children, and had less stress about parenting compared with offenders who did not 

participate. The children benefited as well 

from the structured play therapy, as their 

self-concept scores improved significantly. 

Parent training can also serve as a bridge to 

counseling. Few criminal justice clients want 

their children to wind up in prison. 

Discussions of parenting and the welfare of 

one’s children often promote strong emotional 

explorations and counseling opportunities. 

Adapting Offender Treatment for Specific Populations 101 
Offenders are sometimes more receptive to 

treatment, and more willing to accept prosocial values, when the appeal is made for the 

sake of their children. 

Developing Relationships

Learning how to relate to people and build 

relationships (including how to be a friend) 

takes a lot of work for men. In many cases, this 

is not a matter of rehabilitation but rather 

habilitation; some male offenders do not understand how to be a friend, family member, or 

significant other. They often experience great 

difficulty even talking about this issue, in spite 

of the fact that they want to learn these skills. 

One of the attractions of gang participation is 

that it gives members a sense of belonging and 

a certainty about their relationships with one 

another that they do not have outside the gang. 

Thus, treatment should encourage men to form 

relationships based on a shared experience 

with recovery. Relationship training also is 

important for job success. Learning how to 

communicate with peers and supervisors is necessary for maintaining employment and 

advancement. 

Working With Violent 

Offenders

While substance abuse treatment providers 

working in any setting may need to discuss violence in a client’s past, this issue is especially 

important when working in the criminal justice 

system because offenders’ violence often has 

led to their arrest and conviction. Clinicians 

also must be aware of the possibility that violence could erupt in the treatment program and 

should pay careful attention to issues that 

could trigger violence between offenders. 

Relationship Between

Substance Abuse and Violence 

Literature on the subject generally concludes 

that substance use often is a cause of or a 

predisposing factor for violence (Friedman 

1998). Alcohol is the most frequently used 

substance that can precipitate violent crime. 

According to victim reports, perpetrators 

were clearly under the influence of alcohol in 

nearly 35 percent of violent crimes; twothirds of victims who suffered violence caused 

by a current or former spouse or partner also 

reported that alcohol was a factor in the incident (Greenfeld 1998). In a 1997 survey, 41.7 

percent of State prison inmates and 24.5 percent of Federal inmates convicted of a violent 

crime reported that they were under the 

influence of alcohol at the time they committed the crime for which they were convicted; 

29 percent of State and 24.5 percent of 

Federal inmates reported that they were 

under the influence of drugs at the time 

(Mumola 1999). 

There is some evidence that cocaine, 

amphetamines, and possibly other substances 

also have the potential to stimulate violent 

acts. The relationship of cocaine to violence is 

better established for those inner-city residents who predominantly use crack cocaine 

(Friedman 1998). The possible effect of race, 

ethnicity, or culture on this relationship has 

not been studied systematically. Although 

more research is needed, there is at least 

some reason to believe that the relationship of 

drug and alcohol use to violence may be 

affected by cultural factors as well (Valdez et 

al. 1997). Earlier substance abuse seems to be 

associated with subsequent violent behavior 

for both women and men. The effect of alcohol as a precipitant of violent crime is better 

established for men than women (Friedman 

1998). 

The relation between substance use and violence is complicated, and there are many 

individual and group differences in the way 

substances are used and how they affect people. Some people may in fact use substances 

in order to be calmer and less prone to violence; others may use them to forget the guilt 

associated with past acts of violence, which 

may then precipitate further acts of violence. 

102 Chapter 6 
Drugs influence levels of violence in other 

ways. The business of manufacturing and selling drugs can be very violent, and offenders 

who have been involved in these activities 

may have committed violent acts in order to 

survive and succeed. A study demonstrating 

that legal prohibitions against the use of alcohol or drugs actually increase the level of violence (and homicide in particular) was published by Miron in 1999. 

Managing Violence 

Within prison culture, violence is an everyday part of life and inmates may resort to violence in order to protect themselves. The 

prevalence of violence in the system reduces a 

client’s feeling of safety within the treatment 

setting. Many offenders react with violence 

because they have never developed the social 

and coping skills necessary to react to problems in more positive ways. This lack of skills 

is even more prevalent in offenders with 

extensive histories of substance abuse. 

Interpersonal violence is also associated with 

methamphetamine abuse (Cohen et al. 2003). 

The prison culture reinforces violent behavior. Individuals who are incarcerated without 

a history of violence quickly learn its value in 

jail or prison. Past violence is an issue particularly for offenders who are making the transition from incarceration to the community 

because past actions may come back to 

“haunt” them. It can be difficult to find treatment programs in the community that will 

accept violent offenders. 

A number of programs have been developed 

to help offenders stop violent behaviors. 

Many of these programs use variations on 

cognitive–behavioral therapy (CBT) and ask 

offenders to look at their “criminal thinking” 

and the ways in which it leads them to commit 

violent crimes. Several programs have been 

developed from the model of the Oakland 

Men’s Project, a community-based violence 

prevention program for men that began in 

1979. This project developed a series of workshops that use role-playing exercises to help 

men understand how society pressures them 

to commit (and rewards them for) violent 

actions. 

Programs such as the Violence Interruption 

Process (VIP) of the Illinois TASC (Treatment 

Alternatives for Special Clients) and the Ohio 

Department of Alcohol and Drug Addiction 

Service’s (ODADAS) Ohio Violence 

Prevention Process (OVPP) were developed 

from the Oakland Men’s Project model. 

Illinois’s VIP works on the assumption that 

violent behavior is 

learned and has an 

institutional as well 

as a personal dimension. When people 

become aware of Treatment should 

encourage men to 

form relationships 

based on a shared 

experience with

recovery. 

how they have 

learned violent attitudes and behaviors, they can learn 

new methods of 

communication and 

resolving conflicts 

(People for Peace 

1996). ODADAS 

provides onsite 

trainings in OVPP 

to substance abuse 

treatment programs, 

corrections programs, school systems, and other groups; trainings touch on a 

variety of issues including the connection 

between substance abuse and violence, the 

role of racism and sexism in violence, and 

building multicultural alliances (ODADAS 

2000). More information on promising violence prevention and psychoeducational programs in a range of locales can be found on 

the Partnership Against Violence Network 

(Pavnet) Web site (http://www.paDV.org). 

Anger management groups are another useful 

intervention with this population but the consensus panel recommends that these groups 

be connected with other interventions and not 

simply provided as a stand-alone treatment 

for violent offenders. A variety of curricula 

are available for running anger management 

Adapting Offender Treatment for Specific Populations 103 
groups in jail or community settings. 

Incentives also are very important when dealing with this population. These are clients 

who have not had much positive reinforcement in their lives and have grown accustomed to reacting to negative reinforcement 

with anger and resentment. Head trauma and 

related brain injury can be another cause of 

violent behavior 

(Diaz 1995; 

Robinson and 

Kelley 2000).

People with 

substance use 

disorders may 

experience a 

coexisting cognitive or physical 

disability. 

In some cases, medication may be

called for in order 

to manage aggressive behaviors 

(Lavine 1997).

When medical, psychiatric, and substance abuse assessments indicate that 

a client’s aggressiveness is not under 

control, pharmacological treatment 

sometimes is considered. 

Treatment Issues

Based on Client’s

Sexual Orientation

Sexual orientation and sexual behavior are 

not necessarily congruent, especially within a 

prison or jail. Many offenders who engage in 

homosexual activity while in jail or prison do 

not self-identify as gay, lesbian, or bisexual. 

Others, who may recognize that they are gay, 

lesbian, or bisexual, do not openly proclaim 

that fact (i.e., are not “out”) in an incarcerated setting because they fear reprisals. The 

institutional culture of men’s jails and prisons 

may recognize only the “passive” or receiving 

sexual partner as gay, which supports a heterosexual self-identification for some men 

who engage in homosexual activity. 

Incarcerated individuals may engage in sexual 

activity with members of the same gender for 

many reasons, not all of which reflect their 

sexual identity. Self-identified heterosexuals 

may engage in prostitution for money or have 

sex in order to gain the protection they need 

to survive within the jail or prison. For such 

individuals, sexual identity can become an 

especially important issue upon release as 

they try to understand their sexual activity 

and how it relates to their identity and sexual 

identification. There may be, in fact, men 

within the prison system who have had more 

sex with men than women but who still identify as heterosexual. These individuals may 

face particular difficulties when they return 

to sex with female partners and may use substances in order to facilitate heterosexual 

activity. 

Reliable data on the prevalence of homosexual behavior in jails and prisons are limited. In 

one study of a low-medium-security prison, 

which claimed to underreport some types of 

sexual behavior, 55 percent of self-identified 

heterosexuals reported being involved in sexual activity in prison (Donaldson 1990). 

Despite disciplinary codes in jails and prisons 

that prohibit all sexual activity, such behavior still occurs. Within men’s prisons there is 

a social hierarchy based on sexual roles. 

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. Relationships 

between inmates imply obligations by each 

partner: the dominant partner to defend his 

partner physically against mistreatment by 

others and the receptive partner to obey the 

other (Donaldson 1990). 

In a study of homosexual behavior in prison, 

Alarid (2000) surveyed men incarcerated in a 

county jail who had requested and received 

protective custody because of their sexual orientation. The gay and bisexual men in the 

group tended to be older and never married. 

104 	 Chapter 6 
Nearly half were African American. Slightly 

more than half of the men in this study selfidentified as bisexual, with one third of those 

preferring female partners (bisexual/heterosexual). Gay and bisexual men were generally 

satisfied with their sexual orientation. Almost 

one fourth of the group (a majority of them 

gay) exchanged sex for money or favors. The 

bisexual/heterosexual group felt more pressure to have sex and often used it to gain the 

protection of another inmate. This is perhaps 

a result of the fact that the group was small in 

number and that other inmates sought them 

as sexual partners. Most of the group believed 

that their fellow jail inmates treated them disrespectfully. Only a few gay inmates and none 

of the bisexuals felt that jail personnel tolerated gay behavior or gay or bisexual individuals. More than a third of this group feared 

being raped in prison and believed that having the protection of a heterosexual was the 

best way to do prison time (Alarid 2000). 

In male institutions, individuals who do selfidentify as gay are often victims of rape 

and/or physical violence. They may need to 

resort to violence to protect themselves or else 

become a sexual partner of someone who can 

protect them. However, these are not typically mutual relationships and the gay partner 

often needs to assume a submissive role that 

may not be compatible with the sexual role he 

prefers; gay inmates often wish to distance 

themselves from these partners upon release. 

Many women also face conflicts between sexual orientation and sexual behavior when 

incarcerated. However, generally, confusion 

around sexual orientation is not as difficult 

for women because sexual encounters in 

prison involve more of a relationship than 

they do for men; sexual activity is often a 

part of a nurturing, family relationship (and 

women often explicitly take on roles as “husbands and wives”). It is assumed that the 

prevalence of homosexual activity in women’s 

jails and prisons is similar to that in men’s. In 

contrast to relationships among men, women 

establish partnerships voluntarily and consensually. These partnerships are generally 

respected by other inmates (Donaldson 1990). 

Female offenders also seem more accepting of 

openly lesbian women than their male counterparts are of openly gay men. Overall, lesbian women have an easier time dealing openly with sexuality while incarcerated than gay 

men. They may develop very close relationships with other women while incarcerated 

and express regret that the relationship may 

end after one partner leaves the institution. 

Some lesbian offenders say that they enjoy 

the sexual freedom that a prison environment 

allows them, and, after release, may express a 

desire to return to a relationship they had 

while incarcerated. 

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 increased substance 

abuse. For more general information on 

working with this population, see A 

Provider’s Introduction to Substance Abuse 

Treatment for Lesbian, Gay, Bisexual, and 

Transgender Individuals (CSAT 2001). 

Treatment Issues

Based on the Client’s

Cognitive/Learning, 

Physical, and Sensory

Disabilities

People with substance use disorders may 

experience a coexisting cognitive or physical 

disability. A study by the New York State 

Office of Alcoholism and Substance Abuse 

Services found that more than 22 percent of 

the clients served by licensed treatment facilities had a co-occurring mental or physical 

disability (CSAT 1998d). Self-reports from 

inmates in 1997 indicate that 31 percent of 

State prisoners and 23 percent of Federal 

prisoners had learning or speech disabilities, 

hearing or vision problems, or mental or 

physical conditions. This includes 108,000 

individuals with learning disabilities, 135,000 

Adapting Offender Treatment for Specific Populations 105 
with physical impairments, 65,000 with hearing problems, and 94,000 with vision problems (Maruschak and Beck 2001). 

Evidence suggests that people with cognitive 

disabilities are disproportionately involved in 

the criminal justice system (Cockram et al. 

1998). Nearly one third of inmates in State 

prisons and one quarter of those in Federal 

prisons report having a physical or cognitive 

disability. These data, derived from selfreports, are likely to underrepresent some 

conditions, including learning disabilities, of 

which inmates themselves may not be aware. 

Ten percent of State and 5 percent of Federal 

prison inmates report a learning disability. 

Also, data from inmates in State prisons show 

that they are three times more likely than the 

general population to have a speech disability 

and more than twice as likely to have 

impaired vision. These inmates are, however, 

slightly less likely to have a hearing impairment, but this can be accounted for by the 

age and gender differences from the general 

population (Maruschak and Beck 2001). 

People with cognitive disabilities are at a significant disadvantage in their contacts with 

the criminal justice system. For example, 

offenders with developmental challenges are 

disproportionately likely to be arrested and 

coerced into a confession for a crime they did 

not commit. They may not understand their 

Miranda rights and are eager to please, ignorant of the value of remaining silent, susceptible to leading questions, insensitive to nonverbal cues, and desirous of appearing competent (Cockram et al. 1998). They also are 

easily led into criminal activity by others, 

and, in their desire to feel like they belong to 

a group, they may even view arrest and incarceration as successful achievements (Wood 

and White 1992). Inside jails and prisons, 

they tend to be victimized by other inmates, 

and often try to hide the presence of their disability in order to avoid further victimization. 

According to focus group interviews with family members of people with cognitive disabilities, one way the criminal justice system could 

better assist people with cognitive disabilities 

is to provide qualified staff members to work 

with them in the early stages of the legal process (Cockram et al. 1998). 

Jails and prisons can be difficult places for 

people with physical disabilities (e.g., there 

may be no wheelchair access and bathrooms 

may not be fitted with hand rails). Sometimes 

clients with disabilities can be moved to other 

facilities that are not necessarily appropriate 

for them, given their sentence (e.g., they may 

be moved to a medium security facility even 

though their sentence warrants maximum 

security). In June 1998, the U.S. Supreme 

Court ruled that State prisons must comply 

with the provisions of the Americans with 

Disabilities Act. This means that they must 

make reasonable accommodations to provide 

access to basic facilities and services for eligible prisoners with disabilities (American Civil 

Liberties Union 1998). 

Certain physical disabilities require medication, and this can pose particular problems 

for treatment facilities in jails and prisons. 

Facilities may need to give offenders medications at specific times that could conflict with 

other scheduled activities. Clients under community supervision require a support system 

that can help them manage their medication 

and oversee compliance. 

Clients who have conditions such as diabetes 

that require the administration of medication 

by means of a syringe may face daily 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 

looking at these triggers and developing a 

relapse prevention plan that addresses them. 

For example, individuals who need to administer medications using a syringe who are no 

longer in a residential program could have a 

friend or relative available to be with them 

when they give themselves their shots (at least 

for the first few months after release). 

Programs can provide these individuals with 

a small safe where they can keep needles and 

should advise them to keep syringes in more 

106 Chapter 6 
than one place so that if any are stolen they 

will still be able to administer their medication. Individuals should always check their 

syringes to see if others have used them and 

should keep a supply of bleach available to 

clean needles if they suspect their needles 

have been used. 

Given the prevalence of disabilities in incarcerated populations, especially among offenders with substance use disorders, the consensus panel suggests that treatment providers be 

able to screen for co-existing disabilities and 

make accommodations for offenders who have 

them. For example, someone with mental 

retardation may not be able to participate in 

a traditional TC and may need to be sent to a 

modified TC or have another suitable treatment option available. Information on treatment for clients with co-existing disabilities 

can be found in TIP 29, Substance Use 

Disorder Treatment for People With Physical 

and Cognitive Disabilities (CSAT 1998d). 

Treatment Issues for

Older Adults

Age is a factor associated with positive treatment outcomes. The older one is the more 

likely one is to stay in treatment, complete 

treatment, and have positive outcomes following treatment. For some older clients the negative consequences of a criminal lifestyle 

accumulate over time, while the body 

becomes less capable of managing substance 

abuse and related stressors, leading to a 

desire for change. Engaging these individuals 

in treatment may be relatively easy. However, 

older offenders also have unique issues that 

counselors need to be prepared to address. 

For one, this population is more prone to 

health problems. Visual impairments and 

hearing loss are factors, along with chronic 

health problems, senile dementia, and dementia related to long-term substance abuse. 

Other characteristics typical of this population that complicate treatment include 

•A slow response to directions 

• Rigid habits 

• The likelihood of a physical condition presenting as an emotional problem 

• Lifelong patterns of criminal behavior that 

cannot easily be altered 

• A lack of assertiveness, suggesting that 

younger, more verbal inmates are more likely 

to get treatment (Chaiklin 1998) 

Readers are referred to TIP 26, Substance 

Abuse Among Older 

Adults (CSAT 

1998c), for more 

information on substance abuse treatment for this popu- Age is a factor 

associated with 

positive treatment

outcomes.

lation. See also 

chapter 9, Issues 

Specific to 

Treatment in 

Prisons, for a 

description of how 

older inmates can 

serve an important 

function in prisonbased substance 

abuse programs. 

Treatment Issues for

Clients From Rural

Areas

In the past, alcohol has been the largest substance abuse problem in rural areas, but that 

is beginning to change. While certain substances of abuse are more available than others, illicit substances are reaching rural communities. There is now no difference in 

prevalence of illicit drug use between large 

and small metropolitan areas and rural areas 

with the exception of marijuana (National 

Center on Addiction and Substance Abuse 

[CASA] 2000). In an evaluation of substance 

abuse in rural Nebraska, marijuana was 

found to be the most common drug (as it was 

in urban areas), but methamphetamine abuse 

was more common than cocaine abuse; those 

Adapting Offender Treatment for Specific Populations 107 
who abused substances tended to be younger 

than those in urban Nebraska and were more 

likely to be involved in the selling of drugs 

(Herz 2000). However, these patterns vary by 

region; for example, in rural northern 

Louisiana, cocaine abuse predominates and 

methamphetamine abuse does not seem to be 

a significant problem (Monroe 1998). Abuse 

of OxyContin has been more common in several rural areas, such as the eastern 

Kentucky and western Virginia areas of 

Appalachia. 

Clients from rural communities have distinct 

cultures that differ from region to region. 

Treatment staff working with clients from a 

particular rural population should seek to 

understand that culture in the same way they 

would any other. Increasingly, offenders from 

urban areas are being sent to prisons located 

in rural regions and staffed by local residents; here again, a cultural clash can develop, and training can help staff understand 

the cultural background of offenders coming 

from urban areas. 

Services available in rural areas may also be 

more limited than those in more densely populated regions. A rural jail, for example, is 

generally unable to develop a substance abuse 

treatment program because its resources are 

limited. Community supervision programs in 

rural areas also have particular difficulties. 

Few programs will be available, there is little 

coordination between programs, 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. 

Advice to the Counselor: 

Rural Clients, Rural Counselors 	 

• Clients from rural communities have distinct cultures that 

differ from region to region. In addition, more and more 

offenders from urban areas are being sent to prisons in 

rural regions with local staff. 

• Counselors should seek to understand urban–rural differences in culture as they would any other. 

Treatment Issues for

People With CoOccurring Substance 

Use and Mental

Disorders

According to a study conducted in 1998, an 

estimated 283,800 offenders in jails and 

prison and another 547,800 on probation 

reported having a mental disorder and/or had 

stayed overnight in a mental hospital (Ditton 

1999). Reported mental disorder varied 

across setting, with 16.2 percent of inmates in 

State prison, more than 7 percent of Federal 

prison inmates, 16 percent of jail inmates, 

and 16 percent of probationers reporting 

mental disorders or a stay in a mental hospital. Rates were substantially higher for 

women than men and for Caucasians than 

African Americans or Hispanics/Latinos. 

Individuals with mental disorders were more 

likely to have been under the influence of 

substances at the time of their offense and 

substantially more likely to report a history 

of substance abuse than others (Ditton 1999). 

The National GAINS Center, a Substance 

Abuse and Mental Health Services 

Administration (SAMHSA) initiative to study 

mental health and substance abuse services 

for people in the criminal justice system, estimates that of jail inmates identified with mental illness, 64.3 percent reported alcohol or 

drug use at the time of the offense. Among the 

State prison population the figure is 58.7 percent (National GAINS Center 1997). 

Even conservative estimates report high rates 

of mental disorders. Ditton 

(1999) reports that three previous studies of inmates in jail or

State prison with rigorous sampling methods found rates of

mental disorders to be between 8

and 16 percent. A study of

incarcerated women awaiting

trial in a Chicago jail found significantly higher rates of mental

disorders based on offender 

108 Chapter 6 
reports of psychiatric symptoms; 18.5 percent 

of the women had experienced symptoms of a 

severe disorder (i.e., schizophrenia/ 

schizophreniform, manic episode, major 

depressive episode) at some point during their 

lives, 33.5 percent had experienced PTSD, 

and 70.2 percent had a substance use disorder (Teplin et al. 1996). 

More information on the treatment of clients 

with COD can be found in TIP 42, Substance 

Abuse Treatment for Persons With CoOccurring Disorders (CSAT 2005c). 

Identifying Co-Occurring 

Disorders

There is a great deal of stigma associated with 

mental disorders even within the culture of 

prisons and jails. At the same time, in correctional institutions, substance abuse does not 

carry the same degree of stigma as it does in 

the outside community. In some prison settings, procedures such as public medication 

lines expose the inmate with a mental disorder to public ridicule, adding to the stigma 

and reinforcing the inmate’s reluctance to 

admit to his or her disorder. Offenders may 

be willing and able to face talking about their 

criminal activity or substance abuse but 

reluctant to discuss their mental disorder. 

Consequently, actual rates of mental disorders in this population are likely to be higher 

than self-reported rates. 

Because one disorder can mask or imitate the 

other, accurate diagnosis of COD requires 

skilled screening and assessment. Assessment 

should look for both problems at the same 

time, rather than separating assessments for 

mental disorders and substance abuse. 

Regular reassessment is also important. 

Trained staff should be used to perform such 

assessments. Most prison programs for 

inmates with COD do use doctoral-level staff 

for initial screenings (Edens et al. 1997). For 

more on screening and assessing for COD, see 

chapter 2. 

Co-Occurring Disorders

Treatment Programs

In order to serve the high number of offenders 

with mental and substance use disorders, a 

number of diversionary and corrections-based 

programs have been developed for offenders 

with COD. 

Diversionary programs for 

offenders with co-occurring 

disorders 

These programs, generally referred to as 

Mental Health Courts, currently exist in a 

handful of municipalities across the country 

(Broner et al. 2002). SAMHSA has funded 

jail diversion programs at nine sites for 

offenders with COD. In the Eugene, Oregon, 

program, for example, mental health and 

substance abuse treatment is collaborative; 

sanctions applied are sensitive to mental 

health problems and the case manager is a 

mental health specialist who acts as court liaison (National GAINS Center 1999b). 

Prison- and jail-based programs for offenders with cooccurring disorders 

In addition to diversion programs such as 

mental health courts, there has been a rapid 

growth in corrections-based co-occurring programs during recent years, from only 2 State 

systems that had developed these programs in 

1993, to 7 systems with programs in 1997, to 

18 systems in 2002 (Edens et al. 1997). 

However, few State systems have systematic 

procedures for identifying and tracking 

prison inmates with COD. Moreover, little 

research has yet been done on the effectiveness of these programs. Preliminary outcome 

data from one study comparing a modified 

therapeutic community (MTC) program for 

prison inmates with COD with treatment as 

usual and with a mental health group showed 

the MTC group to have fewer new arrests, 

Adapting Offender Treatment for Specific Populations 109 
less use of illicit drugs, and better compliance 

with treatment regimens (Sacks et al. 2001). 

Several features distinguish the programs that 

treat inmates with COD from other criminal 

justice substance abuse treatment programs: 

•An integrated treatment approach is used 

whenever possible. Mental health treatment 

staff, substance abuse treatment staff, and 

criminal justice staff are located in the same 

program unit, and often share in decisionmaking. In some jurisdictions, both correctional officers and community supervision 

officers have been successfully involved in 

treatment team meetings, treatment groups, 

and other therapeutic activities. A wide 

range of treatment approaches are implemented, according to the client’s stage of 

treatment. Collaboration and/or consultation may be adequate to serve offenders 

who have less severe COD. 

•Both disorders are treated as “primary.” 

Integrated treatment involves simultaneous 

consideration of both disorders and attention to the interactive nature of these disorders. However, the scope and intensity of 

treatment activities will vary according to 

the client’s needs and functioning level. 

•Comprehensive treatment services are flexible and individualized. Treatment should 

be adapted to address different levels of 

symptom severity, functioning, and commitment to treatment. Both early intervention 

and active treatment interventions should 

be adapted for different diagnostic groups 

and for offenders with special needs (e.g., 

those with cognitive impairment, women 

with trauma and abuse histories). 

•Treatment approaches that are commonly 

used in substance abuse treatment settings 

(e.g., TCs, cognitive–behavioral treatments, 

relapse prevention, peer and alumni support groups) are adapted to better suit the 

needs of offenders with COD. Common 

modifications include smaller caseloads, 

shorter and simplified meetings, special 

attention to criminal thinking, education 

about medication, and minimizing confrontation (Edens et al. 1997; Peters and 

Hills 1997). 

•Treatment is provided in graduated “phases” or “stages,” using a highly structured 

psychoeducational treatment approach. 

Early phases of treatment include a focus 

on orientation, assessment, development of 

treatment plans, and engagement and persuasion activities. Didactic approaches are 

particularly useful in early stages of treatment to help offenders understand the 

nature of their mental disorders and biological aspects of both disorders. Secondary 

phases focus more on “active treatment,” 

such as development of coping and life 

skills, lifestyle change, and cognitive– 

behavioral interventions. Later phases may 

include relapse prevention, peer mentor 

activities, vocational training, reentry planning, and linkage with community support 

and treatment programs. Case management 

and relapse prevention activities often are 

provided throughout the various phases of 

treatment, with a particular emphasis during prerelease and reentry phases. In jails, 

where the relatively brief period of incarceration may prevent the use of a long-term 

phased treatment approach, services may 

focus on assessment, brief psychoeducational interventions, community “in-reach” services, and linkage to community services. 

•The focus of treatment is long term, with an 

emphasis placed on continuity of treatment 

in aftercare and postrelease settings. 

Recovery and stabilization for offenders 

with COD often occurs over a period of several years and includes multiple treatment 

episodes. COD treatment programs should 

provide linkage with other community 

treatment and ancillary service providers, 

and should develop detailed aftercare, transition, and postrelease plans to ensure continuity of services. These should include 

provisions to furnish an adequate supply of 

psychotropic medications for the offender 

during transition from institutional to community programs. The offender also should 

be monitored carefully during transition 

periods, when stress levels are high and 

110 Chapter 6 
there is increased risk for recurrence of 

mental health symptoms, substance abuse 

relapse, and recidivism. Forensic coordinators or other case managers have been used 

successfully in some jurisdictions to help in 

community transition. 

•Staff are trained and experienced in treating both mental disorders and substance 

abuse. A blend of staff experience is needed, including those trained in working with 

acute symptoms of mental disorders and 

those who have worked in specialized substance abuse treatment settings, such as 

TCs. Cross-training activities are useful to 

share information from the perspectives of 

each of the treatment disciplines, and also 

from the perspective of security/community 

supervision. 

Programs for offenders with 

co-occurring disorders under 

community supervision 

This group of offenders will have particular 

difficulties finding aftercare programs to 

accept them because of the stigma associated 

with the combined problems of COD and a 

criminal record. Nor will most traditional 

community mental health interventions be 

effective for them, as they typically have complex problems that require specialized treatment (Broner et al. 2002). Community supervision of offenders with COD also requires 

specialized strategies (Peters and Hills 1997), 

including 

•Recognition of special service needs 

• Use of supportive rather than confrontational approaches 

•Positive reinforcement for 

small successes and progress 

•Different expectations regarding response to supervision 

• Flexible responses to infrac-

tions 

•Use of concrete directions 

• Highly structured activities 

• Ongoing monitoring 

• Enlistment of support from family members 

to work with offenders with COD where 

appropriate 

• Close coordination between the community 

supervision/probation officer and the offender’s clinician 

Medication Management 

Substance abuse treatment providers working 

with people with COD need to understand 

and be able to help educate clients about the 

importance of medication management and 

compliance. Clients sometimes have trouble 

distinguishing between “good” and “bad” 

drugs, particularly at the beginning of treatment. The distinction is made more difficult 

by the fact that the “good” medications are 

more expensive and more difficult to obtain 

than illicit drugs. There still is a myth within 

the substance abuse treatment field that use 

of psychotropic medication by individuals 

with co-occurring mental disorders should be 

discouraged. Programs in criminal justice settings should update their formulary so that 

they are using the most up-to-date medications. Offenders entering jails may have particular problems around medications because 

they may not be able to receive necessary 

medication while incarcerated or may not be 

given a supply of medication upon discharge 

(which they might need until they can get prescriptions filled). It often takes well over a 

month to be seen by a psychiatrist and to 

receive a prescription for medication. In 

addition, certain medications (e.g., antidepressants) take several weeks to build up to 

effective levels in the bloodstream. Moreover, 

Advice to the Counselor: 

“Good” and “Bad” Drugs

• Clients with COD need help with medication management, especially in distinguishing between substances of 

abuse and licit medication. 

• Counselors must be alert to inmates who skillfully mimic 

the symptoms of mental disorders in order to receive

medications.

Adapting Offender Treatment for Specific Populations 111 
 

individuals often do not have enough money 

to pay for the medication. The consensus 

panel suggests that programs working with 

people who are making a transition from 

institution to community need to ensure that 

these clients have an adequate supply of psychotropic medications. 

On the other hand some inmates can skillfully 

manipulate signs and symptoms of mental disorders in order to receive medications with 

sedative properties. Some of these medications (such as benzodiazepines, prior-generation antidepressants, and antipsychotics) can 

have serious and severe side effects. These 

medications can be sold to other inmates or 

exchanged for favors. 

Case Management Services

Case management services are useful in providing access to a broad range of mental 

health and substance abuse services and are 

complementary to a range of other treatment 

approaches used with offenders with COD. 

Research indicates that case management services can lead to improvement in a client’s 

functional status and fewer hospitalizations 

during an extended followup period (Mueser 

et al. 1997). One model is Intensive Case 

Management (ICM). ICM is provided by multidisciplinary teams that include mental 

health treatment staff, substance abuse specialists, housing specialists, and community 

supervision officers. These teams often share 

caseloads to provide flexibility in coverage. 

Participation in treatment is provided 

through crisis and outreach services, use of 

specialized engagement and motivational 

strategies, and culturally relevant programming over an extended period of time. 

Services provided by case managers are 

developed to address the stage of COD treatment (Lurigio 2000b). This includes an early 

emphasis on client engagement and commitment to the recovery process, and is followed 

by persuasion to consider abstinence and to 

begin active behavior change. Later stages of 

treatment include the use of cognitive–behavioral interventions, development of a drugfree social support network, understanding of 

relapse risks, and use of relapse prevention 

skills. Another frequently employed case 

management approach for use with COD is 

the Assertive Community Treatment model 

(ACT) (Brown 2003; Stein and Test 1980). 

Key elements of this approach include crisis 

intervention, supportive therapy, substance 

abuse counseling, skills training, medication 

monitoring, housing support, vocational rehabilitation, specialized dual diagnosis groups, 

family psychoeducational groups, and family 

outreach activities. 

Special Considerations in

Treating Antisocial Personality

Disorder (ASPD) 

Substance abuse often is associated with criminal or antisocial lifestyle and is highly correlated with ASPD (Knop et al. 1998; Robins 

and Regier 1991). Someone with ASPD does 

not accept society’s values or norms and acts 

without guilt; he sees other people as objects 

to meet his needs. According to the Diagnostic 

and Statistical Manual of Mental Disorders, 

4th edition (DSM-IV), ASPD “is a pattern of 

disregard for, and violation of, the rights of 

others” (American Psychiatric Association 

[APA] 1994, p. 645). In order to be diagnosed 

with ASPD, a person needs to demonstrate, 

after the age of 15, three or more of the associated traits. (See Figure 6-1 for list of traits.) 

Given these criteria it is easy to see why 

offenders who abuse substances often are 

diagnosed with ASPD. In a sample of 325 psychiatric patients who had recently been hospitalized, Mueser and colleagues (2000) found 

that both a history of incarceration and 

ASPD were predictive of substance use disorders. In another study that looked at clients 

in substance abuse treatment, Compton and 

colleagues (2000) found that 44 percent qualified for ASPD at some time during their life. 

Research from a male prison TC found 52 

percent of clients had ASPD (Wexler and 

Graham 1993). 

112 Chapter 6 
Figure 6-1 

Traits of ASPD (DSM-IV) 

• Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or 

pleasure 

• Irritability and aggressiveness, as indicated by repeated physical fights and assaults 

• Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor 

financial obligations 

• Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing 

acts that are grounds for arrest 

• Impulsivity or failure to plan ahead 

• Reckless disregard for safety of self or others 

• Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen 

from another 

Source: Hare et al. 1991. 

While it is generally believed that ASPD is 

more common in men than women, available 

data are mixed. Researchers studying people 

in psychiatric hospitals (Grilo et al. 1996), in 

treatment programs for alcoholism (Cornelius 

et al. 1995), and in homeless populations 

(North et al. 2004) have found significantly 

higher rates of ASPD for men than for 

women. Galen and colleagues (2000), however, found prevalence rates of 16 percent for 

men and 22 percent for women in a group of 

235 clients at outpatient substance abuse 

treatment centers. Rates are high for offenders of both genders. A study of women entering prison in North Carolina found that rates 

of ASPD were significantly higher than for 

women in the general population (Jordan et 

al. 1996), and Teplin and colleagues (1996) in 

their study of women in Cook County, 

Illinois, jails found that 13.7 percent met 

DSM-III-R criteria for ASPD within the 6 

months prior to their incarceration. 

The panel cautions that some people who 

meet the criteria for ASPD do not really have 

the disorder—their behaviors are the result 

of other factors, most notably substance 

abuse. The behavior of these clients is 

improved greatly after treatment. It is not 

easy, though, to determine who really does 

have ASPD and who does not. There also are 

people who have ASPD but who lie about 

behaviors that qualify for this diagnosis. 

Psychopathy is a term used to describe a 

more extreme form of ASPD. In addition to 

the criminal tendencies apparent in ASPD, 

people with psychopathy also exhibit affective 

and interpersonal dysfunction (Hare et al. 

1991). Moreover, offenders who score high on 

the PLC-R (the test for psychopathy; see 

chapter 2 for more information) have higher 

rates of recidivism and are more prone to violence both in and out of criminal institutions 

(Hare et al. 1991). 

ASPD and psychopathy are difficult to treat 

and in this regard are addressed somewhat 

differently from other mental disorders. 

Approaches used for offenders with ASPD 

and psychopathy are typically focused on 

behavior management rather than on counseling or other therapeutic techniques. These 

approaches involve heightened accountability 

(i.e., surveillance and monitoring), highly 

structured programming, and application of 

carefully crafted sanctions and incentives for 

targeted behaviors. 

People with severe ASPD require intensive, 

long-term residential treatment for their disorder and for substance abuse; if they interrupt treatment they are likely to return to 

Adapting Offender Treatment for Specific Populations 113 
 

previous behaviors. It should be noted, however, that about half of all people with ASPD 

display fewer antisocial behaviors as they 

grow older, beginning in their 40s or 50s 

(APA 1994). More information on the treatment of clients with COD can be found in TIP 

42, Substance Abuse Treatment for Persons 

With Co-Occurring Disorders (CSAT 2005c). 

Special Considerations in

Treating Borderline 

Personality Disorder (BPD) 

According to the DSM-IV, borderline personality disorder is characterized by “a pervasive pattern of instability of interpersonal 

relationships, self-image, and affects, and 

marked impulsivity beginning by early adulthood and present in a variety of contexts” 

(APA 1994, p. 654). It can include recurrent 

suicidal or self-harming behavior, intense 

anger or inability to control anger, and stressrelated, psychotic-like symptoms (see Figure 

6-2, below). Women are three times more 

likely than men to be diagnosed as having 

BPD (APA 1994). 

Treating offenders with BPD requires great 

care due to their emotional instability, tendency toward violence, and risk for selfdestructive or suicidal behavior. Moreover, 

because of their tendency to idealize counselors, the therapeutic relationship is likely to 

be intense, and the offender with BPD is likely to have strong reactions to the counselor. 

The American Psychiatric Association recommends that treatment for people with BPD 

take into account these special features: 

•Co-occurring disorders. In addition to substance use disorders, mood disorders, eating disorders (especially bulimia), PTSD, 

anxiety disorders, dissociative identity disorder, and attention deficit/hyperactivity 

disorder are especially common in people 

with BPD. 

•Use of alcohol and illicit substances. People 

with BPD rarely are forthcoming about 

their use of alcohol and illicit substances. 

Counselors should inquire specifically 

about substance use from the beginning, 

and continue to educate clients about the 

dangers of substance use. 

Figure 6-2 

Borderline Personality Disorder 

People diagnosed with BPD must have five or more of the following behaviors: 

• Frantic efforts to avoid real or imagined abandonment 

• A pattern of unstable and intense interpersonal relationships characterized by alternating between 

extremes of idealization and devaluation 

• Identity disturbance or markedly and persistently unstable self-image or sense of self 

• Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, 

reckless driving, binge eating) 

• Recurrent suicidal behavior or gestures, or self-mutilating behavior 

• Affective instability due to marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) 

• Chronic feelings of emptiness 

• Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant 

anger, recurrent physical fights) 

• Transient, stress-related paranoid ideation or severe dissociative symptoms 

Source: APA 2000. 

114 Chapter 6 
 

 

•Violent behavior and antisocial traits. 

Treatment courses will vary according to 

the degree of violent or antisocial behavior. 

In mild cases (e.g., shoplifting), cognitive 

therapy is recommended. For more severe 

cases, residential treatment (e.g., a TC) 

may be effective. Episodic violence may 

benefit from the use of mood-stabilizing 

medication. For severe antisocial features, 

hospitalization may be required. 

•Self-destructive behavior. Addressing selfdestructive behavior is a primary part of 

treating BPD. Behaviors such as self-mutilation, suicide attempts, risky sexual behavior, and reckless driving are immediate 

threats to the individual and should be 

given treatment priority. Helping clients to 

think through the consequences of destructive behavior can be of use. 

•Childhood trauma and PTSD. While not 

universal, childhood trauma is very common among people with BPD. Treating 

offenders with BPD will often entail 

addressing the trauma and symptoms of 

PTSD. 

•Dissociative symptoms. Because there often 

is comorbidity between BPD and dissociative disorders, counselors must also be 

aware of the likelihood that the offender 

with BPD experiences transient dissociative 

symptoms (e.g., depersonalization, derealization, and loss of reality testing), and/or 

dissociative identity disorder. Counselors 

can assist by exploring the extent of the dissociative symptoms, the current issues that 

may lead to dissociative episodes, and the 

nature of dissociative symptoms. It may 

also be helpful to teach clients how to control dissociation and to work through posttraumatic symptoms. 

•Psychosocial stressors. Stress can heighten 

the symptoms of BPD, trigger relapse, and 

undermine recovery. Moreover, because of 

their intense fear of abandonment, many 

clients with BPD will be sensitive to any 

perceived rejection within any relationship, 

including the client–counselor relationship. 

Counselors should thus be watchful of reactive behavior that often results when the 

offender feels in danger of being abandoned. 

A general clinical observation is that the TC is 

an effective treatment for both ASPD and BPD 

through the emphasis on interventions that 

facilitate socialization and maturity. 

Special Considerations in

Treating Depressive and

Bipolar Disorders

Treatment strategies for offenders with cooccurring major depressive disorders have 

focused on modifying thoughts that lead to 

depression or that are related to substance 

abuse. Issues surrounding loss and trauma 

are typically addressed when an offender is 

able to tolerate uncomfortable mood states 

without turning to substance abuse. Activities 

are designed to promote understanding of 

how trauma and abuse experiences are 

expressed through emotions, physical reactions, and behaviors, including substance 

abuse. In addition to the interventions for 

depressive disorders, treatment for offenders 

with bipolar disorders addresses impaired 

judgment that occurs during manic episodes, 

and the effects of substance abuse on judgment. Treatment strategies often focus on 

building an acceptable set of coping responses 

to manic or hypomanic impulses, as well as 

medication adherence when warranted. 

Special Considerations in

Treating Schizophrenia/ 

Psychotic Disorders

Treatment for offenders with co-occurring 

psychotic disorders is designed to address disorganized thought patterns and communication style. Specialized approaches used in 

treatment include use of concrete concepts, 

avoiding harsh confrontation, and greater use 

of structured exercises and written materials. 

Adapting Offender Treatment for Specific Populations 115 
 

 

Offenders who have psychotic disorders often 

abuse substances for many of the same reasons as other individuals. Key treatment components include education in drug refusal 

skills, identification of strategies to fight boredom, building supportive social networks, 

and medication adherence. 

Special Considerations in

Treating Attention Deficit/ 

Hyperactivity and Other

Cognitive Disorders

Interventions for offenders with co-occurring 

attention deficit/hyperactivity disorder 

(AD/HD) focus on interpersonal difficulties, 

social skill deficits, and cognitive skill-building to address impulsiveness and aggression. 

Information should be conveyed visually as 

well as orally when possible. Short therapeutic sessions provided in environments that 

have few distractions are preferable. With 

this population it is particularly important to 

repeat important themes and to rehearse key 

skills in various settings. Those with cognitive 

disorders need concrete, practical information and skills. (See also TIP 29, Substance 

Use Disorder Treatment for People With 

Physical and Cognitive Disabilities [CSAT 

1998d].) 

Special Considerations in

Treating PTSD, Phobias, and

Other Anxiety Disorders

Treatment of co-occurring anxiety disorders 

focuses on interventions to improve social 

skills and to modify cognitions associated with 

difficult interpersonal situations, particularly 

those that augment anxiety. It is particularly 

important in treating clients with anxiety disorders for the counselor to be calm and reassuring. Clients with PTSD often make slow 

progress in achieving the trust necessary in a 

therapeutic alliance. It is important not to 

encourage discussion of traumatic events, 

particularly early in treatment. Those whose 

trauma-related symptoms are severe can benefit from learning techniques to help them 

focus on staying in the “here-and-now.” 

Recovery from PTSD often requires longterm treatment from specially trained clinicians. Counselors should be prepared to refer 

these clients to trauma experts. (See also the 

forthcoming TIP Substance Abuse and 

Trauma [CSAT in development f].) Clients 

with phobias can be especially sensitive to 

social situations and may need help in participating in mutual self-help groups. Specialized 

approaches, including use of medications, to 

reduce anxiety-induced insomnia also may be 

indicated. 

People With Infectious

Diseases

HIV, AIDS, and tuberculosis are more prevalent among inmates than in the general population. At the end of 2002, 2 percent of all 

inmates in State and 1.1 percent of all 

inmates in Federal prisons were known to be 

infected with the HIV virus. Rates of HIV 

infection were higher (3 percent) for female 

inmates of State prisons than for males (1.9 

percent) (Maruschak 2004). In 2002 they 

were also higher for African-American (1.2 

percent) and Hispanic/Latino (2.9 percent) 

jail inmates than for white jail inmates (.8 

percent) (Maruschak 2004). More than a 

quarter of all inmates known to be HIV-positive in 2002 were held in New York State, 

amounting to 7.5 percent of that State’s total 

prison population (Maruschak 2004). 

According to 2002 data, 0.50 percent of 

inmates in State prison had confirmed cases 

of AIDS, three and one-half times the rate for 

the general population (Maruschak 2004). 

Evidence suggests that sexually transmitted 

diseases (STDs), hepatitis B and C, and 

tuberculosis also affect inmates disproportionately (Hammet 1998; Hammet et al. 1999; 

Varghese and Fields 1999). Routine screening 

for STDs and hepatitis is not included in 

many correctional systems, and, although 

HIV prevention programs are becoming more 

common, few correctional systems have 

116 Chapter 6 
implemented systemwide programs to educate 

inmates about these diseases or to institute 

preventive measures. High-risk behaviors for 

the spread of HIV occur with great frequency 

in correctional facilities. These include 

unprotected sexual activity, substance use, 

and tattooing. The data clearly show that 

there is transmission of HIV between inmates 

(Hammett et al. 1999). Curricula for HIV 

prevention are available in many prisons. 

However, although female inmates have higher rates of HIV than their male counterparts, 

few HIV educational programs have been 

developed for the particular needs of women. 

Project ARRIVE 

The Federal prison system undertakes random HIV testing of inmates for data collection 

purposes, and all inmates are tested on 

release; otherwise inmates are tested only if 

there is a clinical indication that they may be 

HIV-positive or if they request testing. States 

have various procedures for testing the HIV 

status of inmates. Some States test all inmates 

who meet the criteria for belonging to a highrisk group, some test everyone entering the 

facility, and still others test inmates upon discharge from the facility. More information on 

substance abuse treatment for people with 

HIV/AIDS can be found in TIP 37, Substance 

Abuse Treatment for Persons With HIV/AIDS 

(CSAT 2000e). 

Project ARRIVE, a NIDA-funded AIDS prevention training model, was designed specifically for recently released parolees with histories of intravenous drug use—a population particularly vulnerable to 

resuming high-risk behaviors (Wexler et al. 1994). ARRIVE’s assumption was that reinforcing parolees’ 

general social and personal rehabilitation could reduce the risk of contracting AIDS. The program 

incorporated the principles and techniques found to be useful for treating those with substance use disorders in other settings. 

•Social learning approach to prevention training. The training program emphasized learning skills to 

resist relapse and develop personal and social competencies (Botvin et al. 1984) and included rational 

decisionmaking, coping with anxiety, assertiveness, and relaxation skills. 

•A strong self-help orientation. Participants were encouraged to accept responsibility for their behavior; to develop their capacity to change negative features of their daily lives; and to engender a sense 

of mutuality, trust, and honesty among participants (Gartner and Riessman 1977). 

•Use of principles effective in TC programs (De Leon 1999, 2000; DeLeon and Ziegenfuss 1986). Some 

ARRIVE training staff were themselves in recovery and could function as role models. In addition, the 

program fostered the development of peer support networks. Graduates were encouraged to continue 

their association with the program through weekly aftercare groups. 

•Job readiness preparation and placement assistance. 

These elements were combined into a structured 8-week, 24-session AIDS prevention program. Each 

new class met for 2 hours a night, three times per week over an 8-week period. Participants received $10 

per session for a total of up to $240 if they attended all 24 sessions. Trainees also were given two subway 

tokens per session. ARRIVE participants were offered confidential HIV testing and counseling. 

During the NIDA study, a total of 394 eligible parolees were recruited, of whom 241 (61 percent) attended the Training Program, including 164 program completers, for a 68 percent graduation rate. (During 

the second half of the program, 81 percent graduated.) The outcome evaluation, conducted 1 year after 

study recruitment, compared program graduates with parolees who never attended, controlling for 

observed group differences at baseline. ARRIVE participation significantly decreased most sexual and 

some drug-related risk behaviors and improved parolees’ community adjustment during the followup 

period (Wexler et al. 1994). 

Adapting Offender Treatment for Specific Populations 117 
While HIV/AIDS is widely recognized as a 

serious and significant problem within prisons, other infectious diseases are not always 

given the same attention. A vaccine is available for hepatitis B that could control the 

spread of that disease. However, the prevalence of hepatitis C virus (HCV) is increasing. 

In California, 41 percent of incoming prisoners were positive for HCV in 1994. 

Prevalence rates among HIV-positive offenders are higher (Hammett et al. 1999). Because 

the incubation period is so long (approximately 20 years), many offenders who have the 

disease will not experience its effects until 

after they are released. Consequently, not all 

prison systems recognize hepatitis C as a 

problem; nor do they expend costly resources 

on its treatment. Rates of tuberculosis (TB) 

have declined since 1991 both in the general 

population and among incarcerated offenders, although they are still higher among 

inmates. Not all systems routinely screen for 

TB and report results. There is a risk to correctional employees of contracting TB due to 

insufficient control measures (Hammett et al. 

1999). 

Medical Care 

Research indicates that medical care for 

offenders in the criminal justice system is 

inadequate and underfunded, and the burden 

is increasing as the inmate population ages. 

This exacerbates poor health habits and 

neglect of health care not uncommon among 

Advice to the Counselor: 

Infectious Diseases

• Education about infectious diseases such as HIV/AIDS and 

hepatitis C is a useful addition to a treatment program. 

However, this education must take care not to cause 

additional problems such as fights over fear of infection. 

• Counseling by peers who are HIV-positive provides information from a credible source. 

• Health improvement can be included as a goal for clients 

and can be written into their treatment plans. 

people who come in contact with the criminal 

justice system. Medical care is extremely 

important for offenders with substance use 

disorders, who often have a number of medical problems. While using alcohol and illicit 

drugs, offenders often ignore their health 

problems. When they finally enter treatment 

they could have several problems that have 

been untreated except for self-medication. If 

they are in pain they are less able to focus on 

their substance abuse treatment. As a consequence, substance abuse treatment staff often 

request that the institution pay greater attention to medical issues and advocate for medical services for their clients. 

Substance abuse treatment staff also should 

stress the importance of good health when 

working with offenders. Health improvement 

can be included as a goal for clients and written into their treatment plans. 

Prevention and Education

Educational programs about infectious diseases are a useful addition to a treatment program but cannot stand alone without counseling and treatment for those diseases. Simply 

informing a group of offenders about the dangers of infectious disease without helping 

them deal with the possibility of infection can 

actually cause additional problems, such as 

fights caused by fears of infection. Prevention 

and testing efforts often work more smoothly 

if integrated into a substance abuse treatment 

program, as counseling staff can 

work with an individual and 

help him or her deal with concerns and fears. Programs can 

use peers who are HIV-positive 

to provide education to other

offenders; in addition to providing other offenders with information from a credible source,

peer education helps the person

who is HIV-positive feel that his 

or her life has some sense of 

purpose.

118 Chapter 6 
Sex Offenders

Self reports of those incarcerated for rape or 

sexual assault reveal that 23 percent admitted 

they were under the influence of alcohol alone 

when they committed their crime, another 15 

percent acknowledged using both alcohol and 

drugs, and an additional 5 percent reported 

they had been using drugs alone (CASA 

1999). That even these self-report numbers 

considerably underestimate the pervasiveness 

of substance abuse among sex offenders is 

suggested by the fact that 42 percent of those 

arrested for sex offenses tested positive for 

drugs at the time of arrest (CASA 1999). 

Similar evidence for alcohol use is not available but can be presumed to be considerably 

higher. Among incarcerated sex offenders, 

two of every three have a history of alcohol or 

drug use, abuse, or addiction (Peugh and 

Belenko 2001). 

While the high prevalence of substance abuse 

among sexual offenders is clear, solid information about the relationship between substance abuse and sexual offending is not readily available. While many convicted sex 

offenders will admit to problems with alcohol 

or illicit drugs, it is unusual for someone 

identified with alcohol or drug problems to 

freely disclose illegal sexual behavior. The 

negative consequences of such an admission 

would usually be too great. Consequently, 

what is known about the co-occurrences of 

substance use disorders and the commission 

of sex offenses comes mainly from the personal history and self reports of identified sex 

offenders within the criminal justice system 

and their victims. 

Sex offenders apprehended and labeled 

through the criminal justice system are 

thought to represent a small portion of those 

who actually commit sexual offenses (Center 

for Sex Offender Management 2001a). Only 

those individuals actually convicted of sexual 

offenses are likely to be identified as a sex 

offender subgroup with COD requiring specialized attention. And for this population, 

the focus of treatment is likely to be the sexually deviant behavior. Alcohol and drug issues 

are usually seen as one part of a broad array 

of problems contributing to the sex offense 

and specific attention to substance abuse 

issues may comprise only one of many treatment modules designed to address these 

underlying problems (Barbaree et al. 1998). 

Many sex offenders with substance abuse 

issues are excluded from many substance 

abuse treatment programs. Analysis of 

Bureau of Justice Statistics data reveals that 

34 percent of sex offenders receive drug treatment in prison, as opposed to 42 percent of 

other violent offenders (Peugh and Belenko 

2001). Often if they are to get any treatment 

for their substance abuse problems, it must 

be in or in conjunction with a sex offender 

treatment program. Otherwise, to participate 

in substance abuse treatment, they must conceal their sex offender identities and histories—not a promising foundation for fostering 

the self-disclosure treatment requires. 

The subpopulation of sex offenders among 

offenders who require interventions for substance abuse issues raises many questions and 

complications, especially since they also may 

be concurrently mentally ill, culturally 

diverse, developmentally disabled, or otherwise high need (Raymond et al. 1999). Sex 

offenders often stir strong emotions and reactions (Jenkins 1998). The criminal justice system, other offenders, and the community at 

large typically think of sex offenders, particularly those whose victims are children, as a 

different class of criminal. Within jails and 

prisons, if identified, they are at great risk of 

being victimized by other inmates (and sometimes correctional staff) because of the nature 

of their crimes. Some States provide sexoffender–specific treatment services for a 

portion of these inmates, pre- and postrelease, and many counties require treatment 

as one of the conditions of probation (Burton 

and Smith-Darden 2001). When released 

from incarceration, sex offenders are 

required to register with local authorities, 

often receive more stringent supervision than 

other offenders, can be subject to community 

Adapting Offender Treatment for Specific Populations 119 
 

notification procedures, frequently encounter 

serious problems finding appropriate housing, and may have their identities and pictures made available on the Internet (Center 

for Sex Offender Management 2000a). 

Some Relevant Facts About 

Sex Offenders

The image of the typical sex offender conjured by lurid newspaper headlines bears 

only some resemblance to the actual picture. 

The blanket term “sex offenders” includes a 

population so heterogeneous that only a few 

generalizations are not inaccurate and misleading (Center for Sex Offender Management 

2000b). Although once there were thought to 

be discrete offender types—rapists, child 

molesters, incest offenders, exhibitionists—an 

increasing body of evidence derived from 

polygraph examinations of convicted offenders demonstrates that there is considerable 

“crossover” between behaviors once thought 

to define these subgroups. Thus nearly 9 of 

10 offenders originally thought to have only 

adult victims were found, under polygraph 

examination, also to have victims under 18. 

Similarly, 36 percent of those convicted of an 

incest offense disclosed that they also had victimized adults (English et al. 2000). One 

important distinction, however, is that sexual 

offenses committed while intoxicated (e.g., 

date rape) are unusual occurrences and do 

not represent habitual behavior. These problems are more about impulse control amplified by alcohol and other substance use and 

often can be treated in substance abuse programs. 

It now is generally accepted that no single 

causative factor can adequately explain the 

commission of sexual offenses. Only multifactorial explanations that take into account 

the presence, to various degrees, of deviant 

sexual arousal, lack of victim empathy, inadequate social skills, personal trauma history, 

criminal association, thinking errors, and 

other elements now appear to provide adequate models for understanding these crimes. 

The use of alcohol and drugs is seen as contributing to disinhibition but is never thought 

to be a stand-alone explanation for sexual 

offending (Laws et al. 2000). 

Sex-Offender–Specific 

Treatment 

The emergence, over the past 20 years, of an 

increasingly solid body of research-based 

information about sexual offending has led to 

correspondingly sophisticated treatment models and outcome studies (Marshall et al. 

1998). Treatment focus areas are based on an 

emerging set of “dynamic” (i.e., modifiable) 

risk variables. One widely used instrument 

for assessing such factors is the Sex Offender 

Needs Assessment Rating (SONAR) (Hanson 

and Harris 2001). Risk factors identified in 

the SONAR include intimacy deficits, negative social influences, antisocial attitudes, 

inadequate sexual self-regulation, and general 

self-regulation. Addressing such factors in 

non–sex-offender-specific treatment might 

have some impact on reducing the risk of sexual recidivism. A growing body of solid 

research provides evidence that, overall, 

treatment now reduces the reoffense rate 

between 10 and 17 percent (Center for Sex 

Offender Management 2001b). 

Relapse Prevention: The 

Common Thread

With some modifications, relapse prevention 

concepts and formulations borrowed from the 

substance abuse treatment field have been 

found to fit sex offender programming needs 

quite well (Laws 1989; Laws et al. 2000). At 

present, relapse prevention—or the more 

broadly designated cognitive–behavioral therapy—has grown to be the dominant model 

used by most sex offender treatment programs, whether institutional or communitybased, so that currently over 80 percent of 

programs in North America identify “cognitive–behavioral/relapse prevention” as their 

primary treatment model (Burton and Smith120 Chapter 6 
SHARPER FUTURE 

Awareness of the presence of significant numbers of sex offenders among inmates participating in 

California’s in-prison substance abuse treatment programs—as high as 30 percent—led to the development of a specialized aftercare program specifically tailored to address both substance abuse and sex 

offense issues concurrently. For many reasons, in-prison programs do not address sex offense issues. 

SHARPER FUTURE (Social Habilitation and Relapse Prevention – Expert Resources), a private-sector 

forensic mental health agency, has been operating a program under contract in central Los Angeles since 

1999 to meet the needs of parolees who have completed one of the in-prison substance abuse programs 

but who are screened out of other aftercare programs because of their sex offense histories. (SHARPER 

FUTURE also has a component to treat offenders with mental disorders.) 

SHARPER FUTURE is staffed by licensed clinicians with expertise in treating both areas concurrently. 

The existence of many parallels between treatment strategies for substance abuse and for sex offense 

issues offers a foundation for such an integrated approach. Concepts from relapse prevention apply 

equally well to both areas of concern. 

Because of restrictions in California codes prohibiting registered sex offenders from sharing a common 

residence, SHARPER FUTURE is exclusively outpatient. As an outpatient program, SHARPER 

FUTURE cannot fully continue but does support the therapeutic community philosophy that is the 

foundation of the prison-based system. Although the program is considered “aftercare” for substance 

abuse issues, which have been directly addressed previously in the institutional setting, the sex offense 

issues are addressed directly for the first time only in this outpatient phase. During the 14-month intensive treatment phase of SHARPER FUTURE, participants, all on parole, attend three 2-hour groups 

per week. A weekly aftercare group can subsequently continue until the end of the parole period or 

beyond. 

Because personal issues related to substance abuse already have been addressed in prison and because 

the level of shame related to sex offense behavior generally is much more intense, greater resistance in 

dealing with the sexual behavior is common. Frequently analogies with substance abuse cycles, behavior 

chains, thinking errors, low capacity for delayed gratification, and similar themes offer a more acceptable entrance to the sex offense work. Creating a group treatment culture supportive of the work needed 

to address deviant sexual patterns is essential to treatment success. 

Standards of the Association for the Treatment of Sexual Abusers (ATSA—see http://www.ATSA.com) 

require substantial training and experience for staff involved in treating sex offenders and finding such 

qualified staff, especially individuals who also have expertise in substance abuse treatment, has been a 

challenge, as has working collaboratively within such a large and complex system as the California 

Department of Corrections. Future goals include replicating this pilot program in other geographical 

areas and, ultimately, developing structures to allow the sex offense issues to be addressed from the 

beginning of treatment in specialized separate tracks of the in-prison substance abuse treatment system. 

Adapting Offender Treatment for Specific Populations 121 
Darden 2001). Sharing such a common lineage has the benefit of permitting easy 

movement in the treatment setting between 

relapse prevention as applied to substance 

abuse and relapse prevention as applied to 

sex offending. 

Areas of Divergence 

Important differences prevent a simplistic 

merger of sex offender treatment and substance abuse treatment models. Sex offender 

treatment usually is provided by specially 

trained—sometimes specifically credentialed—mental health professionals, and 

interventions can include medical and behavioral efforts to modify deviant sexual arousal 

patterns (ATSA 2001). Stakes are higher 

because any “relapse” involves another traumatized victim and can lead to a long, even 

lifetime, prison sentence. Since the primary 

goal is community safety, sex offender treatment usually involves close collaboration with 

the criminal justice system, represented by 

probation and parole officers. Great caution 

is exercised with regard to encouraging mutual support efforts between sex offenders and, 

consequently, self-help support systems are 

ordinarily unavailable. Treatment themes seldom are discussed freely with support persons outside of the program since the stigma 

and other social consequences of being a sex 

offender are considerably higher than for 

those in substance abuse recovery. 

Conclusions and

Recommendations

The consensus panel believes the following 

points and recommendations merit emphasis: 

•The panel recommends that screening and 

assessment for a history of physical/sexual 

abuse be included as part of intake assessments for men and women in criminal justice 

treatment settings. Referral information 

should be provided to inmates who report 

prior abuse and who are interested in receiving services related to this abuse. 

•Use of “strengths-based” approaches to substance abuse treatment is highly recommended, particularly for female offenders. 

These interventions are considered effective 

in improving self-esteem. 

•Substance abuse treatment programs in jails 

and prisons (including TCs) should include 

vocational programs for men and women. 

Offenders under community supervision 

also should have access to community vocational programs. 

•Treatment programs in women’s institutions 

are encouraged to use the segregation of 

genders within the criminal justice system 

to the advantage of their clients by developing treatment programs that specifically 

address women’s needs. 

•The panel encourages jail and prison programs to allow for more interaction between 

incarcerated mothers and their children; 

the 2–4 hours of supervised visitation per 

week that many institutions allow is not sufficient for mothers or their children. 

•Given the high rates of co-occurring mental 

disorders in the offender population, more 

treatment programs need to be developed 

for offenders with COD. 

•Given the prevalence of cognitive and physical disabilities in incarcerated populations, 

especially among offenders with substance 

use disorders, treatment providers need to 

be able to screen for and to provide accommodations for offenders who have these coexisting disabilities. 

•Because mental health and substance use 

disorders can mask or imitate each other, 

accurate diagnosis of these disorders 

requires skilled screening and assessment. 

Assessment should look for evidence of both 

disorders, rather than providing separate 

assessments for the disorders. Regular 

reassessment for COD also is important, 

and should be conducted at major transition points in the criminal justice system by 

staff with specialized training in this area. 

•Substance abuse treatment programs for 

offenders should include staff who reflect 

122 Chapter 6 
the cultural diversity of the population they 

are treating. Efforts need to be made to 

adopt treatment to specific cultural populations (e.g., ethnicity, race, age, sexual orientation, rural cultures, socioeconomic 

class, and language). Counselors need to be 

aware of different cultural sets of values, 

biases, and assumptions related to communication, therapeutic style, and interpersonal contact and should be trained in techniques for adapting treatment approaches 

to reflect these differences, in order to more 

effectively engage and maintain clients in 

program services. 

•The therapeutic community has been successfully modified to treat specific populations, including female offenders and 

offenders with COD. 

Adapting Offender Treatment for Specific Populations 123 
 

 

 

In This
 Chapter... 

Introduction 

Characteristics of the 

Population 

Treatment Services in the 

Pretrial Justice System 

Trial and Postverdict 

Periods 

Diversion to Treatment 

What Treatment Services 

Can Reasonably Be 

Provided in the Pretrial 

Setting? 

Treatment Issues 

Developing Pretrial 

Treatment Services 

Resources 

Conclusions and 

Recommendations 

7 Treatment Issues in
 

Pretrial and

Diversion Settings
 

Overview 

The pretrial period of criminal justice processing is unique in that for 

most people it is brief and the outcome is uncertain. Yet, it represents an 

opportunity to identify those who could benefit from substance abuse 

treatment and begin to engage them in the process. Providing effective services at this early stage of involvement with the criminal justice system can 

result in heightened motivation to seek treatment and decreased recidivism. 

After characterizing the population of arrestees, this chapter describes 

the processes of arrest, arraignment, plea bargaining, trial, presentencing, and sentencing. Diversion to treatment can occur at several points 

during the pretrial phase. Several types of diversion, including drug 

treatment courts, are discussed. The chapter continues with a discussion of some of the strategies that are effective during the pretrial stage, 

as well as some of the issues that are specific to it. Some of the qualities 

of effective pretrial and diversion programs are the next topic: the staff 

resources, training, coordination, program components and procedures. Finally, the chapter describes several existing diversion programs and lists resources, research findings, and conclusions. 

Introduction

There are several challenges in developing treatment interventions during pretrial criminal justice processing and the presentencing phase. A 

large number of offenders move relatively quickly through the system, 

and many different agencies are involved with each case and supervision. At the pretrial stage, offenders have been charged with a crime, 

not convicted, and involvement with treatment may or may not be in the 

offender’s legal interests. The trauma and uncertainty of the arrest can 

either help or undermine motivation for treatment. Diversion to treatment can occur at several points before incarceration. The offender 

may opt for treatment in lieu of incarceration or to reduce the length of 

incarceration by participating in treatment. 

125 
Variations in local prosecution and diversion 

practices may affect a jurisdiction’s ability to 

develop the criminal justice treatment linkages presented in this chapter. Not all jurisdictions have established procedures or programs for clients who abuse substances; those 

jurisdictions that do have programs to treat 

offenders often maintain such programs with 

limited resources. Recognizing the disparities 

between available treatment programs for 

offenders, the consensus panel posited the following observations as a starting point for 

discussions of treatment in pretrial and diversion settings. 

•Expanding and institutionalizing pretrial 

treatment services are important goals. The 

pressure of overcrowded jails and prisons is 

expanding and institutionalizing programs 

for drug treatment in pretrial and diversion 

settings nationwide. In the past, the criminal 

justice system and the treatment community 

have often operated independently, but the 

advent of drug courts and other diversion 

programs has created a better climate for collaboration. 

•Treatment remains a low priority in the criminal justice system at the pretrial stage, 

although it has been credited with helping to 

reduce criminal behavior. Each jurisdiction 

decides what priority to give substance abuse 

treatment and whether it merits significant 

financial resources. Outside of formal drug 

court and diversion programs, treatment 

access is limited. 

• Pretrial defendants are often uncertain as to 

the status of their case and experience significant disruption related to their arrest. The 

uncertainty of their case disposition influences a counselor’s ability to engage an individual in treatment. For example, defendants 

may be unsure whether treatment will be 

required by the court as part of their sentencing arrangements, or whether voluntary 

pretrial involvement in treatment would be 

more rigorously monitored than standard 

probation that they would receive as an alternative to involvement in diversion programs. 

For some, the arrest provides strong motivational leverage to engage individuals, while 

for others, the stress related to arrest and 

lack of clarity regarding their case disposition 

makes offenders less receptive to treatment. 

This chapter highlights some of the innovative 

programs to treat offenders and the issues that 

substance abuse treatment and criminal justice 

personnel are likely to encounter when treating 

clients in a pretrial or diversion setting. 

Characteristics of the 

Population

In 2000, the Arrestee Drug Abuse Monitoring 

Program (ADAM) collected data on male 

arrestees from 35 urban sites (National 

Institute of Justice 2003). Of the male arrestees 

tested and interviewed, more than 50 percent 

from every site tested positive for at least one 

National Arrest Highlights in 2003 

•Estimated total U.S. arrests: 13,639,479. 

•Number of arrests for drug law violations: 1,678,192. 

•Number of arrests for driving under the influence: 1,1448,148. 

•83.7 percent of arrestees were aged 18 or older. 

•46.3 percent of arrestees were under age 25. 

•76.8 percent of arrestees were male. 

•Drug arrests rose 22.4 percent between 1994 and 2003 while total arrests declined 2.8 percent. 

•Between 1994 and 2003 the number of females arrested increased by 12 percent while the number of males 

decreased by 7 percent (FBI 2004). 

126 Chapter 7 
 

 

 

 

 

drug. Marijuana was the drug detected most 

frequently, followed by cocaine. 

In the 29 sites where data were collected on 

women, more than half tested positive for at 

least one drug. Unlike the male arrestee population, cocaine was most frequently detected 

among female arrestees, followed by marijuana and methamphetamine (National Institute 

of Justice 2003). 

Nationally, 65 percent of all arrestees test 

positive for an illicit drug. Seventy-nine percent of arrestees are “drug-involved,” meaning they tested positive for a drug, reported 

that they had recently used drugs, had a history of drug dependence or treatment, or 

were in need of drug treatment at the time of 

their arrest (Belenko 2000). 

Approximately 13.6 million arrests were made 

in 2003, including 1.7 million for drug violations, the largest category of arrests. Seventyseven percent of all the individuals arrested 

in the United States during 2003 were male. 

This represents a 0.4 percent drop in the 

arrests of males and a 1.9 percent increase in 

the number of arrests of females compared to 

2002 figures. Drug- and alcohol-related 

arrests occurred at a rate of 1,470 per 

100,000—the most numerous of crime types 

(Federal Bureau of Investigation 

[FBI] 2003). 

In 2003, of arrests nationwide, 

71 percent were Caucasian, 27 

percent were African American, 

and the remainder were of other 

races. Race distribution figures 

also showed that Caucasians 

accounted for 68 percent of the 

property crime arrests, and 61 

percent of the violent crime 

arrests (FBI 2003). 

Despite the common assumption 

that most offenders are incarcerated shortly after arrest, 

studies show that the majority of 

drug-involved offenders are 

supervised in the community following arrest. For example, in 1996 in large 

urban areas, 62 percent of drug traffickers 

and 71 percent of other drug offenders were 

released before trial (Dorsey and Zawitz 

1999). 

The Need for Treatment 

Services

Very few arrestees were in treatment at the 

time they entered the criminal justice system, 

yet 24 percent of those interviewed for the 

ADAM study in 1997 indicated that they needed treatment. Thirty-six percent of arrestees 

reported use of cocaine, but only 6 percent had 

ever received drug treatment (National 

Institute of Justice 2000). 

Treatment Services in

the Pretrial Justice 

System

The process through which an accused individual moves from arrest to full discharge of a sentence has many decision points, each with 

many variations from jurisdiction to jurisdiction, and each with many decisionmakers and 

possible decision outcomes. 

Advice to the Counselor: 

General Considerations for
 

Working With Clients in the 

Criminal Justice System
 

• Treatment should not compromise the due process rights 

of defendants. 

• Treatment professionals should bear in mind the pre 

sumption of innocence that exists during the pretrial 

period. 

• Defendants’ due process rights are of vital interest and 

affect what they are willing to agree to and the type of 

information that they are willing to disclose. 

• Defendants should not be coerced into waiving due pro 

cess rights. 

Treatment Issues in Pretrial and Diversion Settings 127 
Arrest 

Arrest is the taking of a suspect into legal custody by police, probation or parole officers, 

or other authorized officials. Arrest may be 

authorized pursuant to a judicial warrant, 

which is issued when there is probable cause 

to believe that a crime has been committed 

and that the suspect committed the crime. 

Arrest without a warrant may be made by a 

police officer when there is probable cause to 

believe a felony was committed by the suspect. Arrests for misdemeanor violations generally require a warrant, except when the 

arresting officer sees the suspect committing 

the misdemeanor (e.g., in some cases of drug 

possession). Police have some discretion in 

whether to make arrests, although some jurisdictions have mandated arrest in certain situations, such as domestic violence or drunk 

driving. 

For many individuals, further involvement in 

the criminal justice system might be prevented if police were informed about substance 

abuse and empowered to make referrals to a 

responsive treatment system. The consensus 

panel suggests that, when possible, police officers should use their community contacts to 

explore substance abuse treatment services 

options for individuals involved with substances who come to their notice but who are 

not arrested. 

Advice to the Counselor: 

Diversion to Treatment Decision Points

• Diversion to treatment can take place at several points in 

the criminal justice process: 

> After arrest and prior to initial arraignment or bail 

hearing 

> After initial arraignment appearance or bail hearing 

> After preliminary hearing/probable cause hearing 

> After guilty plea but before sentencing 

> After conviction and sentencing, with sentencing suspended pending treatment completion 

From a treatment perspective, arrest and the 

related crisis may have a positive outcome. 

Arrest can be a significant event in a person’s 

life, and for offenders whose arrest was related to their substance abuse, the event might 

make it difficult for the person to deny substance abuse problems. Arrest offers the 

opportunity for the individual to voluntarily 

choose to enter substance abuse treatment. 

Thus it is important for connections to be 

made between the treatment and criminal justice systems at this point. Representatives 

from both the criminal justice and substance 

abuse treatment systems can view arrest as an 

important point from which to establish linkages, engage the defendant in interventions, 

and promote collaboration between the systems. 

It must be noted, however, that involvement 

of substance abuse treatment providers at the 

point of arrest may raise constitutional issues. 

If the arresting officer transfers the individual to substance abuse treatment rather than 

to the criminal justice system (which has laws 

protecting defendants’ rights), questions may 

be raised about due process, civil liberties, 

and extension of the criminal justice system 

beyond permissible bounds. Once an individual has been arrested, the defendant is subject to the authority of the criminal justice 

system even if he or she has been transferred 

to treatment. The level of responsibility 

granted to the treatment program should be 

defined clearly, understood by 

both systems, and incorporated 

into the information flow 

between systems.

Arraignment 

Arraignment is a technical term 

signifying presentation of the 

charges to the defendant. In

many jurisdictions the term is

reserved in felony cases for the 

presentation of charges in superior court. A first appearance is 

held in the lower court after 

arrest for bail setting and proba128 

Chapter 7 
 

ble cause review. This hearing is not referred 

to as an arraignment. 

The period of time between arrest and 

arraignment is a window of opportunity to 

intervene and articulate the value of substance abuse treatment. Drug testing, screening, and assessment for substance abuse and 

dependence, needs assessment in other areas, 

and relapse prevention are important components of intervention at this time as well as at 

other points along the continuum. The consensus panel recommends a multidisciplinary 

approach, with treatment providers available 

to work with police and court personnel to 

guide offenders who abuse drugs into treatment. 

During arraignment, charges are brought 

against the defendant, and the defendant is 

informed of his rights. The defendant then 

enters a plea in response. Additional personnel, including staff from pretrial service agencies, judges, prosecutors or defense attorneys, court referral officers, and representatives of referral systems, handle this process 

and become involved as the defendant moves 

through the arraignment process. Each of 

these individuals can refer the defendant to 

substance abuse treatment services. 

As a result of the arraignment, a defendant 

can be released on his or her own recognizance (i.e., a sworn promise to return); 

detained pending the posting of a certain 

amount of bail; detained with no bail (very 

unusual); or released under certain conditions, such as keeping a curfew, reporting 

periodically to a supervising officer, or wearing an electronic tracking device. 

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. Should 

the individual fail to comply with the conditions of release, he or she can be returned to 

jail for detention prior to trial. Successful 

completion of the treatment or other conditions can mitigate the sentence imposed by the 

court if the offender is convicted. The consensus panel recommends that, ideally, judges 

should mandate as a condition of release that 

offenders receive treatment within 24 hours. 

Pretrial Diversion: Treatment 

in Lieu of Prosecution

In some instances, arrest charges against the 

defendant are dropped if the person completes treatment. The decision to order treatment as part of pretrial diversion typically, 

though not always, rests with the prosecutor’s 

office. The prosecutor offers to cease all prosecution of the case if the defendant completes 

the prescribed treatment regimen. However, 

if the defendant fails to complete the treatment and to satisfy the other conditions of 

diversion, he may risk being sentenced more 

harshly (if prosecution proceeds and a conviction results) than if the individual had 

never entered the diversion program. 

Because pretrial diversion occurs before an 

individual enters a guilty plea or is convicted 

by a judge or jury, the defendant is still technically innocent. Anxiety about the outcome 

of pending charges may motivate those 

charged to agree to treatment, and many 

treatment providers view this as an ideal time 

to intervene and offer the individual an 

opportunity to participate in treatment. 

Plea Bargaining 

With court docket overcrowding, plea bargaining is used in a large number of cases. In 

a plea bargain, defendants are allowed to 

plead guilty to lesser charges than the charges 

that they would have had to face at trial. In 

most cases, especially misdemeanors or lowlevel or nonviolent felonies, the sentence is 

agreed to by prosecutor and defense attorney 

as part of the plea bargaining agreement. So 

although judges have the power to change the 

Treatment Issues in Pretrial and Diversion Settings 129 
sentence, they generally do not do so except 

in unusual circumstances. 

Incorporation of substance abuse concerns 

into the plea bargaining process is a key element in strategies to link the justice and 

treatment systems. 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 they are ready for services. However, just as overcrowded court 

dockets force the hand of criminal justice system officials on certain decisions, overcrowded caseloads can make it difficult for treatment programs to accept new clients. In some 

cases, defendants who are 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 

Advice to the Counselor: 

Information Management 

During the Pretrial Stage 

• Information management is the key to identifying treatment needs and can provide treatment and related ser 

vices during the pretrial stage more effectively. 

• Because of the complexity of the pretrial phase (with 

many different agencies involved in a short or uncertain 

time period), it can be difficult to access necessary information on a timely basis. Also, treatment providers may 

not be permitted to provide certain information regard 

ing clients to criminal justice staff. As a result, the infor 

mation needed for clinical or case decisions may not be 

available at the appropriate time. 

• Pretrial information about a defendant can be grouped 

into the following categories: 

> Criminal record 

> Prior compliance with supervision 

> Pretrial evaluation 

> Substance abuse assessment information 

> Substance abuse treatment information 

> Mental health treatment 

> Relevant medical information 

the need for recovery and treatment involvement. 

Pretrial Diversion: Probation

Before Judgment 

Another form of pretrial diversion is Probation 

Before Judgment. Under this scheme, the 

defendant is placed on probation (usually 

unsupervised) and the charges are pending. If 

the probation is completed successfully (which 

may include court-ordered treatment) then the 

charges may be dropped. This happens commonly in regular traffic court but can be used 

as a mechanism within diversion programs as 

well. 

Trial and Postverdict 

Periods

Trial

A trial is a court hearing in which 

a prosecutor presents a case 

against the defendant to show that 

he or she is guilty of a crime. The 

defendant presents information to 

support the plea that he or she is 

not guilty. A judge or jury decides 

the verdict. 

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). 

Prior to sentencing, a presentence investigation is usually 

conducted. The investigation is 

conducted after the plea is 

entered or after the conviction is 

handed down. In some plea-bargained cases, a plea may be withdrawn after the presentence 

investigation is completed and 

130 Chapter 7 
 

sentencing recommendations are made. 

However, in some jurisdictions, the prosecution conducts an investigation prior to making 

the plea offer, thereby preventing the problem of changes in plea at the sentencing stage. 

Many jurisdictions have presentence investigation agencies that specialize in writing the 

presentence report. Elsewhere, probation 

officers compile the report. The sentence or 

penalty handed down by the judge is based on 

the information compiled in the report. 

Therefore, with more relevant information 

available, the judge is better equipped to 

make an appropriate sentencing decision. 

This is another point where 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. 

In many States, serious legal constraints preclude sharing information contained in the 

presentence investigation. In some States, 

only the judge can see the report—not even 

the defendant can see it. However, the presentence investigation report may contain 

information highly relevant to developing a 

substance abuse treatment plan for the individual. 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. (For more information on confidentiality, see CSAT 2004.) 

Sentencing 

If the verdict is “guilty,” either the judge or the 

jury, depending on the State, determines the 

sentence or the penalty imposed in the case. In 

many States, the sentence or penalty is based 

partially on the information that has been compiled in the presentence investigation report. 

Increasingly, States are passing laws to ensure 

that the penalty is based on the offense without 

regard to information contained in the report. 

Laws requiring the sentence to be based on 

fixed criteria are known as sentencing guidelines, and their purpose is to eliminate wide 

judicial discretion that can result in disparate 

sentences by jurisdiction within a system or 

even by courtroom. However, these guidelines 

allow for very little flexibility based on defendant-specific factors such as substance use or 

mental disorders. 

Diversion to Treatment 

Much of the substance abuse treatment that 

occurs in the pretrial setting is in the form of 

diversion from prosecution into treatment. In 

other cases, diversion is conducted after conviction but before sentencing. This model is 

used extensively by drug treatment courts 

(DTCs) (see description below) and provides 

safeguards so that prosecutors can effectively 

reinstate charges for those individuals who 

are unsuccessfully terminated from diversion 

programs. Diversion is a “multi-systems collaboration between criminal justice and community-based agencies [that] allows programs 

to begin to address potential contributing factors to recidivism” (Broner et al. 2002, p. 

87). It is a “mechanism to identify those in 

need of treatment, to broker treatment, housing, medical care, vocational and educational 

training, and often to remain involved with 

the individual . . . in the community” (Broner 

et al. 2002, p. 97). DTCs are a primary mechanism through which offenders are diverted 

into treatment. Diversion to treatment 

depends to a large extent on the statutory 

framework that guides processing defendants 

and on the prosecutor’s approach to resolving 

cases through placement in treatment. 

Drug Treatment Courts

In communities throughout the United States, 

DTCs are dramatically changing the way the 

criminal justice system deals with offenders 

who use drugs. Drug courts and other diversion programs hold considerable promise for 

Treatment Issues in Pretrial and Diversion Settings 131 
engaging and retaining offenders who are 

involved with drugs in treatment and related 

services. DTCs share the underlying premise 

that drug abuse is not simply a criminal justice system problem, but a public health 

problem. American University’s Drug Court 

Clearinghouse and Technical Assistance 

Project documents over 1,000 operational 

drug courts as of December 2003, with many 

more in the planning process. (See TIP 23, 

Treatment Drug Courts: Integrating 

Substance Abuse Treatment With Legal Case 

Processing [Center for Substance Abuse 

Treatment {CSAT} 1996].) Preliminary outcome research indicates that DTCs are effective in engaging and retaining offenders in 

treatment and can significantly reduce criminal recidivism during program participation 

and following release from the DTC (Belenko 

2001). 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. 

DTCs were established in response to the 

realization that incarceration for longer periods and under mandatory sentencing laws 

was not having a significant effect on drugusing behavior. Instead, the courts, jails, and 

prisons were becoming more and more congested. DTCs provide diversion from jail or 

prison through expedited involvement in 

treatment for nonviolent offenders with substance abuse problems. 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. Several different diversion 

models are used by DTCs (some operating 

within the same jurisdiction), including presentence diversion, processing through postplea or presentence arrangements, and postconviction arrangements. The essential 

“core” of DTCs is a collaborative partnership 

between the courts, substance abuse treatment providers, community supervision, and 

other ancillary services to achieve sustained 

participation in treatment, coupled with regular oversight and monitoring by the court. In 

contrast to the adversarial nature of traditional criminal court processing with its focus 

on prosecution of cases, DTCs feature more 

of a rehabilitation team approach that couples mandatory treatment involvement with 

accountability through surveillance, monitoring, and regular feedback to the court and 

drug court team. Drug courts provide more 

rigorous supervision and accountability than 

is provided for offenders on traditional probation. 

Typically drug court planning and oversight 

teams determine the DTC structure, treatment delivery model, and selection of treatment providers. A DTC team consists of 

judge, prosecutor, defense counsel, treatment 

provider, corrections personnel, local social 

service and mental health representatives, 

and housing authorities to help in the design 

of the most responsive treatment model possible. Though DTCs vary, the goal is essentially 

the same: treatment for offenders dependent 

on drugs instead of incarceration or probation (CSAT 1996; Hora et al. 1999). 

Figure 7-1 (p. 134) depicts the role of DTCs 

in substance abuse treatment and highlights 

the importance of creating and maintaining 

cooperative working relationships between 

the substance abuse treatment and criminal 

justice systems. It is vital that information 

flow smoothly among the courts, case management staff, and substance abuse treatment 

professionals. Judges must have access to 

evaluation and screening reports, drug 

screens, and information about the client’s 

participation in treatment. At the same time, 

substance abuse treatment counselors, social 

workers, and mental health professionals 

involved with the client’s case must be aware 

of any requirements or restraints imposed by 

the courts. Figure 7-1 also demonstrates the 

need for evaluation and reevaluation. During 

the treatment and recovery process, the 

132 Chapter 7 
 

10 Key Components of Drug Courts 

The following components were developed by a national committee of experts for the Office of Justice 

Programs, Drug Courts Program Office (National Association of Drug Court Professionals 1997). 

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

• Using a nonadversarial approach, prosecution and defense counsel promote public safety while protecting 

participants’ due process rights. 

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

• Drug courts provide access to a continuum of alcohol, drug, and related treatment and rehabilitation 

services. 

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

• A coordinated strategy governs drug court responses to participants’ compliance. 

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

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

• Continuing interdisciplinary education promotes effective drug court planning, implementation, and 

operations. 

• Forging partnerships among drug courts, public agencies, and community-based organizations generates 

local support and enhances drug court program effectiveness. 

client’s level of functioning, mental health status, and physical condition may change along 

with his treatment needs. Continual monitoring will allow both systems to tailor treatment 

to the client’s stage of recovery by identifying 

and addressing emerging health or mental 

health issues. 

In DTC proceedings, the judge takes an 

active and leading role in monitoring the 

offender’s progress in the treatment process 

through mandatory court appearances and 

data from urinalysis. The judge encourages 

the offender to stay in treatment through 

graduated rewards and sanctions. Generally, 

treatment lasts about a year, although incentives and sanctions can shorten or lengthen 

this time (Hora et al. 1999). 

Treatment through drug courts usually consists of three or four phases: 

•Orientation, drug education 

•Treatment 

•Relapse prevention, educational/vocational 

services 

•Aftercare and transition 

A range of treatment interventions is employed 

in DTCs. Most use a tapered approach that 

employs intensive outpatient treatment during 

initial stages of treatment, followed by progressively less intensive involvement in outpatient 

treatment (e.g., 1–3 times per week) in later 

stages of the program. In addition to regular 

involvement in treatment, DTC clients attend 

regular status hearings in court, receive individual and group counseling, are involved in 

case management services, are drug tested, and 

participate in peer support groups and a range 

of other ancillary services. 

Other Diversion Models

Treatment Accountability for 

Safer Communities (formerly 

Treatment Alternatives to 

Street Crime) (TASC) 

TASC programs focus on providing a bridge 

between treatment providers and the criminal 

justice system and offer a range of services, 

including screening and assessment, referral 

Treatment Issues in Pretrial and Diversion Settings 133 
134 Chapter 7 
Figure 7-1 

Substance Abuse Treatment Planning Chart for Treatment-Based Drug Courts 

Treatment Issues in Pretrial and Diversion Settings 135 
to community-based services, monitoring of 

treatment progress and compliance, case 

management and brokering community services, and court liaison. TASC programs 

sometimes are embedded with treatment agencies or court services departments, and, in 

some cases, are freestanding organizations. 

TASC programs have a long history of collaborative work in the criminal justice system. 

Early evaluations of TASC programs were 

generally positive, although limited in scope. 

An evaluation of five TASC programs (one for 

juvenile offenders) found mixed results. 

While TASC programs were consistently successful in identifying offenders who abused 

drugs and referring those offenders to treatment, three of the sites outperformed the others in at least one measure of subsequent 

drug use, while results on criminal recidivism 

were inconclusive. Study authors report that 

the findings on TASC programs were “consistently favorable,” although modest and, in 

some cases, confined to offenders with more 

problematic behavior (Anglin et al. 1999). 

Diversion programs established through constitutional 

ballot initiatives 

A number of ballot initiatives have been 

approved by the electorate in Alaska, 

Arizona, California, Oregon, and other States 

that have significantly affected the way in 

which drug offenses are processed in the 

criminal justice system. Several of these initiatives have focused on use of marijuana for 

medical purposes and decriminalization of 

drug possession offenses. Others, such as 

Proposition 200 in Arizona and Proposition 

36 in California, have been more far reaching 

and require diversion to treatment for nonviolent drug offenders who meet certain eligibility criteria. Similar initiatives are scheduled to appear on the ballot in other States. 

These ballot initiatives also restrict the use of 

sanctions (e.g., jail incarceration) that can be 

applied and provide procedural safeguards to 

prevent incarceration. These initiatives have 

been perceived in some jurisdictions as a 

direct threat to other existing diversion programs such as drug courts. A preliminary 

study of the Arizona initiative indicates that 

significant savings were provided to taxpayers 

in the form of reduced demand for jail and 

prison space. 

Proposition 36: The 

Substance Abuse and Crime 

Prevention Act 

In November 2000, California voters 

approved a ballot initiative, Proposition 36 

(Substance Abuse and Crime Prevention Act 

[SACPA] of 2000). The intent of SACPA was 

to reserve space in prisons and jails for serious and violent offenders, to increase public 

safety through reduction of drug-related 

crime, and to expand treatment and rehabilitation for offenders involved with drugs. The 

SACPA initiative changes State law to provide 

substance abuse treatment and community 

supervision for certain groups of nonviolent 

drug-involved adult offenders who would otherwise be sentenced to institutional settings or 

supervision in the community. All offenders 

charged with nonviolent drug-related offenses 

are potentially eligible to receive treatment 

services through the initiative. Offenders who 

use a firearm during the commission of their 

offense, who have additional nondrug offenses, or who refuse drug treatment as a condition of probation are ineligible for SACPA 

participation. The initiative establishes the 

Substance Abuse Treatment Trust Fund and 

provided $60 million for fiscal year 

2000–2001, and $120 million for each subsequent fiscal year, ending in 2005–2006. 

Although the long-term effects of SACPA 

await examination in the future, early studies 

provide information about the people being 

served. Compared to non-Proposition 36 

clients in treatment, Proposition 36 clients 

were more likely to be men in their first treatment episode receiving outpatient services for 

methamphetamine and marijuana use. They 

were less likely to use heroin or injection 

drugs (Hser et al. 2003). Another study 

136 Chapter 7 
indicated that criminal justice clients 

(whether or not they came from Proposition 

36) with high-severity drug abuse were less 

likely to be admitted to residential programs. 

Of high-severity outpatient clients, the 

SACPA clients were more likely to be rearrested for a drug-related offense (Farabee 

et al. 2004). 

Diverting individuals with 

co-occurring disorders 

People with some types of mental disorder are 

more frequently jailed than sent to hospitals. 

About three quarters of these individuals also 

have a substance use disorder (Broner et al. 

2001a). Their multiple problems present a 

challenge to criminal justice personnel. 

Some of these individuals are good candidates 

for diversion in the approximately 50 jailbased diversion programs that currently 

exist. Arrestees with co-occurring disorders 

can enter a diversion program in either the 

pre- or postbooking phase. In prebooking 

diversion, the police officer is the decisionmaker, although few police departments provide training in specialized responses to those 

with mental disorders. In postbooking diversion, there is usually screening, mental health 

evaluation, and negotiation between diversion 

and legal staff for a diversion rather than 

prosecution. In some postbooking programs, 

drug court procedures for case management 

have been adapted for a population with cooccurring disorders. In others, a “mental 

health court,” based on the drug treatment 

court model, has been established. These 

courts focus on the mental disorders rather 

than on prosecution. 

Many of those with co-occurring disorders do 

not respond well to traditional community 

interventions; their problems are too complex. It is clear that integrated treatment is 

more effective than either parallel treatment 

of mental disorders and a substance use disorder or sequential treatment of the two 

(Weiss and Najavits 1998). Drake et al. 

(1998b) concluded that treatment outcomes 

were especially improved when treatment 

lasts 18 months or longer. 

Work by Steadman and colleagues (1995) 

notes six central features of effective diversion programs for offenders with co-occurring 

disorders: integrated services, key agency 

meetings, boundary 

spanners, strong 

leadership, early 

identification, and Recent

evaluations 

of drug court 

programs

throughout the

United States

indicate that they

are achieving their 

goals. 

distinctive case management. Boundary 

spanners in this context are individuals 

with knowledge of 

both criminal justice 

and treatment systems who can bring 

the systems together 

to collaborate on the 

shared goal of 

obtaining substance 

abuse and mental 

health treatment for 

an individual who 

must answer to 

restrictions set by 

the criminal justice 

system. 

Driving Under the Influence 

courts 

Recent evaluations of drug court programs 

throughout the United States (Belenko 2001), 

which work to rehabilitate drug offenders, 

reduce recidivism, and save money, indicate 

that they are achieving their goals. This success has prompted practitioners and various 

institutions such as the National Association 

of Drug Court Professionals and the U.S. 

Department of Justice to discuss the potential 

benefits of widespread use of Driving Under 

the Influence (DUI) courts. Although arrests 

for DUI have been on the decline since 1987, 

serious, habitual abusers of alcohol remain 

largely unaffected by stiff criminal penalties 

and public awareness campaigns to stop 

Treatment Issues in Pretrial and Diversion Settings 137 
drunk driving (National Drug Court Institute 

1999). 

Similarities between repeat DUI and drug 

offenders have led many practitioners to 

believe that DUI or combined DUI/Drug 

Courts can be effective. Both types of offenders have a serious substance abuse problem 

and both require treatment, a strong support 

system, and the ability to overcome denial. 

However, unlike 

drug offenders, 

For some 

offenders, 

especially during 

the pretrial stage, 

a brief 

intervention can 

determine if 

treatment is 

necessary. 

DUI offenders tend

to be employed, 

and because of

their generally 

more stable family

situations, they 

tend to be able to 

draw on greater 

emotional and 

financial resources. 

But perhaps the 

most significant difference between the 

two is that DUI

offenders usually 

believe that because

the substance they 

ingest is legal, they

do not have a substance abuse problem (National Drug 

Court Institute 1999). 

In November 1998, practitioners from seven 

legal jurisdictions formed the DUI/Drug 

Court Advisory Panel at the invitation of the 

National Drug Court Institute to discuss 

establishing DUI courts that are modeled 

after drug courts and/or expanding existing 

drug courts to include DUI cases. The panel 

also addressed the many barriers to achieving 

this goal, including a lack of funding, a negative “soft on crime” perception held by the 

public, delayed adjudication, and minimal 

incentives for offenders to enter treatment 

(e.g., reduced or suspended jail time) 

(National Drug Court Institute 1999). 

 

What Treatment 

Services Can

Reasonably Be 

Provided in the 

Pretrial Setting? 

The large number of offenders who are supervised in the community, time constraints, 

supervision issues, and multiple agencies limit 

the services that can reasonably be provided 

in the pretrial setting. Below is a general 

description of intervention strategies and 

treatment components recommended by the 

consensus panel that can be used in a pretrial 

setting. 

Intervention Strategies

A number of intervention strategies can be 

adapted to the pretrial setting, as described in 

the following section. The time required to 

implement these strategies is necessarily brief. 

Brief interventions 

For some offenders, especially during the pretrial stage, a brief intervention can determine 

if treatment is necessary. Addressing a substance use disorder even briefly is preferable 

to ignoring it. A counselor can use the 

FRAMES approach or other motivational 

enhancement strategies, for example. 

•Feedback is given to the individual about 

personal risk or impairment. 

•Responsibility for change is placed on the 

participant. 

•Advice to change is given by the clinician. 

•Menu of alternative self-help or treatment 

options is offered to the participant. 

•Empathic style is used by the counselor. 

•Self-efficacy or optimistic empowerment is 

engendered in the participant. 

TIP 34, Brief Interventions and Brief 

Therapies for Substance Abuse, describes 

138 Chapter 7 
 

other brief interventions in more detail 

(CSAT 1999a). 

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 (Prendergast et al. 1995). 

Sliding scale (client fees) 

Many drug courts and pretrial diversion programs require participants to pay treatment or 

diversion fees in order to participate. Often 

these are based on ability to pay, or clients are 

allowed to defer some payments until after they 

become employed, one of the principles being 

that charging fees gives the offender some 

“buy-in” to the treatment process. 

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. The service 

is not detoxification. The individual is housed 

and monitored until he can leave safely. Those 

admitted to the Sobering Station are offered 

detoxification services when appropriate. 

Detoxification 

Detoxification is the term used to describe the 

process of withdrawal from alcohol or drugs 

that cause physical addiction. Detoxification, 

as the word implies, entails a clearing of “toxins” from the body. The most immediate purpose is to safely alleviate the short-term 

symptoms of withdrawal from chemical 

dependence, including physical discomfort. 

Detoxification may occur in either an inpatient or an outpatient setting. It involves several procedures for therapeutically supervised withdrawal and abstinence over a short 

term (usually 5 to 7 days but sometimes up to 

21 days), often using pharmacologic treatments to reduce client discomfort and reduce 

medical complications such as seizures. It is a 

first step for many clients who will enter 

treatment, but it is not synonymous with comprehensive, ongoing treatment. The detoxification process entails more than the removal 

of alcohol and illicit drugs from the body; it 

includes a period of psychological readjustment that prepares the individual to enter 

ongoing treatment. 

Withdrawal from certain drugs such as sedative-hypnotics, alcohol, benzodiazepines, and 

barbiturates can be life threatening. Thus, it 

is recommended that medical detoxification 

be provided for these classes of drugs. 

Though not life threatening, opioid withdrawal should also be treated in order to provide 

humane conditions to inmates and to avoid 

the potential for morbidity from dehydration 

as well as suicide attempts. TIP 19, 

Detoxification From Alcohol and Other Drugs 

(CSAT 1995a), describes clinical detoxification protocols for a variety of substances (see 

also the forthcoming revision of TIP 19, 

Detoxification and Substance Abuse 

Treatment [CSAT in development a]). 

Day reporting centers 

Day reporting centers are used to monitor the 

behavior of arrestees in the pretrial setting 

and of probationers and parolees under comTreatment Issues in Pretrial and Diversion Settings 139 
Chicago, Illinois, Day Reporting Center 

A day reporting center established in Chicago supervises detainees awaiting trial, ensures appearance in 

court, and begins to address substance abuse and other service needs. The program consists of a mandatory 15-day orientation phase, from which detainees progress into one of several tracks based on 

assessed needs. Several challenges in developing the day reporting center include (1) time limitations 

that restrict the type of interventions that can be provided, (2) facility limitations related to space and 

treatment activities, and (3) the need to integrate assessment and treatment information within the judicial process and to communicate in a timely manner about security and clinical issues. One interesting 

outcome related to the day reporting center is that approximately half of participants left the program 

when they were no longer required by the court to remain, with those leaving no longer involved in community treatment services. Those who completed the orientation phase of the program were more willing 

to engage in substance abuse treatment. Length of involvement in the day treatment center was associated with reductions in substance abuse (McBride and VanderWaal 1997). 

munity supervision. They provide closer 

supervision than twice-a-week drug testing, 

but are less restrictive than residential treatment. 

Additional treatment 

components 

The vast majority of offenders processed 

through the criminal justice system during the 

pretrial phase have chronic substance problems, as well as high rates of vocational, 

social service, educational, mental, and physical health needs. The following components 

can be an important and useful adjunct to 

standard counseling services offered in the 

pretrial setting and treatment providers may 

need to contract these services out on an asneeded basis. 

•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 

These additional services are integral to fostering long-term recovery but they do add 

cost, more service and supervision layers, 

and the need for case management. In the 

long run, however, treatment can save greater 

costs to the criminal justice, medical, and foster care systems. In a Philadelphia study of 

Medicaid clients receiving outpatient treatment with “enhanced services” (supplemental 

health and social services), McLellan and colleagues (1998) found that on almost all outcome measures, the clients receiving the supplemental services showed the best outcomes, 

including drug and alcohol use. 

Use of Sanctions

Judges and prosecutors have seen that sanctions encourage participation in treatment 

and are necessary to gain public acceptance 

of treatment in lieu of punishment. Sanctions 

include a range of measures that focus on 

holding offenders accountable for their 

actions. When a system of sanctions is implemented in concert with a sound treatment 

plan, offenders swiftly experience real consequences of their actions. This accountability 

is achieved through graduated sanctions. For 

example, an offender in an outpatient program requires drug testing three times per 

week. After a first positive drug test, the 

140 Chapter 7 
 

offender may be required to participate in 

treatment exercises to address reasons for 

relapse and may be required to submit to 

more frequent testing. If the offender continues to test positive, he or she may be required 

to enroll in more intensive services (e.g., residential treatment). Further, if an offender, 

who pleaded guilty and received a deferred 

jail or prison sentence so that he could enter 

treatment, continues to fail to comply with his 

treatment program, despite the imposition of 

intermediate sanctions, the ultimate sanction 

of a sentence of incarceration will be 

imposed. It is important, from a motivational 

standpoint, that other program participants 

see what will happen to them (i.e., incarceration) if they fail to comply with their treatment programs. 

Other sanctions such as victim impact meetings encourage the offender to recognize how 

drug-related activities affect the community. 

If the offender fails to complete the required 

treatment activities, victim restitution may be 

imposed as the next level of sanctions. By 

holding offenders accountable, graduated 

sanctions can be effective in redirecting individuals away from substance abuse and 

toward recovery. In general, the availability 

and use of sanctions tends to strengthen the 

impact of treatment, just as involvement in 

treatment tends to strengthen adherence to 

community supervision arrangements. 

Examples of sanctions used 

in diversion 

•Means-based fines (also called “day” fines). 

The total amount of these fines is calibrated 

to both the severity of the crime and the 

discretionary income of the offender, with 

the calibration and calculation established 

by the court as a whole for all cases in 

which this type of fine is to be imposed. 

(This type of fine contrasts with traditional 

fines that are imposed at the discretion of 

the judge according to ranges set by the legislature for particular offenses.) Defendants 

with more income (and/or fewer family obligations) pay a higher overall fine than those 

with lower incomes (and/or more obligations) for the same crime. This approach to 

setting the fine amount is typically coupled 

with expanded payment options and collection procedures that are tighter than usual. 

•Community service. This is the performance 

by offenders of services or manual labor for 

government, private, or nonprofit organizations for a set number of hours with no payment. Community service can be arranged 

for individuals, case-by-case, or organized 

by corrections agencies as programs. For 

example, a group of offenders can serve as 

a work crew to clean highways or paint 

buildings. 

•Restitution. Restitution is the payment by 

the offender of the costs of the victim’s losses or injuries and/or damages to the victim. 

In some cases, payment is made to a general 

victim compensation fund; in others, especially where there is no identifiable victim, 

payment is made to the community as a 

whole (with the payment going to the municipal or State treasury). 

•Outpatient or residential substance abuse 

treatment centers. Both public and private 

treatment centers may be contracted to provide treatment to offenders, as described in 

this TIP. 

•Day reporting centers or residential centers 

for other types of treatment or training. 

These centers are established to provide 

services other than substance abuse treatment. For example, a center may provide 

skills training to enhance offenders’ 

employability. Offenders must report to the 

center for a certain number of hours each 

day, and/or report by phone throughout the 

day from a job or treatment site, as a 

means of monitoring. 

•Intensive supervision probation. The level 

and types of supervision that are labeled 

intensive vary widely but usually involve 

closer supervision and greater reporting 

requirements than regular probation for 

offenders. This level can range from more 

than five contacts per week to fewer than 

Treatment Issues in Pretrial and Diversion Settings 141 
four per month. Supervision usually entails 

other obligations (to attend school, have a 

job, participate in treatment, or the like). 

•Intensive supervision parole has similar 

requirements and variations but is usually 

provided by parole agents to offenders who 

have completed a prison term and who are 

serving the balance of their sentences in the 

community. 

•Curfews or house arrest (with or without 

electronic monitoring). Offenders are 

restricted to their homes for various durations of time, ranging from all the time to 

all times except for work or treatment 

hours, with a few hours for recreation. 

Frequently, the curfew or house arrest is 

enforced by means of an electronic device 

worn by the offender, which can alert corrections officials to his or her unauthorized 

absence from the house. 

•Halfway houses or work release centers. 

Offenders are restricted to the facility but 

can leave for work, school, or treatment. 

The facility is in the community or attached 

to a jail or similar institution. 

•Brief jail incarceration (e.g., for 1–3 days). 

Brief incarceration is often used with 

offenders who have committed major program infractions in DTCs or in other diversion programs. This provides respite from 

temptations to use drugs and is useful in 

reinforcing the importance of sobriety and 

treatment. In some cases, incarceration can 

be used counterproductively for DTC or 

diversion participants if it is lengthy and if 

it prevents the offender from reengaging in 

treatment activities. 

•Boot camps. Typically, a sentence to a boot 

camp (also called shock incarceration) is for 

a relatively short time (3 to 6 months). As 

the name implies, boot camps are characterized by intense regimentation, physical 

conditioning, manual labor, drill and ceremony, and military-style obedience. 

Because boot camps are a form of incarceration, some in the criminal justice field 

reject their inclusion in the category of 

intermediate sanctions. Others include boot 

camps because placement in them is intended to take the place of a longer, traditional 

prison term. Several research studies have 

shown that boot camps do not significantly 

reduce criminal recidivism or substance 

abuse. One potential explanation for these 

findings is that most boot camps do not provide intensive substance abuse treatment 

services. 

How to use sanctions 

Evidence on the usefulness of sanctions from 

other institutional settings demonstrates several 

principles. 

•The efficacy of a punishment is determined, 

in large part, by the individual’s history 

and circumstances. 

•Sanctions must be of sufficient intensity so 

the client does not become habituated to 

threats and punishments, yet not so severe 

that the judge exhausts all options for sanctions. 

•A sanction should be delivered for each 

infraction. 

•To the extent possible, sanctions should be 

delivered immediately after the undesirable 

behavior. 

•Undesirable behavior must be reliably 

detected (e.g., through mandatory urinalysis two or three times per week). 

•Sanctions must be predictable (by explicit 

statements of behavioral expectations) and 

controllable through the individual’s 

actions. 

•Behavior does not change by punishment 

alone; desired behaviors should be rewarded. Desired behaviors include those that are 

incompatible with drug use, those that are 

naturally rewarding, and those that are 

likely to be rewarded by the client’s social 

environment (Marlowe and Kirby 1999). 

Rewards for positive behavior and behavior 

change in DTCs include public praise and 

recognition of achievement by the judge and 

other staff, reduction of fees or time in the 

program, small prizes such as key chains or 

142 Chapter 7 
 

movie tickets, and certificates of phase and 

program completion. 

Treatment Issues

The counselor–client relationship in a pretrial 

setting raises unique challenges. For one, the 

role of the counselor can become blurred 

between therapist and gatekeeper, answerable 

to both the treatment and the criminal justice 

communities. In the midst of this role confusion, the client’s legal rights need to be carefully guarded. 

The discussion below highlights some of the 

issues counselors operating in a pretrial setting 

are likely to face. 

Importance of Screening 

Unpredictability characterizes the hours and 

days immediately following arrest. The rapidly developing nature of arrest and arraignment creates a challenge for counselors in 

gaining access to the arrestee. Arrests can 

occur at odd hours, while assessment staff are 

unavailable. Interviewing conditions, such as 

in a police lockup, are less than ideal. Still, 

the consensus panel believes that detainees 

should receive screening for substance abuse 

offenders who do not genuinely have a drug 

or alcohol problem will participate in treatment nonetheless. One example is a drug 

dealer who does not have a substance use disorder, but earns income from drug trafficking. During assessment the offender may deny 

using substances. However, once a clinician 

threatens to send the offender back to the 

judge, the offender may prudently decide he 

is boxed into “admitting addiction.” In this 

instance, the offender is simply using common 

sense to avoid harsher sentencing and 

improve his chances for leniency in the criminal justice system. 

To address this dilemma, the panel suggests 

that treatment counselors assess collateral 

evidence of a substance use disorder. 

Orientation and other “pretreatment” program components are also used to determine 

individual readiness and commitment to 

treatment, prior to involvement in more 

intensive program services. Not every offender is appropriate for treatment. For example, 

if a counselor assesses an individual who does 

not have a substance use disorder, the person 

should be referred back to the judge in order 

to avoid denying the offender’s due process 

rights, such as the right to a speedy trial. 

Early drug screening and the use of profesduring the initial intake procedure to determine whether further assessment should be recommended or whether referrals 

should be made. (See chapter 2, 

Screening and Assessment, for 

examples of appropriate screening instruments.) Prompt 

screening is also important to 

identify offenders in need of 

detoxification services. 

It is important for counselors to 

understand that offenders sometimes sign up for treatment 

because “it’s the thing to do.” 

Accessing drug treatment can 

help an individual appear more 

sympathetic in the eyes of the 

court. Understanding this, some 

Advice to the Counselor: 

Operating in a Pretrial Setting 

• Counselors must maintain a client’s confidentiality. One 

strategy is to avoid discussing the client’s criminal case. 

• Counselors should bear firmly in mind that the client is 

presumed innocent before trial. 

• Counselors should be realistic about the responsibilities 

that a client is capable of handling in pretrial settings. 

For example, it is unrealistic to believe that a defendant 

will suddenly become a model citizen, meeting all of his 

or her responsibilities, simply because of an arrest. 

• Counselors should avoid allowing individuals to be inadvertently penalized for enrolling in treatment. 

• Counselors should be aware that clients may be more 

focused on “beating the case” than on recovery. 

Treatment Issues in Pretrial and Diversion Settings 143 
sional alcohol breathalizers can also be helpful in determining the need for further 

screening and treatment. 

To better identify individuals with substance 

abuse problems and to provide informed 

diversion to treatment services, several jails 

have implemented a comprehensive screening, 

and use systematic “case finding” approaches 

(National GAINS Center 2000; Steadman et 

al. 1999). In some areas, TASC program staff 

perform these activities; in others, different 

types of “boundary spanners” perform these 

tasks. Generally, these are people who are 

knowledgeable about criminal justice processing and different community treatment systems and resources. 

Meeting Immediate Needs

The pretrial setting can create difficult 

scheduling problems for clients. Individuals 

may have lost their jobs because of an arrest, 

and clients who are employed may wonder 

how they will hold onto their job if they are 

required to attend treatment. Counselors 

tend to believe that putting an individual into 

treatment is of primary importance during 

Advice to the Counselor: 

Addressing the Client’s

Immediate Needs

• Detoxification needs: Screen for the need for detoxifi 

cation services and refer clients when appropriate. 

Train staff in signs and symptoms of withdrawal so 

that staff can detoxify clients from alcohol and drugs. 

• Childcare issues: Provide on-site childcare at treatment 

facilities. 

• Potential forfeiture of public housing: Notify an individual’s landlord that the individual is receiving treat 

ment. 

• Transportation needs: Provide bus tokens, car-service 

vouchers, and transportation support. 

• Medical needs: Ensure that medical needs are 

addressed, including receipt of prescription medicines 

and screening for infectious diseases. 

this time period; however, they should be sensitive to the fact that although treatment is 

critically important, it is not always the 

client’s most pressing priority. This is especially true when weighed against considerations such as displacement from housing and 

lack of appropriate childcare. Many clients 

who are navigating more immediate and 

pressing needs are not ready to engage in the 

therapeutic process. Effective triage helps to 

build client trust and lays a foundation for 

successful engagement in therapy. 

The consensus panel recommends that counselors prioritize case management services to 

include the most pressing client needs, such 

as food, clothing, shelter, and medical treatment. Does the client need detoxification? Are 

there childcare issues to be resolved? Is the 

client in need of medication? 

Maintaining Existing Services

In many U.S. communities, individuals 

receiving Federal disability supports, such as 

Medicaid, Social Security Insurance, or 

Social Security Disability Insurance, often 

lose their benefits if they are detained in jail. 

Although Federal regulations do 

not require these supports to be 

terminated for jail detainees, 

misunderstandings regarding 

policies often result in loss of 

services. Upon release, these 

individuals must re-apply for 

Federal supports, a somewhat 

lengthy process that often creates a delay in access to community treatment services. A lapse 

between incarceration and treatment without benefits means that 

these individuals are often 

unable to meet their basic subsistence, health, and mental 

health needs and usually lose 

any stabilization gained while in 

jail, bringing them back in contact with the criminal justice system after a short period of time 

(National GAINS Center 1999b). 

144 Chapter 7 
 

Although Federal policies do not require an 

individual’s benefits to be terminated immediately upon incarceration, they do stipulate a 

timeframe after which benefits cannot be 

received. Whether communities suspend or 

drop an individual’s Medicaid benefits 

depends on the State (National GAINS Center 

1999b). 

In Lane County, Oregon, diverted individuals 

with co-occurring mental and substance use 

disorders experienced difficulties in maintaining uninterrupted treatment due to issues 

with Medicaid and Social Security Insurance 

benefits. In response, the County raised its 

concerns with the Oregon Medical Assistance 

Program director. The State recognized this 

situation as a continuum-of-care issue for 

those with short-term stays in the jail. The 

State adopted the Interim Incarceration 

Disenrollment Policy, which states that individuals cannot be disenrolled from the 

Oregon Health Plan during their first 14 days 

of incarceration (National GAINS Center 

1999b). 

In addition to this policy change, Lane 

County has coordinated with the local application processing agency for Medicaid and 

Social Security Insurance. This relationship 

allows detainees who did not have benefits 

upon booking or who have been incarcerated 

longer than 14 days to begin the application 

process while still in custody. Diversion program participants are now given priority and 

are able to regain or obtain benefits within a 

few days (National GAINS Center 1999b). 

The staff of the Lane County diversion program reports that the disenrollment policy 

has been crucial for offenders and has greatly 

benefited program participants. Other jail 

staff members, providers, and advocates are 

also encouraged to develop a thorough understanding of the rules regarding Federal benefits, and to maintain an open line of communication with the State Medicaid agency and 

local Social Security office (National GAINS 

Center 1999b). 

Protecting Clients’ Rights

The client’s due-process rights can affect the 

counselor’s role in the pretrial setting. Clients 

and counselors should not discuss the client’s 

ongoing criminal case. The boundaries of the 

counselor’s responsibilities can begin to blur 

when clients discuss their criminal cases. 

Counselors should avoid the situation of being 

forced to report to a prosecutor something 

they have been told concerning the client’s 

case. 

A memorandum of understanding (MOU) can 

also protect a client’s rights. An MOU signed 

by the prosecutor will ensure that the prosecuting attorney in the case will not use information gathered during the treatment process 

against the client. A judicial order attached to 

such an MOU may carry more weight: If the 

judge rules that information given to a treatment provider is out of bounds for a prosecutor, the client has that much more assurance 

that he or she may speak freely to the counselor. 

Presumption of Innocence 

The issue of presumption of innocence points 

to an essential difference between the legal 

and therapeutic cultures. It also poses a challenge for treatment counselors during the pretrial phase. The dilemma is this: For individuals to participate in drug treatment, they 

must first admit to having a drug problem. As 

a result, when the crime is possession of 

drugs, counselors often have a more difficult 

time presuming a client’s innocence. 

“Presuming their innocence never occurs 

to me. I’m usually trying to convince the 

clients they have a problem.” 

—Counselor 

Coercive Power of 

Treatment Staff 

The impact of arrest itself carries trauma, 

uncertainty, and disruption that are different 

from being in jail. This uncertainty can either 

help or hinder counselors who are trying to 

Treatment Issues in Pretrial and Diversion Settings 145 
engage clients in treatment. The aftermath of 

the arrest often provides additional motivational leverage and counselors can better 

engage their clients in treatment by assessing 

this motivation. Are they seeking to avoid 

prosecution? Do they want to remain in the 

community? Counselors who perceive clients’ 

motivation and assist them in meeting shortterm goals provide strong incentive to engage 

them in the treatment process. For counselors, the keys to meeting these short-term 

goals are awareness of resources and the ability to offer them. 

Counselors working in the pretrial setting 

have additional leverage with clients in that 

they are responsible for making recommendations to the court concerning adherence to 

and progress in treatment. However, the 

counselor’s role is potentially more adversarial. Self-disclosure to a counselor is not necessarily in the client’s best interest. As a result, 

it may be more difficult to engage the client in 

an open relationship. The counselor should 

inform the client at the outset that at some 

point it may be necessary to report to the 

court or pretrial supervision staff. The counselor should be absolutely clear about this 

process, its requirements, and his or her role 

in relation to the community supervision 

agency. In some settings, such as drug courts, 

counselors are part of a multidisciplinary 

team and play a vital role in case reviews and 

determining clients’ disposition. For example, 

counselors provide regular and periodic 

reports regarding client treatment adherence 

and progress. The judge may defer to the 

counselor’s opinion regarding recommendations for the client’s promotion to different 

phases, or graduation from the program, giving the counselor additional leverage in motivating clients to engage in treatment. 

Checks and Balances on a 

Counselor’s Influence 

The power of the counselor in pretrial and 

diversion settings raises several important 

ethical questions. Should counselors be able 

to circumvent a client’s release conditions? 

What assurance is provided that counselors 

will act with fairness and consistency? What 

measures can be taken to prevent counselors 

from abusing this power? Should some type of 

oversight mechanism be established to avoid 

the potential abuse of power? These types of 

checks and balances are incorporated within 

drug treatment courts. For example, team 

staff meetings provide a forum for discussion 

to review each case prior to court hearings 

and to achieve consensus regarding what the 

judicial and drug court program response will 

be to infractions or other critical incidents. 

Developing Pretrial
 

Treatment Services
 Efforts to expand and institutionalize treatment programs in order to make them a standard part of the pretrial criminal justice system often face a number of challenges. In 

planning such programs, the consensus panel 

believes the following strategies may be helpful: 

• Increase the number of experienced counselors and trained clinical staff. 

• Create special licensing and certification for 

counselors who provide treatment in the pretrial setting. 

•Increase awareness of the importance of the 

pretrial setting in promoting clients’ successful recovery. 

•Educate the media concerning the effectiveness, usefulness, and importance of providing treatment in pretrial and diversionary 

settings. 

•Demonstrate that the services provided are 

effective in reducing substance abuse and 

recidivism. 

•Expand treatment options to include brief 

interventions and treatment readiness 

programs. 

•Consider the effects of treatment on case 

processing. 

146 Chapter 7 
 

 

Baltimore’s Response to Drugs and Crime 

Since the early 1990s, Baltimore, Maryland’s substance abuse prevention and treatment agency, the 

Board of Directors of Baltimore Substance Abuse Systems, Inc. (BSAS), has faced a crime rate that is 

double the national average, an increase in the spread of infectious diseases, and economic costs of drug 

use exceeding $2.5 billion a year. Baltimore’s drug problem is among the worst in the Nation. At least 

60,000 Baltimore city residents need alcohol and drug treatment (Smart Steps 2000). 

In its efforts to tie high-quality, readily available treatment to comprehensive wraparound services, 

BSAS recognizes that outside help is crucial, given the strict limitations on Baltimore’s own budget. To 

aid in this effort, neighborhoods across the city have come together to form a Crime and Drugs Solution 

Work Group, whose major goal is to improve the quality and quantity of drug treatment. Another organization, the Greater Baltimore Interfaith Clergy Alliance, which represents over 200 congregations in 

the region, is working to strengthen community-based treatment services in neighborhoods throughout 

the city. Over the past several years, The Baltimore Sun, the city’s major newspaper, has editorialized 

frequently to raise awareness of the need to boost the city’s investment in drug treatment. Other local 

organizations and foundations have advocated more public funding for treatment, and have even contributed their own dollars (Smart Steps 2000). 

For more information on Baltimore’s commitment and approach to improving drug treatment, go to 

http://www.drugstrategies.org/Baltimore. 

•Include stakeholders from a variety of 

domains in the planning process. 

Effective Pretrial and

Diversion Programs

The consensus panel recommends that to be 

effective in providing substance abuse treatment, diversion programs need adequate staff 

resources, training, and coordination, along 

with program components adapted to criminal justice settings. These recommended elements are discussed in detail below. 

Staff resources 

Staff for effective programs can include both 

counseling personnel and individuals in liaison and administrative roles. Counselors can 

provide information regarding how to access 

treatment services and available treatment 

programs. A liaison resource coordinator can 

disseminate this information, or an administrator can maintain a database of treatment 

programs, supervise referrals, and provide 

coordination between treatment and the 

court. As “boundary spanning” staff members, they can perform the delicate balance 

between social work, social justice, and social 

control. 

To ensure that trained personnel are available to deliver services on a timely basis, programs could hire additional staff or link to 

other treatment programs and agencies. For 

example, treatment providers may not have 

the ability to offer anger management or literacy training classes in a particular program 

site. Given the cost of maintaining these specialists, agencies could provide these services 

through contract vendors. Clinical agencies 

may also need to contract for backup staff in 

order to reduce the size of caseloads and to 

provide 24-hour services for offenders who 

are arrested and/or processed during “off 

hours.” 

Training 

Cross-disciplinary training for effective programs emphasizes the importance of substance abuse interventions and criminal justice supervision while making available the 

Treatment Issues in Pretrial and Diversion Settings 147 
information that all staff members need. 

CSAT has provided technical assistance to 

States seeking to establish cross-training programs. While early efforts focused on training 

probation officers and treatment staff, more 

recent training activities have focused on creating multidisciplinary teams of staff from 

different systems that collaborate to engage 

and retain offenders in treatment. The 

Addiction Technology Transfer Centers 

(ATTCs), funded by CSAT, also offer an 

extensive array of training and resource 

materials for use by criminal justice and 

treatment professionals. For more information, contact the ATTC National Office at 

(816) 482-1200, or their Web site at 

http://www.attcNETWORK.org. 

Effective substance abuse treatment is culturally competent. That is, the programs and 

staff demonstrate behaviors, attitudes, and 

policies that enable them to work effectively 

in cross-cultural situations (Cross 1989). 

Cultural competence is based on understanding and respect for differences among people 

and groups. It is important to recognize that 

culture plays a complex role in people’s lives 

and in the development of substance abuse 

problems and their treatment. Cross-training 

is an appropriate time to review practical 

examples of cultural competence in program 

development and operation. Staff require 

training in cultural diversity and issues specific to the cultural populations that they 

serve. (See the forthcoming TIP Improving 

Cultural Competence in Substance Abuse 

Treatment [CSAT in development b].) 

The consensus panel suggests that judges, too, 

must stay informed about issues in many 

areas. Organizations such as the American 

Bar Association, the National Judicial 

College, the National Association of State 

Court Judges, the American Judicature 

Society, and the National Association of State 

Judicial Educators ensure that judges receive 

many kinds of information and training. 

Coordination 

Effective programs include mechanisms for 

coordination and information exchange 

between substance abuse and criminal justice 

agencies (including MOUs, discussed below). 

For example, individuals need to be screened 

for diversion, and their treatment histories 

given; diversion programs often require that 

specific conditions be met. Both situations 

entail communication between agencies if the 

defendant is to receive appropriate treatment. 

In addition, the pretrial environment 

requires coordination in making key clinical 

decisions, including determination of the 

treatment intensity, duration, modality, setSuggestions for Improving the Timing of Treatment 

Effective programs work to optimize the timing and sequencing of treatment services. The following 

approaches can be helpful: 

•Provide screening and assessment at the earliest possible point in the justice system. 

•Move offenders into treatment as soon as possible. 

•Provide several levels of care, including detoxification. 

•Develop flexible sanctions so clients who have been unable to access treatment are not punished for this. 

•Provide services to increase the offender’s motivation to engage in treatment. 

•Address the offenders’ denial. 

•Use brief interventions, where appropriate. 

•Identify treatment and ancillary resources in the community. 

148 Chapter 7 
 

ting, and specific services required. 

Counselors can work with the court to develop consensus-building approaches to deal 

with these critical issues that arise during the 

course of treatment, with the goal of developing mechanisms to advise judges regarding the 

best course of action for an individual’s treatment. Decisions regarding diversion to treatment that provide a balanced consideration of 

public safety needs are complex when offenders have multiple cases in different courts, 

including noncriminal systems (e.g., family 

court, housing court, child welfare cases). 

Some offenders are already on probation, 

parole, or other types of supervision when 

they are arrested. The challenge is then to 

determine and arrange a hierarchy of services 

within multiple systems (e.g., criminal justice, 

treatment, child welfare). 

Successful interagency cooperation requires 

information sharing that is coordinated as 

quickly as possible. Establishing commonly 

accepted protocols, such as those required for 

sharing information, is also useful in promoting this coordination. (For information on 

confidentiality, see CSAT 2004.) Case managers 

who provide wraparound services and work 

within both the treatment and justice systems 

are also instrumental in improving interagency coordination and can address critical 

issues such as insurance coverage and navigating through managed care networks. 

Memorandums of 

Understanding 

MOUs are useful for clarifying who has 

responsibility for various decisions related to 

sanctions, treatment, and case disposition, 

and under what conditions these decisions 

can be modified. Effective programs set up 

MOUs to establish guidelines and procedures 

for treating the client, sharing information, 

and maintaining the confidentiality of information. First, MOUs foster cooperative interagency relationships by ensuring that each 

component of the treatment system is aware 

of how the other components will access, 

share, and use information (Tauber et al. 

1999). Second, when participants sign the 

consent to disclosure (permitting the counselor to share information from the client’s 

treatment), the MOU can be used to explain 

how information will be distributed to the 

criminal justice system. (See also CSAT 2004.) 

The following are the consensus panel’s 

recommendations for elements that 

should be contained in MOUs. 

• MOUs typically note that discussions at team 

meetings are confidential, in part because of 

legal concerns but also to promote trust and 

fairness. 

•If outsiders are permitted to attend treatment team meetings, the MOU should 

require them to sign an agreement that they 

adhere to the confidentiality provisions of 

the law (redisclosure) and the MOU. 

•MOUs should state that the prosecutor’s 

office will not use information obtained in 

the drug treatment to prosecute the participant, with two exceptions: child neglect or 

abuse and crimes committed at the treatment center or against treatment personnel. 

A prosecutor frequently learns of offenses 

by participants, particularly drug possession offenses. In some cases, an offender 

who commits a crime may lose eligibility for 

the drug court program (among other possible consequences) but should not be prosecuted for crimes based on information that 

was acquired during the drug court proceedings. 

•The MOU should describe the conditions 

under which the information can be shared 

or held confidential. 

•The MOU should encourage the free flow of 

information within the drug court team to 

promote the drug court’s mission. 

•The MOU should include rules governing 

the storage of, and the access to, written 

and electronic records. Federal law 

requires such written policies (Tauber et al. 

1999). 

Treatment Issues in Pretrial and Diversion Settings 149 
that sanctions are provided in a fair, consistent, and timely manner. 

How can a public defender convince a client 

that treatment might be best if it goes against 

the client’s legal interests? The role of the 

counselor is to engage the client in treatment—but the role of the attorney is to advocate the wisest legal course. The attorney’s 

role becomes more complicated when the need 

for treatment is identified. Legal counsel traditionally plays the role of gatekeeper, 

although negotiating treatment issues in the 

pretrial setting can call for a different role. 

Defense counselors need specific training in 

what can and cannot be achieved in treatment, and the advantages and potential risks 

related to the clients’ enrollment in treatment. 

The use of drug testing in the pretrial setting 

is somewhat controversial. It is argued that 

because drug use is associated with criminal 

behavior, those currently using drugs are 

more likely to commit additional crimes if 

they are released into the community while 

awaiting trial, and that these individuals are 

less likely to appear for trial if they continue 

to use drugs. Belenko and colleagues (1992) 

report that drug testing does not appear to be 

a cost-effective method for predicting which 

defendants are at risk for pretrial misconduct. Their examination of pretrial drug testing at six sites showed that the testing did not 

consistently predict pretrial misconduct better than other information available at the 

time (e.g., prior arrest record, indications of 

ties to the community). 

Belenko and colleagues (1992) make several 

additional arguments against pretrial drug 

testing for detainees in the absence of treatment. First, one could argue that judges 

Procedures To Serve the Best 

Interests of the Offender

Even at the pretrial stage, the best interests of 

the offender may be seen differently by the 

substance abuse treatment and criminal justice 

systems. While the former strives to assist 

offenders in recovery, the emphasis in the criminal justice system is to prevent further illegal 

actions and ensure compliance with court 

orders and conditions. A common goal of both 

programs is to prevent recidivism. 

A central challenge for treatment in the criminal justice setting is determining who has 

jurisdiction over program violations. 

Offenders may not know the “rules” or the 

exact consequences of their actions. Clients 

may fail to complete obligations in the criminal justice system without violating treatment 

requirements. The question becomes: Should 

clinicians report this violation if it could 

adversely affect the individual’s treatment? 

Does the discretion of the clinician undermine 

the sanctity of the judicial system? Other concerns include the format of a clinician’s 

report: If a violation occurs, should the 

report be in a regular general format or an 

immediate communication? 

Sanctions, as well as incentives to engage in 

treatment, should be described in clear written guidelines. This information should be 

provided to clients in the presence of their 

attorneys in order to make certain they 

understand the sanctions. These guidelines 

should be grounded in reality. For example, 

jailing an employed individual can be potentially excessive punishment. The sanctions 

should be fair, consistent, and involve each of 

the agencies. Education and cross-training 

are needed for both criminal justice and 

treatment professionals in order to ensure 

The Paradox of Diversion, Treatment, and Public Safety 

Diversionary treatment is perceived as a threat to public safety because offenders are quickly placed back 

into the community. However, over the long run, diversionary treatment increases public safety because 

individuals involved in substance abuse treatment are less likely to commit crimes (Belenko 2001). 

150 Chapter 7 
 

would be more likely to release detainees if 

they required periodic drug testing because 

this condition of release would act as a system 

for monitoring their behavior. In fact, this 

has not happened. Second, staff costs and 

costs for purchasing drug-testing equipment 

are substantial. Third, the accuracy of drug 

testing technology is not perfect. False-positive results can have serious consequences for 

a defendant, and given the number of drug 

tests an offender is required to take over the 

course of 6 months, the chances of receiving 

at least one false-positive result can be significant. Finally, mandatory drug testing raises 

constitutional issues of due process, selfincrimination, and unnecessary search and 

seizure. 

Pretrial drug testing is considered a search 

under the Fourth Amendment to the U.S. 

Constitution. Court rulings have determined 

that it complies with due process when collection and testing procedures meet the legal test 

of reasonableness (Bureau of Justice 

Assistance 1999). From the treatment perspective, however, part of the difficulty with 

drug testing is that it can only flag the presence or absence of certain drugs. It cannot 

discriminate between chronic and casual 

users—between those with a substance use 

disorder who would benefit from treatment 

and those who are experimenters. 

Drug testing alone does not provide enough 

information to make decisions about pretrial 

release or detention or referral for treatment. 

Rather, these results should be combined with 

other information available in the pretrial 

setting or from a thorough clinical assessment. Drug testing is, however, a necessary 

and useful adjunct for monitoring offenders’ 

compliance with conditions. As an intermediate sanction, drug testing often decreases 

drug use among offenders. Although drug 

testing and sanctions alone are limited in 

what they can provide, there are some individuals who will stop using drugs if they are 

tested. 

Many clinicians believe that offenders who 

have not been able to access drug treatment 

should not be punished for testing positive. 

Nonetheless, use of drug testing alone without 

sanctions is sometimes used as an alternative 

to treatment and may lead to an individual’s 

exclusion from treatment. The Washington, 

D.C., Drug Court provides drug testing and 

sanctions without drug treatment. This combination of sanctions without treatment is 

referred to as the “Coerced Abstinence 

Model.” The D.C. Drug Court does demonstrate reduced recidivism, though the impact 

on drug use is unclear (Belenko 1990). 

Resources

Examples of Diversion

Programs

These programs, in the view of the consensus 

panel, exemplify effective diversion programs. 

While some are still in operation in 2005, others are not. 

Brooklyn Drug Treatment 

Alternative to Prison (DTAP) 

Program 

The Brooklyn Drug Treatment Alternative to 

Prison program was established by Kings 

County District Attorney Charles J. Hynes in 

1990 to divert nonviolent felony offenders 

with one or more prior felony convictions and 

a documented history of drug abuse into 

treatment. Although DTAP started as a 

deferred prosecution model, in 1998 the 

DTAP shifted to a deferred sentencing model 

(Kings County District Attorney’s Office 

2001). 

DTAP’s target population includes nonviolent 

felons who, under New York State’s SecondFelony Offender Law, face a mandatory 

prison sentence. Defendants accepted into 

DTAP have their sentences deferred while 

undergoing 15–24 months of rigorous, intensive drug treatment. Those who successfully 

Treatment Issues in Pretrial and Diversion Settings 151 
complete treatment are returned to court to 

have their charges dismissed. The program is 

a therapeutic community with a rigid structure, rules, timetables, and goals. As of 

March 2005, 2,094 individuals have begun the 

program, 831 have completed it, and 374 are 

currently enrolled (Kings County District 

Attorney’s Office 2001). 

A 5-year study of the program indicates that 

53 percent of these participants have completed it (National Center on Addiction and 

Substance Abuse [CASA] 2003). Their rearrest rates and reconviction rates are significantly lower than a matched sample of 

offenders who received regular processing in 

the criminal justice system. After 2 years, 

DTAP graduates were 87 percent less likely to 

return to prison. In addition, preliminary 

results show that graduates had decreased 

their drug use compared with offenders who 

dropped out of the program or did not participate. Those participating in DTAP stayed in 

treatment longer than those in the general 

treatment population (17.8 months, compared 

to 3 months). Retention rates were highly 

associated with high levels of perceived legal 

pressure to remain in treatment. The average 

cost for a person in DTAP compared favorably with costs of incarceration: $32,975 versus $64,338 (CASA 2003). 

Memphis Prebooking Jail 

Diversion Program 

Memphis police officers have been specially 

trained to handle mental health and substance 

abuse crises while on patrol. They receive 

training in psychiatric diagnosis, substance 

abuse issues, de-escalation techniques, community mental health and substance abuse 

resources, and legal issues. The officers have a 

working relationship with the University of 

Tennessee’s Medical Center and help community agencies implement treatment plans for those 

diverted to treatment. 

Montgomery County 

(Pennsylvania) Pre- and PostBooking and Coterminous 

Jail Diversion 

The county’s Emergency Services works closely 

with County Administration and a local Task 

Force to maximize multidisciplinary involvement in the diversion program. Its success is 

credited to police training, a 24-hour crisis 

response team, inpatient treatment, case managers, and an outreach team. Prebooking uses 

psychiatric treatment in lieu of arrest while 

postbooking involves regular screenings for 

incarcerated individuals with mental health 

and substance abuse problems. By taking an 

offender directly to psychiatric treatment while 

concurrently filing charges, police engage coterminous jail diversion, which diverts the individual from criminal incarceration. The program was funded through a CSAT grant to the 

University of Pennsylvania. 

Addiction Prevention and 

Recovery Administration and 

the Salvation Army 

These two organizations have formed a partnership to expand the current communitybased residential treatment program, 

Salvation Army Beacon for Adult Males in the 

Justice System, through a grant awarded by 

the U.S. Department of Health and Human 

Services. The program, which was funded 

through a CSAT grant to the District of 

Columbia’s Department of Health Addiction 

Prevention and Recovery, addresses the 

needs of men in pretrial or presentence status 

who abuse substances and who have been 

charged with a nonviolent drug-related crime. 

The program currently serves 95 men annually, but the grant will increase the number by 

30 and incorporate Treatment Readiness and 

an aftercare component. 

152 Chapter 7 
Substance Abuse and Mental 

Health Services 

Administration 

To help States break the pattern of incarceration without treatment and reduce the high rate 

of recidivism, SAMHSA provides grants for 

diversion and reentry programs for adolescents, 

teens, and adults with substance use and mental 

disorders. These grant programs focus on treatment as well as housing, vocational and employment services, and long-term supports. For 

more information go to http://www.samhsa.gov. 

Bureau of 

Justice SAMHSA

provides grants

for diversion and 

reentry programs

for adolescents,

teens, and adults

with substance use

and mental

disorders. 

Assistance 

(BJA) 

The BJA in the U.S. 

Department of 

Justice is authorized 

by Congress under 

the Edward Byrne 

Memorial State and 

Local Law 

Enforcement 

Assistance Program 

to make grants to 

States in order to 

improve the functioning of the local 

criminal justice system. The program 

places emphasis on 

violent crimes and 

serious offenders, and the enforcement of 

State and local laws that establish offenses 

similar to those in the Federal Controlled 

Substances Act. The Drug Court Grant 

Program in the BJA administers financial and 

technical assistance and training to State, 

local, and tribal governments and jurisdictions to develop and implement drug treatment courts. (Additional information is available at http://www.BJA.gov.) 

Assistance for drug treatment courts 

The National Association of Drug Court 

Professionals (NADCP) is the main member 

organization that provides advocacy and support for the development of drug treatment 

courts throughout the country. The group has 

an extensive training and technical assistance 

program with experience in planning and 

implementing drug courts and establishing 

community linkages with law enforcement. A 

network of 27 mentor drug courts uses practitioners to act as resources at meetings and 

conferences and onsite visits. (For more 

information, see the NADCP Web site at 

http://www.nadcp.org/.) 

Other pretrial diversion 

models 

•Phoenix, Arizona’s and Eugene, Oregon’s 

Substance Abuse and Mental Health Services 

Administration (SAMHSA) Diversion 

Projects (for co-occurring disorders) 

•Jacksonville, Florida, Drug Court (pays for 

aftercare) 

•Pensacola, Florida, Drug Court (serves as 

“mentor” court for other drug treatment 

courts) 

•San Bernardino, California, Drug Court 

(higher level of supervision and services provided for the most serious offenders) 

•Reno, Nevada, Family Drug Court (one of 

the earliest family/dependency drug courts) 

•South Carolina’s statewide diversion program 

•Various sites participating in the SAMHSA 

Jail Diversion project 

Program Resources

The following resources include instructional as 

well as financial assistance. 

Treatment Issues in Pretrial and Diversion Settings 153 
Training outlets 

•National Association of Pretrial Services

Agencies (http://www.napsa.org/)

•National TASC Conference (for case managers, assessment staff, clinicians)

(http://www.nationaltasc.org/)

•National Drug Court Institute (provides targeted training for all of disciplines involved in

drug courts; judges, prosecutors, defense

attorneys, probation officers, treatment professionals) (http://www.ndci.org/

aboutndci.htm)

•National Association of Drug Court

Professionals Annual Training Conference

(http://www.nadcp.org/)

•The National GAINS Center

(http://gainscenter.samhsa.gov/) 

Conclusions and

Recommendations

The consensus panel highlights the conclusions 

and recommendations as follows: 

•The vast majority of offenders processed

through the criminal justice system during

the pretrial phase have chronic substance

abuse problems, as well as high rates of

vocational, social service, educational, mental, and physical health needs.

•The rapid movement of offenders through

different points of processing in the criminal justice system complicates delivery of

substance abuse treatment services and presents challenges in sharing information and

encouraging continuity of involvement in

treatment.

•Pretrial services programs face many challenges in identifying and referring offenders

in need of treatment. These include providing timely clinical assessment, timely referrals to services, effective monitoring of

treatment progress, referral, and case management.

•Pretrial drug testing is unlikely to be more

effective than indicators such as the prior

arrest record and family or other community ties in predicting pretrial misconduct 

(Belenko et al. 1992). 

•Treatment providers face several challenges

in serving pretrial clients. These include

developing processes to transfer information between jails, courts, community

supervision, and treatment agencies, and

strategies to identify and resolve potential

conflicts between courts, supervision, and

treatment staff related to clinical decisionmaking, sanctions, and level of supervision.

•Access to effective treatment and other services is sometimes limited for offenders at

the pretrial stage.

•Diversion from prosecution and treatment

can occur at several points in the criminal

justice process and can result in a variety of

case dispositions (Anglin et al. 1999; Broner

et al. 2002).

•There is a significant need for cross-training

of criminal justice and treatment staff, use

of culturally sensitive treatment approaches, and for stakeholder involvement in program planning in pretrial and diversion settings.

•Community task forces provide an important mechanism to coordinate activities of

various community agencies that are

involved in diversion programs.

•To capitalize on the initial and sometimes

fleeting interest in personal and lifestyle

change that can accompany arrest, individuals in pretrial settings should be screened

as soon as possible for substance use disorders, detoxification needs, and other immediate needs.

•Mental health screening and assessment

should be conducted as soon as possible

after consideration for diversion programs,

and when appropriate, clients with mental

disorders should be referred to specialized

programs that are tailored to address their

needs.

•Treatment in pretrial and diversion settings

should focus on immediate needs, such as

154 Chapter 7 
 

housing, transportation, economic support, 

and vocational placement and training. 

Counselors should consider use of brief 

interventions that are based on early identification of substance abuse treatment and 

other urgent needs. 

•Drug courts and other diversion programs 

hold considerable promise for engaging and 

retaining offenders who have substance use 

disorders and for reducing substance abuse 

and criminal recidivism during periods of 

program participation and following program completion. 

•Providing access to continuing involvement 

in community recovery services is essential 

to maximize the long-term impact of pretrial and diversion programs. 

•Diversion programs for those with co-occurring disorders are most effective when they 

provide integrated treatment for mental disorders and substance use disorders (Broner 

et al. 2002). 

•Few studies have examined treatment services in pretrial and diversionary settings. 

Further research could help identify and 

reduce gaps in services, identify beneficial 

services, inform clinicians regarding useful 

and effective changes, evaluate program 

effectiveness, and assist in providing program funding. 

•More research is needed to determine the 

economic costs and benefits of treatment 

interventions at the pretrial stage. Intensive 

and long-term programs that target firsttime or low-risk offenders are not likely to 

be cost-effective. At the same time, limited 

nonintensive interventions for chronic serious offenders are also unlikely to be costeffective. 

Treatment Issues in Pretrial and Diversion Settings 155 
 

8 Treatment Issues

Specific to Jails

In This
 Chapter... 

Definitions 

Trends 

Treatment Services in 

Jails 

Description of the 

Population 

Key Issues Related to 

Treatment 

What Treatment Services 

Can Reasonably Be 

Provided in a Jail 

Setting? 

Coordination of Jail 

Treatment Services 

Examples of Jail 

Treatment Programs 

Research Related to Jail 

Treatment 

Recommendations for 

Treatment Providers 

Overview 

This chapter addresses treatment options that can be provided for jail 

inmates with substance use disorders who are incarcerated for relatively short periods of time. This chapter discusses treatment issues specific 

to jails through an examination of what constitutes a jail, who is incarcerated in jail, how and when substance abuse treatment can be provided, and what types of treatment are effective in this setting. 

Recommendations are made regarding the treatment services that can 

be provided within the physical, legal, and policy confines of a jail; and, 

finally, the treatment interventions that are best suited for brief, shortterm, and long-term periods of jail treatment. This is followed by an 

overview of the larger systems that affect treatment in a jail setting. 

Lastly, the chapter outlines the research, provides examples of existing 

programs, and makes recommendations for the treatment of substance 

abuse in jails and detention centers. It should be noted that this chapter 

addresses diversion only as it relates to the jail population. For more 

information on diversion, see chapter 7. 

Definitions

Jails (also called detention centers) house diverse groups of people 

detained for a wide variety of reasons. Jails confine people during the 

adjudication process (i.e., arraignment, criminal court, grand jury, 

hearings, trial, sentencing). 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 

a holding facility for 

•Individuals who have allegedly violated probation, parole, or bail conditions 

•Those who are absconding from court-ordered programs or other community placements 

•Juveniles who are awaiting transfer to juvenile authorities or adult State 

prisons 

157 
Defining a Jail 

For the purposes of the Jail Manager Certification Program only, the American Jail Association defines a 

jail as 

1. A county, municipal, or regional facility(ies) that houses pretrial and sentenced inmates and/or an 

institution that houses pretrial and sentenced inmates where the State is responsible for jail operation(s) (e.g., Alaska, Connecticut, Delaware, Hawaii, Rhode Island, Vermont); and/or a private facility that houses pretrial and sentenced inmates and exists to serve the local jail needs of the community in which it operates. 

AND/OR 

2. A facility that houses only pretrial detainees, regardless of what entity operates it. This includes, but 

is not limited to, facilities that house people for less than 72 hours (lockups); facilities that house 

Federal or military custody inmates awaiting trial (e.g., the Immigration and Naturalization Services, 

U.S. Marshals, Armed Forces); institutions where the State is responsible for the operations of jails, 

and private facilities. 

AND/OR 

3. A local government or private facility that houses convicted people who, without this facility’s existence, would serve their sentence in the local jurisdiction’s jail (e.g., Milwaukee County House of 

Correction). 

A facility is not a jail if its purpose is to house sentenced inmates 

1. Who are, or who would be under normal circumstances, incarcerated in a State institution 

2. Who are, or who would be under normal circumstances, incarcerated in a Federal institution 

These institutions include State prisons, Federal prisons, Texas State Jails, State work camps, and State 

boot camps. 

•Inmates awaiting transfer to State, Federal, 

or other local authorities 

•Inmates transferred from overcrowded 

Federal, State, or other prisons 

•Individuals detained by the military 

•Those held for protective custody 

•People punished for contempt 

•Witnesses detained by the court 

•People with mental illness pending transfer to 

appropriate mental health facilities (Harlow 

1998) 

The approximately 3,365 jails in the United 

States (Stephan 2001) range in size from small 

jails located in rural areas to large jails typically located in or near large urban areas. The 

sociodynamics of jails vary according to size. 

For example, inmates housed in jails that serve 

rural communities often are familiar with other 

inmates, while those incarcerated in large, 

complex systems have less chance of being 

housed with someone they know. 

Trends

Several recent trends have led to changes in 

the jail population. Enactment of harsher 

sentencing laws for drug offenses has led to 

increases in the number of minority and 

female inmates. At the same time, significantly reduced funding for the mental health care 

system has led to an increase in the number 

of multiproblem inmates (National GAINS 

Center 2002; Peters 1993; Peters et al. 1997). 

As a result of these changes, jails house growing numbers of individuals who have been 

displaced from traditional societal “safety 

nets” such as State hospitals. By necessity, 

jails have enlarged the scope of their mission 

158 Chapter 8 
 

to serve as community “gatekeepers” in identifying and addressing a range of psychosocial 

problems, such as HIV/AIDS, domestic violence, educational deficits, homelessness, 

mental illness, and, increasingly, substance 

use disorders (Peters and Matthews 2002). 

Substance use disorders among the jail population have risen since the 1980s. In 1989, 67 

percent of jail inmates had committed a drug 

offense or used drugs regularly. By May 1998, 

that number had increased to 70 percent— 

approximately 7 in 10 jail inmates. An estimated 16 percent committed their offense to 

obtain money for drugs (Wilson 2000). 

Increases in jail substance abuse treatment 

programs have not kept up with this trend 

(Belenko and Peugh 1998; Peters and 

Matthews 2002). In recent years, however, 

levels of substance use and abuse seem to 

have stabilized or even decreased slightly 

depending on the substance in question. In 

2002, 66 percent of jail inmates reported regular alcohol use (down from 66.3 percent in 

1996) and 68.7 percent reported regular illicit 

drug use (up from 64.2 percent in 1996), with 

regular use defined as use at least once a 

week for a month or more (James 2004). 

Jails often serve as the first opportunity for 

offenders to have their substance use disorder 

and other problems (e.g., other mental disorders) identified, to have their acute needs stabilized (e.g., detoxification from alcohol or 

opioids), and to receive referrals to in-house 

or community services (Peters and Matthews 

2002). In fact, many offenders’ initiation into 

treatment is in jail (Mumola 1999). Thus, the 

challenge to jail administrators is two-fold: to 

recognize the need for treatment and to 

understand that treatment must vary based 

on the population (e.g., by culture, average 

length of stay, type of crimes, psychosocial 

needs). 

Treatment Services

in Jails

Findings from several studies indicate the 

effectiveness of in-jail substance abuse treatment programs in reducing criminal recidivism (Peters and Matthews 2002). Reductions 

in rearrests for treated inmates range from 5 

percent to 25 percent in comparison to 

untreated inmates, over followup periods of 6 

months to 5 years. Treated inmates also have 

a longer duration to rearrest following release 

from incarceration, relative to untreated 

inmates. Other positive outcomes associated 

with in-jail treatment include reduced rates of 

relapse among treatment participants (Tucker 

1998), lower levels of depression (San 

Francisco County Sheriff’s Office Department 

1996), and fewer disciplinary infractions 

(Tunis et al. 1997). Cost savings associated 

with jail treatment programs have been 

reported from $156,000 to $1.4 million per 

year (Center for Substance Abuse Research 

1992; Hughey and Klemke 1996). 

Despite the positive outcomes associated with 

in-jail treatment, two-thirds of jails do not 

offer treatment (excluding such ancillary services as assessment, self-help groups, and 

educational programming) (Substance Abuse 

and Mental Health Services Administration 

[SAMHSA] 2000). About two-thirds have selfhelp programs and about 30 percent have 

detoxification programs. Of jail inmates who 

reported ever having used drugs, only one in 

eight had participated in any treatment (even 

broadly defined) since their admission, and 

most of those reported were self-help programs (Wilson 2000). 

Description of the 

Population

At midyear 2003, local jails held or supervised 762,672 people, of whom approximately 

10 percent (71,371) were outside the jail facility (e.g., under electronic monitoring, in outside treatment programs, on work release, 

etc.); this figure represented a 3.9 percent 

Treatment Issues Specific to Jails 159 
increase over the number of inmates held in 

jail at midyear 2002. Between 1995 and 2003 

the number of jail inmates per 100,000 residents increased from 193 to 238, an increase 

of over 23 percent. More than half of the 

adult jail inmates (60.6 percent) were not yet 

convicted of the crime for which they were 

being held (Harrison and Karberg 2004). 

According to a 1999 survey of jail inmates, 5 

percent were known to be noncitizens 

(Stephan 2001). 

Crimes

Crimes committed, or allegedly committed, by 

jail inmates are fairly evenly divided between 

violent offenses (24.4 percent), property 

offenses (24.4 percent), drug offenses (24.7 

percent) and public-order offenses (24.9 percent). The most common offenses are drug 

trafficking (12.1 percent), assault (11.7 percent) and drug possession (10.8 percent) 

(James 2004). Compared to other jail 

inmates, offenders driving while intoxicated 

are older, better educated, and more likely to 

be Caucasian and male (Maruschak 1999a). 

Income and Education

According to 2002 data, approximately 44 

percent of jail inmates had not received a 

GED or graduated from high school. Twentynine percent of jail inmates were not working 

at all at the time of their arrest and only 57.4 

percent were employed fulltime. Jail inmates 

also reported low incomes, with 59 percent 

reporting monthly incomes of less than $1,000 

(James 2004). 

Gender

Between midyear 1995 and midyear 2003, the 

percentage of male inmates dropped from 

89.8 percent to 88.1 percent, while the percentage of female inmates rose from 10.2 to 

11.9 percent. This means that as of 2003 men 

were per capita eight times more likely than 

women to be in a jail. During the year prior 

to June 30, 2003, the number of female 

inmates in jail rose 6.3 percent while the 

number of male inmates increased by 3.7 percent (Harrison and Karberg 2004). 

Over 55 percent of jailed women report physical or sexual abuse prior to admission, with 

44.9 percent reporting physical abuse and 

35.9 percent reporting sexual abuse (James 

2004). Women are also more likely to be identified as having mental illness. Approximately 

22.7 percent of female inmates and 15.6 percent of male inmates were identified as having 

mental illness (Ditton 1999). A survey of 

inmates in State prisons and jails indicated 

that men with mental illness were twice as 

likely as other men to report a history of 

abuse (Ditton 1999). 

Offenses vary by gender. For example, 

women were more likely to be held for drug 

possession than trafficking, whereas the 

reverse was true for men; women were also 

more likely to be held for property offenses 

than violent offenses, and again the reverse 

was true for men. However, a greater percentage of women in jail are there for drug 

offenses. The common offenses for which 

women in jails were being held in 2002 were 

drug possession (14.5 percent), fraud (14 percent), drug trafficking (10.9 percent), and 

larceny/theft (10.3 percent). For men, the 

most common offenses were drug trafficking 

(12.3 percent), assault (12.2 percent), drug 

possession (10.3 percent), and burglary (7.2 

percent) (James 2004). 

Race and Ethnicity

As of midyear 2003, the largest proportion of 

jail inmates were Caucasian (43.6 percent) or 

African American (39.2 percent). African 

Americans were 5 times more likely than 

Caucasians and 3 times more likely than 

Hispanics/Latinos to be in jail (Harrison and 

Karberg 2004). Caucasian jail inmates reported higher rates of mental illness (21.7 percent) than either African Americans (13.7 

percent) or Hispanics/Latinos (11.1 percent) 

(Ditton 1999). Among convicted jail inmates, 

Caucasians were more likely to be using alco160 Chapter 8 
hol (38.5 percent) and/or illicit drugs (33.2 

percent) at the time of their offense than 

African Americans (29.3 percent and 27.3 

percent respectively) or Hispanics/Latinos 

(30.1 percent and 23.8 percent respectively) 

(James 2004). 

Substance Abuse 

A history of drug use is a common characteristic of the jail population, although patterns 

of use have changed somewhat in recent 

years. Compared to jail inmates in 1996, 

inmates in 2002 reported more use of marijuana, depressants, stimulants (other than 

cocaine), and hallucinogens in the month 

prior to the offense and less use of cocaine 

and heroin/opioids. As noted earlier, in 2002, 

66 percent of jail inmates reported regular 

alcohol use and 68.7 percent reported regular 

illicit drug use. Approximately 35 percent of 

all convicted males and 31 percent of females 

reported that they had been drinking alcohol 

when they committed their offenses (James 

2004). Of convicted jail inmates who were 

actively involved with drugs, 72 percent were 

on criminal justice status at the time of their 

arrest (i.e., were on probation or parole, had 

pretrial status, were out on bail, or had 

escaped) (Wilson 2000). 

The percentage of those who participate in 

substance abuse treatment programs in jails 

varies widely. The average population is 

young, male, and, like the general jail population, fairly evenly distributed between 

African Americans (42 percent) and 

Caucasians (39 percent). The majority of participants (58 percent) are ordered to treatment programs as a condition of their sentence, and most have prior felony convictions 

(Peters and Matthews 2002). The percentage 

of jail inmates who used alcohol or other 

drugs regularly participating in some type of 

substance abuse treatment (including selfhelp group participation) after arrest has 

increased from 12.3 percent in 1996 to 15.1 

percent in 2002 (James 2004). Among inmates 

jailed for driving while intoxicated (DWI) 

offenses, only 17 percent are involved in programs such as self-help and educational 

groups for alcohol abuse, compared with 62 

percent of probationers who receive these services. Only 4 percent of those jailed for DWI 

receive any type of alcohol abuse treatment 

including detoxification or counseling 

(Maruschak 1999a). 

HIV Status

At midyear 2002, 1.3 percent of jail inmates 

who reported their test results were known to 

be HIV positive (Maruschak 2004), rates far 

in excess of those within the general population (Centers for 

Disease Control and 

Prevention 2004a). 

Between 1998 and The percentage of

those who participate in substance 

abuse treatment 

programs in jails

varies widely. 

1999, AIDS-related 

deaths accounted for 

8.5 percent of all 

deaths in jails making it the third leading cause of death in 

jails (death by natural causes was the 

leading cause of 

death, followed by 

suicide) (Maruschak 

2001). However, the 

number of AIDSrelated deaths in 

jails decreased from 9 per 100,000 inmates in 

2000 to 6 per 100,000 in 2002 (Maruschak 

2004). 

In 2002, 3 percent of African-American 

women, 2.9 percent of Hispanic/Latino 

inmates (both male and female), 1.6 percent 

of Caucasian women, 1 percent of AfricanAmerican men, and .6 percent of Caucasian 

men reported testing positive for HIV. 

African-American men, however, made up the 

largest number (163,219) of HIV-positive jail 

inmates (Maruschak 2004). 

Treatment Issues Specific to Jails 161 
Co-Occurring Mental Disorders

In 1998, an estimated 16 percent of jail 

inmates reported either a mental disorder or 

an overnight stay in a mental hospital. Mental 

illness was most commonly reported by 

offenders between the ages of 45 and 54, with 

23 percent identified as mentally ill (Ditton 

1999). Many people 

with mental illness 

Jails can serve a 

pivotal role in 

engaging family 

members, peers, 

and community 

organizations in 

supporting the 

recovery efforts of 

inmates. 

cycle through jails

repeatedly. 

Individuals with

mental illness are 

admitted to jails at

approximately eight 

times the rate at 

which they are 

admitted to public 

psychiatric hospitals. As a result, 

there are more people with severe mental illness in U.S.

jails than in State 

hospitals (Torrey et 

al. 1992). A review 

of administrative

data for jail 

detainees and 

inmates in New 

York City found that approximately 15,000 

people with mental health problems cycle 

through that correctional system and back 

into the community each year, of which a significant portion have co-occurring disorders 

(Lamon et al. 2002). The Urban Justice 

Center, a New York City advocacy group, 

reported that detainees and inmates with 

mental illness spend significantly more time 

incarcerated—an average of 215 days versus 

42 days—when compared to those not identified as mentally ill (Winerip 1999). One study 

found that homelessness is strongly associated 

with mental illness among jail inmates: half of 

the ever-homeless sample of inmates in the 

New York City correctional system responded 

positively to at least one mental illness screening question (Michaels et al. 1992). Of those, 

many, if not most, are repeat offenders. 

According to the research collected and 

reported by the National GAINS Center 

(2002), 6.4 percent of male and 12.2 percent 

of female jail detainees have severe mental illness. Among male detainees at intake, 2.7 

percent meet the criteria for schizophrenia/ 

schizophreniform disorder, 1.4 percent for 

mania, and 3.9 percent for major depressions. Among female detainees, 2.0 percent 

meet the criteria for schizophrenia/ 

schizophreniform disorder, 1.4 percent for 

mania, and 10.5 percent for major depression. Twenty-nine percent of male and 53 percent of female jail detainees have a substance 

use disorder, and both male and female 

detainees have a 72 percent rate of both mental illness and substance use disorders 

(National GAINS Center 2002). Inmates with 

both disorders are significantly more likely to 

have multiple problems in terms of employment, family relations, and health, and are at 

greater risk for not complying with treatment, 

rearrest, homelessness, violence, and suicidal 

behavior when compared to those without this 

combination of disorders (Borum et al. 1997; 

Peters et al. 1992; RachBeisel et al. 1999; 

Steadman et al. 1998; Swartz and Lurigio 

1999). In a study of 204 pretrial jail detainees 

in substance abuse treatment in a Chicago 

jail, more than half met the lifetime criteria 

for at least one mental disorder, and the lifetime rates of serious mental illness were higher than those reported in the general jail population. Individuals with co-occurring disorders were also more likely to have been 

arrested for property offenses; to be dependent on alcohol, marijuana, or PCP; and to 

have more than one psychiatric disorder. 

Moreover, the study revealed a correlation 

between severe mental illness, antisocial personality disorder, and drug abuse (Swartz 

and Lurigio 1999). 

162 Chapter 8 
Key Issues Related to 

Treatment 

Several factors affect the availability and 

effectiveness of treatment in jails. It has been 

the experience of consensus panel members 

that treatment, if available at all, may not be 

offered to those in need because the methods 

for screening and selecting treatment participants may not be comprehensive. For some 

inmates, the length of jail stay may be too 

short for substance abuse interventions. 

Others, especially those in pretrial status, 

may decline to participate. Even when services are available, they are not always 

responsive to the inmates’ psychological, 

social, medical, and mental health needs, and 

some inmates have special needs that are too 

complex to be addressed fully in brief or 

short-term treatment. 

This section addresses factors unique to jails 

that the consensus panel believes can impact 

the availability and/or effectiveness of treatment. See chapter 5 for more general issues 

affecting treatment. 

Public Perceptions About Jails

Although jails are designed to improve public 

safety and to provide punishment through the 

short-term detention of defendants and convicted inmates, they are sometimes perceived 

negatively by the public. A negative perception can affect the morale and attitudes of jail 

staff, particularly relating to treatment services. The community may not realize that 

jails hold a significant number of individuals 

who are arrested for low-level, nonviolent 

charges; that many offenses committed by jail 

inmates are related to their substance abuse 

and/or mental health problems; and that most 

will return to their community within a short 

amount of time. 

Through their work with local community 

agencies, treatment staff can assist in dispelling misperceptions and increase the sense 

of inclusion of the jail as part of the community’s network of services. Because of their 

involvement with individuals who often cycle 

through a variety of community services and 

agencies, jails are ideally situated to develop 

partnerships to improve community services. 

Many jails have worked to establish “beachheads” to develop healthcare services, prevention and education programs, and vocational services, particularly for “high-risk” 

groups such as the homeless, those with 

HIV/AIDS, and inmates with co-occurring 

mental disorders. Jails can serve a pivotal 

role in engaging family members, peers, and 

community organizations in supporting substance abuse treatment and the recovery 

efforts of inmates who are enrolled in treatment services. Jails can also help facilitate 

partnerships between community groups and 

local corrections for the purpose of identifying, treating, and referring (through diversion or aftercare) inmates with substance use 

disorders, and reinforce the concept that 

“treatment works.” 

Time Constraints

One of the most serious challenges for substance abuse treatment in jails is the small 

amount of time available, both in terms of 

scheduling treatment and in terms of the 

duration of jail incarceration (Leukefeld and 

Tims 1992). Many pretrial inmates are 

housed in jail for only short periods of time. 

Time constraints are a particularly significant 

factor given that research shows a correlation 

between treatment effectiveness and length of 

time spent in treatment (Swartz et al. 1996). 

A jail must operate on a schedule that 

includes periods of time during which inmates 

are locked-in for inmate count for meals or 

other structured activities (e.g., work). Thus, 

despite the importance of time spent in treatment, programs must compete for the 

inmate’s time. Some jails offer evening programming, but this is sometimes difficult to 

arrange and substantially increases staffing 

costs. Due to scheduling constraints within 

jails, an inmate may have to decide between 

enrolling in a treatment or an educational 

program. 

Treatment Issues Specific to Jails 163 
Also, offenders are confined to the jail for 

limited, and often uncertain, lengths of time. 

This is particularly true for unsentenced, 

pretrial inmates who may be released from 

jail unpredictably following a court hearing. 

Ideally, treatment programming can be developed according to a modular structure that 

accommodates differing time lengths and 

goals—from initial engagement and education 

to developing skills and completing steps. 

Environmental Issues

A large number of people enter jails both as 

visitors and as service providers. While 

reach-in from the community and visits from 

family should not be discouraged, coordinating and overseeing such activities is time consuming for staff who may need to spend time 

processing and escorting visitors that could 

otherwise be spent with clients. Treatment 

providers who visit clients from outside the 

institution may also find a significant portion 

of their time on the premises taken up with 

waiting and processing. 

Jails also maintain a classification-based system that is typically based on security needs 

and bed/space availability, and which may or 

may not coincide with an inmate’s treatment 

needs. Many small, rural, or older jails in 

particular have environments and structures 

that are not conducive to treatment: They 

were built to detain, house, and process 

inmates, and not to provide screening, assessment, or treatment services. There may not 

be individual interview or treatment space 

available, and group treatment space may 

also be scarce. If activity space is available, 

educational, work, religious, and treatment 

programs often compete for this space, and 

the amount of treatment programming is 

often compromised. Architecturally, jail 

activity rooms and housing units are not 

soundproof. Noise can provide distraction 

from treatment activities and can be a source 

of stress for both clients and treatment 

providers. 

Finding space that is private and that provides security for both staff and inmates is a 

challenge. While corrections and treatment 

staff may find joint solutions, informing 

clients of these limitations is important. The 

counselor should also be aware of the limitations this may create for discussing certain 

issues or engaging particular populations 

(e.g., detainees with certain charges, certain 

trauma events, severe mental illness), or even 

for conducting a thorough assessment. 

Privacy is also hampered by the fact that an 

inmate is never alone; there is electronic 

surveillance in jails as well as security personnel and other inmates. 

Gang Affiliation

The counselor should be aware of the jail’s 

policies and programs regarding gang affiliation, including rules regarding who should 

participate in certain groups and activities or 

which actions may lead to an administrative 

Suggestions for Dedicated Program Space 

The effectiveness of substance abuse treatment services would be significantly enhanced by dedicated program space in jails that is isolated from general housing units. Dedicated staff office space would optimally 

be provided in an area within or adjacent to the isolated treatment unit. The benefits of providing dedicated 

treatment space include the following: 

•Privacy in conducting treatment and staff meetings 

•Reduced competition for treatment program space 

•More readily available staff 

•Reduction of issues related to inmate movement and coordination 

164 Chapter 8 
 

or new criminal charge during 

detention. 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, thereby avoiding sending 

mixed messages to the inmate or 

placing him- or herself at odds with corrections. 

Stress Related to Incarceration

A number of issues beyond the individual’s 

readiness for treatment can affect his engagement in the treatment process within a jail 

setting. Many of the stressors identified in 

chapter 5 are present in jails, including trauma related to the recent arrest, uncertainty of 

the legal situation, and possible loss of a job 

or custody of children. Counselors are in a 

position to assist the client in developing coping mechanisms to address substance abuse 

issues within the context of multiple internal 

and external stressors, to clarify which issues 

can be addressed while incarcerated within 

the bounds of certain timeframes, and to 

make referrals to other jail or community services to address non–substance-abuse-related 

issues and to facilitate continuity of treatment 

from jail into the community (e.g., legal and 

medical problems, education, vocational 

training or work programs, diversion or 

aftercare programs). See chapter 7 for a more 

detailed discussion of interpersonal issues facing recent arrestees. 

Issues Related to Justice 

System Processing and Legal

Representation

The legal process can understandably confuse 

detainees, and either this disorientation can 

persist for a lengthy period (e.g., during 

adjournments, plea bargaining, competency 

Advice to the Counselor: 

Jailed Clients

• Counselors should be aware of gang affiliations as well 

as the jail’s policy regarding who should participate in 

certain groups. This knowledge may allow the counselor 

to foresee which activities could be used to inflame gang 

rivalries, set clear group rules for activities, and balance 

security with good treatment practices. 

processes, or diversion planning), or the status of the case can rapidly shift and the 

detainee may be suddenly released from jail. 

Often there is little communication between 

the court, jail staff, and treatment staff, 

which has direct impact on the therapeutic 

relationship, as the detainee’s legal status is a 

major concern. 

Defense attorneys do not always visit clients 

while they are in jail, with brief visits often 

occurring at court prior to the stressful and 

sometimes confusing court proceedings. 

Further, for those detainees who reach out to 

peers for support, information is often inaccurate and can increase their sense of urgency and hopelessness. Due to the wide variety 

of populations incarcerated in jails, detainees 

may learn about scenarios that are not relevant to their own case processes. 

Attorneys do not always recognize the benefits of treatment and may not encourage the 

inmate’s involvement in treatment. For example, due to heavy caseloads, many public 

defenders do not take the time to advise 

clients about how treatment could benefit 

them. In some jurisdictions, the appointed 

defense counsel may not be from the public 

defender’s office and may not be aware of 

diversionary or other treatment options. 

Despite the presence of substance abuse problems, defense counsel may in some cases be 

reluctant to advise their client to voluntarily 

submit to treatment due to conditions of 

supervision that are likely to lead to sanctions 

and incarceration. The flow of information 

between legal and treatment professionals can 

also be problematic, related to the types of 

Treatment Issues Specific to Jails 165 
 

 

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 purposes of counseling. 

Confidentiality

Substance abuse treatment programs should 

establish clear guidelines regarding the type 

of information that may be disclosed after an 

offender has signed a proper consent form. 

The Federal confidentiality laws and regulations protect any information about an 

offender if the offender has applied for or 

received any substance abuse-related services 

from a program covered by the law. 

Programs included are those that specialize, 

in whole or in part, in providing treatment, 

counseling, and/or assessment and referral 

services for offenders with alcohol or other 

drug problems. A different confidentiality 

issue can arise in small, rural jails, where 

inmates and officers often know each other. 

Residents with substance use disorders are 

well known, and it is difficult to keep confidential the fact that someone is receiving 

treatment. For more information about the 

confidentiality laws and regulations and their 

implications for substance abuse treatment in 

jails, see CSAT 2004

Counselor–Client Issues

Given the complexity of the environment and 

issues needing to be addressed, it is useful for 

the counselor to clearly describe his role and 

limitations related to that role, the structure 

of the proposed treatment, and the various 

options available. For instance, the counselor 

should explain whether he or she will become 

involved in legal, family, medical, disciplinary, or other issues. The counselor should 

describe the potential treatment options, how 

these options may or may not impact the 

client’s problems, and what other types of 

treatment or interventions may be needed to 

address the client’s problems that are not 

offered within a jail setting. While the client’s 

reactions to this information may initially 

vary from rage to indifference to relief, offering ways to cope with limitations and stressors 

is more useful than initially placating the 

client. The counselor should be aware of the 

protections and limits to protections that 

informed consent may have. (For more information on confidentiality, see CSAT 2004.) 

Supervision and training 

Supervision and ongoing participation in 

training are essential for jail treatment counselors, given the complexity of issues, presenting symptoms, and behaviors related to the 

inmate population, and the limitations to the 

physical structure and environment of the 

jail. Supervision can support the counselor 

and help clarify the different systems’ 

demands, potential personal reactions to 

these demands, and personal reactions to the 

clients themselves. These clarifications help 

determine when these issues should be part of 

or separate from the treatment and which 

issues should be addressed systemically. 

Support and continued professional development can reduce therapist burnout and 

increase treatment efficacy. 

What Treatment 

Services Can

Reasonably Be 

Provided in a Jail

Setting? 

There have been several efforts to develop 

guidelines for jail-based treatment programs 

that describe model treatment approaches 

and minimum standards of care. For example, the Office for Treatment Improvement 

(now the Center for Substance Abuse 

Treatment [CSAT]) convened a “Criminal 

Justice Treatment Evaluation Meeting” in 

1992 to identify critical elements of jail-based 

166 Chapter 8 
substance abuse treatment programs and jail 

treatment guidelines (SAMHSA 1996). There 

is still a need, however, for more specific 

guidelines that can be operationalized by 

local jails. The American Correctional 

Association (ACA) and the National 

Commission on Correctional Health Care 

(NCCHC) have standards related to jails, but 

they are extremely limited in the area of substance use, and far less specific and detailed 

than those developed for mental health services in jail. No specific guidelines have been 

adopted for substance abuse treatment in jail, 

nor do existing standards account for the 

elaborate contextual and environmental factors affecting treatment in jail settings. 

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 (Leukefeld and Tims 

1992; Peters and Matthews 2002). Some 

detainees are in jail less than a week, during 

which they may receive only assessment and 

referral, whereas others are serving a sentence in a jail setting. Several different durations of treatment are discussed in this section 

to examine the range of treatment options 

that might be provided in jail. In this section 

the panel recommends a framework by which 

to identify priority treatment services, given a 

defined period of time available to provide 

treatment services for inmates. For purposes 

of this section, “brief” treatment is defined as 

up to 30 days, “short-term” treatment is 

defined as from 1 to 3 months, and “longterm” treatment is defined as 3 months and 

longer. Regardless of the duration of treatment, however, the goal should always be to 

engage clients so that treatment and recovery 

can continue when they leave jail. Issues of 

screening and assessment, regardless of the 

setting, are discussed in chapter 2. 

Treatment intensity and duration are increased 

with length of stay, as is the scope of topics that 

can be addressed. More intensive treatment 

services are often necessary, given that the substance abusing lifestyle has taken years to 

develop and cannot be altered in just a few 

weeks. Figure 8-1 (p. 168) outlines optimal 

treatment components that might be deployed 

at each level, followed by a more detailed 

explanation of each. Each successive level of 

treatment in this layered approach includes 

service components from previous levels. 

Regardless of the duration of treatment, complicating factors for those in jail include cooccurring medical problems and histories of 

physical and sexual abuse, unstable relationships and social support structures, poverty, 

homelessness, gender, and cultural differences, among others. 

Combinations of 

factors can interact 

differently with any Support and 

continued 

professional 

development can

reduce therapist

burnout and

increase treatment

efficacy. 

of these subpopulations, have implications for treatment 

strategies, and have 

an impact on treatment outcomes. 

Consequently, when 

designing or adapting treatment programs, it is important to factor in 

these variables along 

with the substance 

choice patterns of 

use and types of previous treatment and 

services. 

Level I: Brief Treatment 

Some offenders may be identified within a 

short period of jail detention for involvement in 

community diversion programs that include 

participation in treatment. For many other 

inmates who are incarcerated 30 days or less, 

case management, referral, and brief interventions can be provided. Brief treatment usually 

focuses on supplying information and making 

referrals. 

Treatment Issues Specific to Jails 167 
Figure 8-1 

Treatment Components 

Brief Short Term Long Term 

Level I Level II Level III 

(1 to 4 weeks) (4 to 12 weeks) (3 months or more) 

Motivational Relapse prevention Communication skills Employment counseling 

interviewing 

Orientation to treat­ 12-Step programs Dealing with domestic vio­ Therapeutic community 

ment/treatment planning, and substance 

abuse education 

lence 

Information on available Basic cognitive skills Anger management Family mapping and 

community resources social networks 

Following through on 12 

steps 

Facilitating access to Identity and culture Problem solving Continued stabilization 

community services 

Community linkage and Strengths building Social skills training Cultural factors 

transition services 

Psychotropic medica­ Criminal thinking 

tions: education and 

compliance 

Motivational enhancement 

therapy and motivational 

interviewing 

Motivational enhancement approaches help 

clients to address their ambivalence about 

involvement in substance abuse treatment, 

and to identify methods of dealing with this 

ambivalence. (For more information about 

motivational interviewing, see TIP 35, 

Enhancing Motivation for Change in 

Substance Abuse Treatment [CSAT 1999b].) 

The goal of this process is to engage inmates 

in a discussion of the treatment process and 

their potential reasons for changing substance 

abuse behavior and to help inmates develop 

their own rationale for changing this behavior. This approach is designed to help counselors work with clients who are ambivalent 

about treatment, in denial about their circumstances, and resistant to change. 

In Project MATCH, the largest clinical trial 

ever conducted to compare different alcohol 

treatment approaches, a four-session motivational enhancement therapy yielded long-term 

overall outcomes that were similar to those of 

other, more intensive outpatient methods. 

Further, the results of this study strongly suggested that motivational interviewing could be 

applied across cultural and economic groups. 

Enhancing detainees’ motivation for change 

and increasing their receptivity to substance 

abuse treatment can be effective in this setting as well. For example, materials developed at Texas Christian University (TCU) 

include a board game called Downward 

Spiral, which helps clients examine the conse168 Chapter 8 
quences of substance abuse. Other useful 

exercises include the Decision Matrix, which 

looks at advantages and disadvantages of continued substance use from the client’s perspective and at the benefits of choosing to discontinue use. This helps identify functional 

aspects of their substance use (e.g., socialization, reduction of negative emotions) that sustain patterns of use, and that may serve as 

barriers to continued abstinence and involvement in treatment. 

Substance abuse education 

Because inmates may not have examined the 

negative health consequences related to substance abuse, an educational component can 

inform and possibly change risky behaviors. 

Films, presentations, and literature can be 

used to present this education. The ultimate 

goal of treatment is abstinence, but people 

who have abused substances long-term have 

had difficulty successfully addressing issues 

such as boredom, anxiety, social discomfort, 

and being ostracized by family and peers. 

Information on available 

community resources 

Community resource information ranges from 

how to obtain a restraining order to what 

community organizations offer substance 

abuse treatment. Counselors in the pretrial 

setting need to be aware of their community’s 

resources in order to assist their clients after 

release. Many of these individuals will be 

released back to the community with their 

numerous needs unchanged and/or unmet. 

Clients can be referred to Alcoholics 

Anonymous (AA) and Narcotics Anonymous 

(NA) groups, and counselors can provide help 

with finding job training programs, general 

educational programs, clothing, food, and 

public assistance. Before this information is 

presented to inmates, however, counselors 

must check to see that an agency will accept 

referrals from the criminal justice system, 

and assess eligibility criteria. Some programs 

have developed resource directories with 

descriptions of community services programs 

and relevant contact information. 

Facilitating access to 

community services 

Incentives can be established for substance 

abuse treatment staff to enter jails to work 

with inmates enrolled in treatment. One step 

is to develop contract language that identifies 

jail inmates as a priority group to receive 

publicly funded substance abuse treatment 

services. Another is to establish funding for 

health benefits. In New York City, for example, an inmate’s Medicaid eligibility in a community program can be reinstated while the 

inmate is still in jail so the paperwork is 

ready when that inmate is released; a similar 

system has also been developed for establishing temporary Medicaid coverage. Some community organizations may be less resistant to 

taking on former inmates as clients if these 

individuals are receiving Medicaid support. 

Once a health problem or mental illness is 

A Voice of Experience 

I believe that jail administrators have an obligation to provide the programs by which inmates can better 

themselves, and this includes alcohol and drug abuse programs. But in South Carolina—and only in South 

Carolina—anyone sentenced to more than 90 days, with the exception of family court, goes to State prison. 

The rest come here. Consequently, with this small average length of stay, it’s very difficult to justify the significant commitment of resources that are needed with such a revolving door atmosphere. 

—Mark F. Fitzgibbons, CJM 

Director, Buford County (SC) Detention Center 

Treatment Issues Specific to Jails 169 
identified, Medicaid may be needed in order 

to cover treatment in the community for those 

affected. 

Community linkage and 

transition services 

Offenders who abuse substances are perhaps 

at their most vulnerable when they are making the transition back to the community. The 

treatment system needs to plan for an inmate 

or detainee who is leaving the jail, and the 

community needs to be prepared to receive 

the individual. Case managers or other types 

of “boundary spanner” staff are particularly 

trained to manage these transitions. They are 

cross-trained in issues related to the mental 

health, substance abuse, and criminal justice 

systems, and will help to facilitate aftercare 

or diversion (Steadman et al. 1995; Taxman 

1998) (see also TIP 30, Continuity of 

Offender Treatment for Substance Use 

Disorders From Institution to Community 

[CSAT 1998b]). 

These staff members can handle multiple 

tasks—from being advocates to understanding the available community resources and 

linking exiting inmates to those resources. 

The most common types of linkage and transition services provided by jail substance abuse 

treatment programs are assessment of aftercare needs, discharge planning, placement 

planning, and coordination with community 

treatment agencies (Peters and Matthews 

2002). Jail aftercare coordinators or treatment counselors, community resource coordinators, or case managers often provide these 

services. Specialized reintegration programs 

are often helpful in developing postrelease 

plans related to housing, aftercare, relapse 

prevention, and employment. 

While the goal of treatment is to help an 

inmate to abstain from substance use, the 

reality is that inmates are at high risk for 

relapse and in some cases overdose upon their 

release from jail. Overdose prevention efforts 

prior to release can prevent deaths, especially 

for inmates who have been off the streets for 

a period of time. Counselors should provide 

inmates with information about the decreased 

tolerance that results from abstinence. 

Psychotropic and other 

medications: Education and 

adherence 

Many inmates will benefit from education 

regarding psychoactive medications, how they 

work, the reason for certain medication 

schedules, flexibility in dosage, side effects 

and how to manage these, and the relationship between mental and substance use disorders and noncompliance with medications and 

decreased efficacy of medications. Clients 

should understand the distinction between 

psychotropic medication and substances of 

abuse but also be informed about which medications can be addictive. This type of education also provides a venue for discussing the 

relationship of mental disorder symptoms and 

the potential sense of stigma associated with 

A Voice of Experience 

Since 1993, the Clark County (NV) Drug Court’s 1,725 graduates have experienced only a 17 percent recidivism rate—as compared with the 80 percent recidivism rate of people addicted to drugs who are released 

from jails or prisons. According to our drug court judge, this is the best method so far to treat people 

addicted to drugs. I agree. To have an impact on substance abuse in the jail population, an approach of 

long-term, high-quality treatment with community follow-up is the answer. 

—Captain Marilyn Rogan 

Clark County (NV) Detention Center 

170 Chapter 8 
A Voice of Experience 

I am a psychologist working in a jail. We learned that our policy of stopping methadone “cold turkey” 

resulted in a very high frequency of booking recidivist inmates on drug charges related to heroin. So, working with our County Executive, we stopped withdrawing and stopped the practice of “stopping” on Sundays. 

Now, if someone comes in, they continue, and we encourage agencies to send their case manager into the jail 

and make plans for the inmate’s release, so there is no gap ... What we’ve noticed is—we have very, very 

few bookings of individuals who were taking methadone. But we haven’t reached the point of initiating 

methadone treatment—that would be our next step. And I think that would be a great idea, because everybody is so happy with what we’ve been doing. 

—Lawrence W. Smith, Ph.D. 

Psychiatric Services Administrator 

King County (WA) Department of Adult and Juvenile Detention 

mental health problems and ongoing medication regimens. 

For a significant number of inmates with a 

history of opioid abuse, review of existing opioid substitution medications will also be quite 

useful, including methadone, levo-alphaacetyl-methadol, buprenorphine, and other 

medications used in detoxification from or 

reduction of opioid use. There has not been 

widespread use of these medications in jails, 

primarily because they are seen as potential 

sources of contraband, prolonging physical 

dependence on opioids, and requiring specialized medical supervision. 

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. Shortterm treatment is built upon the previously 

described basic Level I services. Level II or 

short-term treatment interventions provide 

more focus on coping skills to prevent substance use and sustain recovery. 

Substance cravings, urges, 

and relapse prevention 

Inmates learn about actions that can trigger 

their substance cravings and how cravings 

and urges are tied into relapse prevention. 

They can also complete exercises to identify 

personal “substance use triggers” and review 

strategies for avoiding and dealing with these 

triggers. For example, group discussion may 

focus on what inmates may expect when 

returning to their families, who may not fully 

support their involvement in recovery. While 

support from non–substance-using family 

members can be an enormous contribution to 

help the client stay clean and sober after 

release, reunification with family members is 

often accompanied by stress related to the 

family’s distrust and anger over the offender’s past substance use, unresolved conflicts 

with the partner or spouse, shifting parental 

roles, and added financial obligations (Peters 

1993). Returning to live with family members 

who actively use substances or who condone 

substance use within the home creates additional high-risk situations for the offender. In 

some cases, return to the home environment 

can trigger a relapse. Counselors should 

assess the home situation and possibly examine alternative housing arrangements. 

Counselors may instruct clients that certain 

areas of town (e.g., drug neighborhoods) are 

“no-fly” zones and that they will be violating 

conditions of their treatment program and/or 

supervision if they frequent those parts of 

town. 

Treatment Issues Specific to Jails 171 
Self-help programs 

Level II treatment is an opportunity for 

inmates to learn about self-help programs and 

their availability in the community. While not 

typically considered substance abuse treatment, such groups as NA and AA provide a 

valuable and accessible source of peer support for inmates returning to the community. 

In the past several years, new case law has 

found that AA and NA are essentially religious-based treatment programs (Griffin v. 

Coughlin 1996; Kerr v. Farrey 1996; Warner 

v. Orange County 1999). While many States 

continue to sentence offenders to AA or NA, 

in at least one State (New York), the court 

has found that doing so is a violation of the 

first amendment. Authorities may be able to 

resolve this issue, however, by either removing these coercive requirements or by incorporating nonreligious alternatives (Cohen 

2000). 

Some jails offer alternative types of peer support groups, such as SMART Recovery, 

which is based on cognitive–behavioral principles of Rational Emotive Behavioral 

Therapy. While licensed professionals in the 

community sometimes organize such groups, 

it is individuals in recovery who lead them. 

Basic cognitive skills 

Cognitive skills training helps inmates correct 

thoughts that can lead to criminal behavior 

and substance abuse. These interventions 

help inmates understand the relationship 

between thoughts, emotions, and behaviors, 

and strategies to address maladaptive thought 

processes that can lead to interpersonal conflict, emotional disturbance, and aggressive 

and violent behavior. Cognitive skills learned 

in jail treatment programs are often generalizable to other settings, including work, 

school, and relationships with significant others and family members. 

Strengths building 

Strengths building identifies and uses the 

assets that clients bring to the treatment program to improve their chances for successful 

recovery. Counselors can examine interactive 

ways for participants to recognize their 

strengths, for example, by having inmates 

write something positive about each group 

member, then by identifying characteristics of 

themselves they think are good, and considering how they can build on those strengths in 

the future. 

Researchers at TCU have developed a series 

of readiness and induction interventions that 

incorporate a strengths-building strategy 

(Dees et al. 2000). These interventions give 

participants unique opportunities to define 

their roles in treatment and to discover their 

positive personal strengths and hidden cognitive potentials. In Tower of Strengths intervention, for example, participants examine 

their strengths and those they most wish to 

have. These activities are suitable for use in 

custody or community settings, and can be 

used in groups of up to 35 participants or in 

individual counseling. 

The TCU readiness and induction interventions were designed specifically to overcome 

problems often encountered in working with 

those mandated to treatment. They address 

the distorted and negative expectations about 

treatment common among clients in criminal 

justice programs, and their lack of self-confidence resulting from personal failures, educational and vocational deficiencies, and poor 

coping skills. 

Communication skills 

This type of intervention can improve interpersonal skills and increase assertiveness with 

key family members, significant others, and 

individuals at work. Key activities often 

address effective means of expressing anger 

and other negative emotions, dealing with 

conflict situations, and dealing with problems 

172 Chapter 8 
that arise in personal relationships, whether 

at work or in the home. 

Anger management 

These activities can help inmates recognize 

when they feel angry, identify some of the 

causes of their anger, and learn to use alternative problemsolving techniques to help 

manage their anger. These interventions are 

also helpful in understanding the connection 

between anger and substance abuse, given 

that poorly managed anger often precipitates 

substance abuse. 

Domestic violence 

In these cases, short-term strategies are 

developed to maintain personal safety for victims of domestic violence and protect children, and longer term solutions are considered that involve legal and law enforcement 

action. Having staff who are aware of available community shelter and domestic abuse 

counseling services is also helpful. 

Problemsolving 

These skills allow people to address and solve 

their own everyday problems in a rational 

manner by defining those problems and 

examining potential solutions. Inmates can 

begin by talking about problems they have 

encountered in the past, how they tried to 

solve them, and whether their efforts succeeded or failed. Then they can examine problems 

they have solved in a positive manner. 

Inmates learn how to select a solution rationally, instead of emotionally or acting out 

immediately. This requires that they learn 

how to take time to look at a problem, weigh 

the advantages of alternate solutions, and 

anticipate their effects. 

Discussions involving real incidents of problemsolving can help inmates articulate methods of problemsolving that typically produce 

success. For example, a client might describe 

an argument with his employer, and how he 

or she intentionally arrived 15 minutes late to 

work the next day. If that individual’s 

response did not improve the situation, others 

in the group might indicate what they would 

do when faced with a similar situation: “I 

would avoid the situation,” “I’d try to ignore 

him,” “When he asked me something, I’d get 

defensive.” The purpose of this exercise is to 

identify effective ways to proceed. An effective response that could result in desirable 

responses and outcomes might be, “I went in 

to ask my boss if I 

could speak with 

him for a minute, Strengths building 

identifies and uses 

the assets that

clients bring to the

treatment

program to 

improve their 

chances for

successful 

recovery. 

apologized, gave him 

the reason for the 

tardiness, and made 

a commitment not to 

have this happen 

again.” This 

approach is most 

effective when counselors make use of 

real-life issues, roleplaying, and group 

interaction. 

Social skills 

training 

Social skills training 

can be provided 

independently or as 

part of modules 

related to problemsolving and anger management. This training 

can help inmates deal appropriately with 

coworkers, family members, and friends. The 

process includes acquiring and rehearsing 

drug-free and prosocial skills to deal with 

interpersonal problems faced during recovery. Key components include communication 

skills, assertiveness, skills for developing and 

sustaining interpersonal relationships, and 

specific drug coping skills to handle high-risk 

interpersonal situations. Other areas include 

conflict management and learning interpersonal skills related to work, family, and community settings. 

Treatment Issues Specific to Jails 173 
A Voice of Experience 

Long-term actions, started in jails, which include voluntary acceptance of behavior altering elements, can 

be effective. They must include abusive substance abstinence, the unburdening of the conscience, and the 

concept of continuity of care. Treatment must have a solid aftercare component that provides social, family, 

and community lifestyle changes that encompass jobs as well as education. It must also include daily reinforcement of positive behavior and a new look at life, itself, from a healthy attitude, to be successful. When 

those actions encompass such a program, success of the individual is possible and productive life skills can 

be achieved. 

—Tim Ryan 

Santa Clara County (CA) Department of Correction 

President-Elect, American Jail Association 

Level III: Long-Term Treatment 

When inmates are incarcerated more than 90 

days, more treatment time is available to 

build on the tools provided in short-term 

treatment and aid the inmate in the transition 

back to the community. Level III or long-term 

treatment approaches include components 

similar to those found in residential treatment 

in many community-based programs. These 

interventions are designed to delve more 

deeply into personal values, belief systems, 

and issues related to cultural and family 

background that have supported a substance 

abuse lifestyle. 

Employment counseling 

Employment counseling, which can examine 

an inmate’s employment skills and include 

skills testing, can be incorporated into work 

release or furlough. Counselors should provide pre-employment training (e.g., communication skills with employers, responsibility, 

punctuality) and résumé writing. To elicit 

information to strengthen their résumés, clinicians can ask such questions as what have 

clients done as a volunteer, community member, or in jail that contributes to their 

employment opportunities rather than considering only traditional work experience. 

Counselors can help their clients develop 

action plans for obtaining employment after 

release. 

Building a therapeutic 

community 

Limited duration therapeutic communities 

have been established in some jail programs. 

For a more complete discussion of therapeutic 

communities, see chapter 9, Issues Specific to 

Treatment in Prisons. 

Family mapping and social 

networks 

Family mapping is a structured approach to 

examine the family network and background. 

The purpose is to look at the family and try 

to understand its criminal and/or substance 

use history and how the family adapted over 

the years in an effort to maintain stability. 

The inmate looks beyond his or her immediate family to grandparents, aunts, and uncles 

because many criminal and substance-using 

behaviors run in families and move across 

generations. This close examination helps 

people understand how and why substance 

abuse and other maladaptive behaviors exist 

in their family. 

Female inmates, in particular, remain part of 

their community even while in jail and continue to establish social relationships and maintain social supports. However, while in jail 

they encounter significant problems in maintaining family contact and support, such as 

having their children searched for contra174 Chapter 8 
A Voice of Experience 

Both short-term and long-term substance abuse treatment programs in jails are most effective when accompanied by aftercare within the community upon release. Inmates will readily volunteer to participate in 

treatment programs within the confines of the jail. However, few inmates will participate in voluntary postrelease care. To be effective, the post-release aftercare should be mandatory with ongoing monitoring and 

testing by drug courts. 

band, limits on visitation, glass barriers 

between mother and child, and having staff 

members monitor the visits, which often have 

a negative impact on family relationships. For 

some issues related to the family, it is important to have the family present. 

There are innovative jail programs that work 

with the inmate and child welfare agency to 

create specific visit times for father or mother, caseworker, and child in order to streamline visit procedures for agencies (City of New 

York 2001). Such models may be able to be 

used for other types of family meetings. 

Co-occurring disorders 

Longer term treatment provides the opportunity for learning about the interrelated 

nature of substance abuse and mental disorders, including events leading up to relapse of 

mental disorders, such as discontinuation of 

psychiatric medication. Other 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. 

Treatment of individuals with co-occurring 

substance use disorders and mental illness is 

discussed in greater detail in chapter 5. 

Criminal thinking 

Many inmates have developed ingrained patterns of thinking that contribute to poor 

—Terry L. Bunn, CJM 

Chief Deputy, Custody Operations 

Santa Barbara County (CA) Sheriff’s Department 

interpersonal relationships and lead to conflict with others and involvement in criminal 

behavior. Inmates frequently do not see the 

connection between their criminal behavior 

and these patterns of thinking or belief systems. 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 their criminal behaviors. A number of 

structured curricula have been developed for 

this purpose that blend cognitive and behavioral approaches that are consonant with 

other skills approaches used in jail-based 

substance abuse treatment programs. For 

more information on criminal thinking, see 

chapter 5. 

Coordination of Jail
 

Treatment Services
 The consensus panel believes that in order to 

operate a successful jail drug treatment program, cooperation is needed between funding 

sources, the community, substance abuse 

counselors, criminal justice personnel, outside agencies, and the offender, among others. This section is based on the experiences 

of consensus panel members and highlights 

some of the potential barriers involved in 

coordinating jail treatment services, then discusses a number of possible solutions to barriers that are frequently encountered while 

implementing these services. 

Treatment Issues Specific to Jails 175 
Barriers to Treatment 

A number of factors at work in the jail setting 

have the potential to interfere with effective 

treatment: 

•Lack of funding for services 

•Absence of administrative support for developing comprehensive treatment programming 

•Tensions between substance abuse and criminal justice systems, which have overlapping 

but distinctive concerns (e.g., rehabilitation 

and substance abuse treatment versus safety, 

control, and punishment) 

•Physical space and environment that are not 

conducive to treatment 

•Competing institutional program activities 

•Difficulties in developing mechanisms for 

sharing information between treatment 

providers and criminal justice staff 

•Confidentiality issues and the need to share 

information 

•Lack of case management or continuing care 

•Lack of detoxification services 

•Detoxification symptoms mistaken for mental illness 

•Lack of methadone tapered doses for 

inmates enrolled in methadone treatment 

programs prior to relapse 

•Bringing in family members for family 

reunification or family therapy without 

careful security screening 

•HIV/AIDS and sexually transmitted diseases 

among inmates 

•Inability to provide HIV/AIDS educational 

materials 

•Institutional restrictions related to video 

equipment, TVs, VCRs (for video playback 

of practice job interviews) 

•Difficulties implementing community inreach for supplemental as well as basic 

treatment services 

•Treatment providers’ reluctance to work in 

jails 

The competing goals of the criminal justice and 

treatment systems can sometimes pose problems, though the systems share many of the 

same objectives. Figure 8-2 highlights the specific goals of correctional and treatment systems within jail settings and the shared goals of 

these systems. 

Limited resources 

The limited amount of funding provided for 

treatment in many jails reflects underlying 

community attitudes and beliefs. These 

include the belief that providing services, 

including treatment, runs counter to a jail’s 

“purpose” of punishment and may interfere 

with management. There is also a general lack 

of knowledge of the impact that treatment can 

have on crime. Few are aware of the multiple 

problems that exist in those served by jails, 

the fluidity of this population between the jail 

and the community, and the lack of systematic interventions that would stop the expensive 

jail-streets-jail cycle. Further, the struggle for 

Figure 8-2 

Goals of the Treatment and Corrections Systems in the Jail Setting 

Goals of Treatment System Goals of Corrections System Shared Goals 

Behavior change Safety of inmates Reducing crime 

Public health Safety of jail personnel Reducing substance abuse 

Rehabilitation Punishment Reducing violence 

Long-term good of individual and 

family 

Safety of community Changing behaviors 

176 Chapter 8 
jail treatment resources may mirror the 

underfunding of treatment in the community. 

Jail treatment programs may even compete 

with, or be viewed as competing with, community resources. 

If a community surveys the needs of its jail 

population, scarce treatment resources can be 

allocated in a way that is most effective. Jails 

with adequate resources can develop both 

specialized and generalized substance abuse 

treatment services. Jails with fewer resources 

may choose to divide resources between identification and referral to community programs for inmates who have various co-occurring disorders and problems (e.g., people 

with severe mental illness, the homeless), and 

providing traditional treatment services to 

inmates whose primary problem is their substance use disorder. 

To more efficiently focus limited resources, 

the consensus panel suggests that jail-based 

substance abuse treatment programs have 

clear goals and objectives tied to reasonable 

outcomes, given the limitations imposed by 

the correctional setting. For example, if the 

goal of jail treatment is to reduce inmates’ 

negative health consequences related to their 

substance abuse (e.g., HIV risk), the program 

would be constructed somewhat differently 

than if the goal were for maintenance of sustained abstinence following release from custody. Jail treatment programs have found it 

useful to enlist the help of multiple stakeholder groups that can offer additional resources 

both in the institution and during transition 

to the community. 

Solutions for Coordinating 

Jail-Based Treatment Services

There are a number of ways substance abuse 

treatment providers can work to improve services for people in jails and overcome the 

barriers described above. These are discussed 

in the sections that follow. 

Prioritizing substance abuse 

treatment for traditional 

versus special needs 

populations 

Because of scarce resources, many jails find 

that they must prioritize how to allocate 

treatment services for inmates with differing 

levels of treatment needs. One major issue is 

whether to target populations that require 

specialized care and that are at greater risk 

for relapse, criminal recidivism, and high utilization of community services (e.g., chronically mentally ill, mentally retarded, or 

homeless inmates) or to focus resources on 

inmates with more traditional substance 

abuse treatment needs. There are advantages 

and disadvantages related to targeting one 

group in favor of another. The consensus 

panel recommends that jails assess their own 

resources available for treatment and the 

scope of subpopulations with special treatment needs to devise a plan that ideally would 

address the needs of both groups. Figure 8-3 

(p. 178) compares the advantages and disadvantages of prioritizing substance abuse treatment services for traditional and special 

needs populations. 

Promote understanding of 

institutional security rules 

and confidentiality 

requirements 

An incomplete understanding of the rules 

related to confidentiality of substance abuse 

treatment information and to the security 

guidelines within the institution may lead to 

conflict between correctional and treatment 

staff and may reduce the effectiveness and 

credibility of the treatment program. For 

example, counselors may unwittingly bring 

materials into the jail for treatment purposes 

that could be considered contraband by security staff or may make promises to inmates 

regarding scheduled activities, visitation, telephone calls, or other privileges that are not 

Treatment Issues Specific to Jails 177 
Treatment for Specific Populations Mainstream Treatment 

Advantages Disadvantages Advantages Disadvantages 

Can increase outreach Comprehensive multi- Rapid identification of Possibly less effective 

to detainees and problem screenings and detainees through charge because intensity of 

inmates otherwise not assessments are costly category or urine testing treatment is not matched 

identified or provided to inmates’ needs 

with treatment 

Can reduce correctional officer and inmate 

injuries by providing 

stabilization and observation of potentially 

volatile inmates 

Committed space and 

specially trained professional staff are more 

expensive and could 

reduce resources to general substance abuse 

population 

Interventions reach more 

inmates 

Less effective without discrete program space and 

experienced, trained staff 

Makes more beds available through reduced 

cycling of “high-risk” 

inmates 

Requires more aftercare 

planning staff and coordination with community 

agency visits 

Focuses more resources 

on substance abuse treatment 

Not as effective with special needs populations 

who need more intensive 

services 

Allows for creation of 

aftercare and community linkages for special 

populations 

Allows for direct aftercare and diversion linkage to reduce negative 

outcomes and increase 

positive gains 

Requires aftercare planning staff, coordination 

with community agencies, 

and coordination with 

courts, and may increase 

officer time for court 

transportation and 

staffing agency visits 

Figure 8-3 

Targeted Treatment for Specific Populations Versus Mainstream 

Treatment for Larger Populations 

allowed. A thorough awareness of the rules 

allows the treatment program staff to anticipate these difficulties and develop creative 

solutions. Treatment counselors should be 

invited, and be willing, to participate in training related to security guidelines and methods. Treatment supervisors could also offer 

support by advising counselors on techniques 

for handling safety concerns and conflict with 

security staff. Finally, treatment and jail 

supervisory staff can use cross-disciplinary 

meetings and cross-training activities to jointly address and solve potential areas of conflict related to housing assignments, scheduling, reviewing responses to critical incidents 

(e.g., dealing with contraband), information 

sharing, and other aspects of program development. 

Improve coordination of 

information systems 

A lack of coordinated information can be a 

problem for detainees involved in multiple 

178 Chapter 8 
systems. Several nonproprietary computerized management information systems have 

been developed for this purpose. This software allows efficient, timely, and continuous 

care through treatment matching and followup and may also include data on drug test 

results. One model, based on the University 

of Maryland’s High Intensity Drug 

Trafficking Area Automated Treatment 

Tracking Software (HIDTA-HATTS), enables 

substance abuse treatment and criminal justice personnel to access the same information 

in making decisions about the client (Taxman 

and Sherman 1998). Other proprietary models based on drug courts have expanded their 

applications to include mental health screens 

and assessments. Still other jurisdictions have 

developed mechanisms to share mental health 

and substance abuse database information 

between the correctional institution and the 

community managed care provider (e.g., 

National GAINS Center 1999c). Each jurisdiction involved in developing these types of 

management information systems has worked 

out informed consent and differential confidentiality issues for information sharing. The 

models cited have also developed their work 

in the context of multisystem collaboration 

and at times through formal consensus-building processes between the key stakeholders 

relevant to ensure continuity of treatment 

(Broner et al. 2001b). 

Educate staff regarding 

pharmacotherapies 

Some jail administrators resist 

using pharmacotherapy because 

they are philosophically opposed 

to administering medication 

(e.g., methadone, psychiatric 

medications) to people with substance abuse problems, but most 

jails administer a range of psychiatric medications for inmates 

with mental disorders. Most of 

these medications are not addictive and do not present a risk 

for distribution as contraband 

within the institution. However, relatively few 

jails provide medication-assisted treatment 

for opioids and other drugs. Figure 8-4 

(p. 180) describes some of the advantages and 

disadvantages of medication use, for inmates 

enrolled in jail substance abuse treatment 

programs. 

There are legitimate concerns regarding the 

use of some medications in jails, particularly 

when there are not adequate healthcare staff 

available to monitor and supervise medication 

use. Pharmacological treatments used in jails 

should be monitored by a qualified physician 

or nurse practitioner. Project KEEP is an 

example of a program that integrates pharmacological treatments with a jail environment 

(see p. 181). 

Provide for staff 

development 

Many front-line jails require that staff have 

only a GED or high school diploma and no 

criminal record. While correctional staff 

receive extensive security training, training is 

not always provided in working with specific 

populations and substance abuse treatment. 

Cross-training is an effective approach to 

have correctional and treatment staff learn 

from each other about key issues related to 

institutional security and rehabilitation. 

Correctional officers can benefit from learning about the length, course, and components 

of substance abuse treatment; effective comAdvice to the Counselor: 

Cross-Training 

• Treatment and corrections staff should learn from each 

other. 

• Counselors in correctional settings can benefit from

training in security guidelines, and learning about

inmate behavior and attitudes.

• Correctional staff can benefit from training in working 

with specific populations, components of substance

abuse treatment, and their role in shaping a therapeutic

environment.

Treatment Issues Specific to Jails 179 
Figure 8-4 

Varied Opinions Regarding Medication Use for Inmates 

in Jail Treatment Programs 

Advantages Disadvantages

Provides continuous treatment from community to Belief that “drugs” should not be tolerated in jails 

jail, and jail to community 

Reduces cravings Medications used to combat withdrawal may be used 

as contraband 

Provides a humane response to treating symptoms of May lead to inmates’ selling or trading the medication 

withdrawal and addiction within the population 

Medications are constantly being developed and Side effects are not always known 

improved that can benefit inmates with substance 

abuse and mental health problems 

Benefits of treating medical problems (substance use Benefits to learning to deal with problems without 

disorders) medically drugs 

Resolves/improves symptoms of mental illness and Some medications (e.g., benzodiazepines) can be 

allows the dually diagnosed individual to focus on addictive 

substance abuse issues 

munication strategies with treatment staff 

regarding inmate behavior and attitudes; 

involvement in treatment team, group meetings, and other unit activities; and their role 

in shaping a therapeutic environment. 

Treatment staff can benefit from training 

related to security guidelines, effective communication with corrections staff regarding 

inmate behavior, contraband and other security infractions, and their role in maintaining 

the security of the housing unit and the jail. 

Both corrections and treatment staff can be 

productively involved in identifying critical 

incidents that may occur within the jail treatment unit, the type of information that needs 

to be shared between treatment and corrections staff, and methods of resolving these situations. 

Instituting treatment programs within jails 

creates a unique opportunity for treatment 

staff to collaborate with jail staff in developing in-service training programs and to 

encourage certification and degree training at 

local universities. For instance, New York 

City offers incentives and tuition reimbursement for city employees for both undergraduate and graduate training, along with a forensic certificate, through the New York 

University school of social work. Flexible job 

scheduling could help many employees 

improve their education, and providing 

course work for credit at the job site would 

allow jail personnel to work toward undergraduate or graduate degrees. Another option 

is to set aside time for career development on 

the job—with a few hours per week to take a 

class that will not only help their job performance, but will also aid their career progress. 

Developing community and 

correctional partnerships 

Creating partnerships between the jail and 

the community can allow for the development 

or enhancement of both in-jail treatment programs and coordination of offenders’ transition into community diversion and aftercare/ 

reentry programs. Such a model of cooperation and collaboration exists in many jails in 

the areas of education and health care or in 

some jails for diversion and aftercare of those 

with substance use disorders or other mental 

180 Chapter 8 
Project KEEP 

A significant increase in the number of drug-related arrests in the New York Metropolitan area in 1987 

led to overcrowding and unrest at the Correctional Facility on Riker’s Island. In response, researchers 

developed a program that serves as both a methadone program and an AIDS prevention initiative. 

Called KEEP (Key Extended Entry Program), the program enables opioid-dependent offenders who are 

charged with misdemeanors to be maintained on a stable dose of methadone during their stay at Riker’s, 

and then receive a referral at release to a participating community methadone program. KEEP, intended to be a route into long-term community drug treatment, aims to break the cycle of illicit drug use and 

criminal recidivism. It was one of the first methadone treatment programs of its kind in the United 

States for incarcerated persons addicted to heroin (Tomasino et al. 2001). This program allows for a 

humane detoxification for offenders who desire it upon entry to jail, and it allows new patients to enroll 

in maintenance and to receive treatment in the community. Finally, and most importantly, it provides a 

continuity of care upon release from jail to people enrolled in methadone therapy prior to arrest. 

Seventy-four to 80 percent of methadone treatment patients discharged to the community, mostly to outpatient KEEP programs, report to their designated program. Recidivism rates show that 79 percent of 

KEEP patients were re-incarcerated only once or twice during a recent 11-year period. KEEP data indicate the importance of administering sufficient blocking doses of methadone to patients in outpatient 

treatment centers in order to eliminate heroin craving and to maintain the patients in treatment. About 

6 percent of KEEP patients are at a higher risk for recidivism (e.g., those with co-occurring disorders) 

and require specialized treatment (Tomasino et al. 2001). 

disorders (Broner et al. 2002; Steadman et al. 

1995). Such partnerships allow for the extension rather than duplication of an array of 

community resources to address many of this 

population’s substance abuse, mental health, 

medical, vocational, educational, and social 

service needs. 

On the other hand, coordinating the visits of 

large numbers of community volunteers can 

create both a security and staffing burden for 

the jail. Concerns include staffing patterns, 

security, contraband monitoring, coordinating schedules, staff time, escorting inmates to 

their group room and back, and escorting visitors. Therefore, arranging for services from 

the outside produces an additional workload 

for jail administrators that may in itself be a 

barrier. To overcome these problems, shared 

funding and community organizations’ budgeting for jail officers’ time could be 

employed. To find a compatible blend of 

needs and concerns on both sides, there must 

be a planning structure for community volunteers and jail administrators to facilitate communication and resolve problems. 

Creating linkages between 

jail treatment and diversion 

and reentry court programs 

Although typically operated by the criminal 

courts, drug treatment courts (DTCs) have 

formed productive partnerships with local 

jails in many jurisdictions (Tauber and 

Huddleston 1999). The first phase of treatment in some drug court programs is completed in jail, with intensive services provided 

that focus on a comprehensive psychosocial 

assessment, substance abuse education, and 

engagement in and orientation to treatment. 

In other drug court programs, an initial injail treatment component is optional, depending on the severity of drug treatment needs 

and the importance of a secure treatment setting. Jail treatment is also used with inmates 

who are awaiting placement in drug court 

treatment programs in the community. 

Another major function of jail treatment programs is to provide more intensive services on 

a short-term basis for drug court participants 

who relapse or commit other major infracTreatment Issues Specific to Jails 181 
tions. In these cases, jail programs can serve 

as a therapeutic sanction to remove an individual from salient relapse cues (such as 

drug-using peers), to provide detoxification as 

needed, and to reengage individuals in their 

recovery programs. Many drug courts use 

progressive sanctions that provide an escalating number of days in jail (e.g., 2, 4, 7) for 

designated program infractions. In some 

cases, drug courts have provided longer jail 

sentences, although 

the therapeutic 

effects of these 

Jail programs can 

serve as a 

therapeutic sanction to remove an 

individual from 

salient relapse 

cues. 

sanctions are 

unclear. 

Several drug courts 

have established a

coordinated reentry 

approach with injail treatment programs (Huddleston 

1998; Tauber and 

Huddleston 1999). 

Each of these partnerships is characterized by significant flexibility in 

addressing the individual needs of 

drug court participants. Many of these drug 

courts also continue to monitor participants 

who are placed both in custodial and noncustodial settings. For instance, two drug court 

and jail treatment partnerships (Los Angeles 

County and San Bernardino County, 

California, and Uinta County, Wyoming), 

place offenders in the jail treatment program 

as the first phase of drug court. In the San 

Bernardino drug court, participants are given 

job assignments within the jail that allow for 

attendance in treatment groups and classes. 

In Los Angeles County, a separate housing 

unit is reserved for drug court treatment and 

receives referrals from several drug courts in 

the county. One Los Angeles drug court, 

designed for probation violators (one of 11 

drug courts in the county), requires 3 

months’ in-jail treatment prior to completing 

subsequent phases of the program. In Uinta 

County, Wyoming, drug court participants 

who have been unsuccessful in court-ordered 

treatment are placed in a 6-week jail treatment program as the first phase of drug court 

involvement. While they are in the jail treatment program, participants in Uinta County 

are required to appear in drug court once 

weekly for status hearings. 

In Broward County, Florida, the DTC refers 

participants to a 90-day jail treatment program if they have not successfully completed 

other less intensive approaches (e.g., outpatient treatment) (Tauber and Huddleston 

1999). Individuals sentenced to jail prior to 

involvement in the Broward County drug 

court are also referred to the jail treatment 

program to engage them in treatment quickly. 

The drug court then monitors their progress 

in the jail treatment program and provides a 

reentry mechanism upon their transfer to the 

drug court program. 

In New Castle County, Delaware, the DTC 

has combined both short-term (6 months) and 

long-term (11–18 months) custodial substance 

abuse treatment with continued care upon 

rearrest for probation violators who have 

committed new felony-level offenses. The 

court monitors the individual’s progress 

through the prison- or jail-based treatment 

and develops a reentry treatment plan based 

on input from team members. This has had a 

positive effect on reducing recidivism 

(Statistical Analysis Center 1998). 

Several other drug court and jail treatment 

partnerships offer unique elements. In Los 

Angeles County drug courts, participants who 

are transferring from the jail treatment unit 

to community settings can use transition 

housing. In San Bernardino County, a comprehensive assessment is provided after 10 

weeks of treatment in the jail program and is 

provided to the drug court judge before status hearings. This assessment serves as the 

basis for the court’s decision to order continued in-jail treatment, placement in a community residential treatment program, or placement in a community outpatient program. In 

182 Chapter 8 
New Haven, Connecticut, the drug court 

judge orders jail sentences as a sanction and 

requests on an individual basis that drug 

court participants receive priority access to 

drug treatment and self-help groups during 

the ensuing period of jail incarceration 

(Huddleston 1998). For more information on 

drug courts and diversion programs, see 

chapter 7. 

Examples of Jail

Treatment Programs

Several innovative components and unique features of metropolitan jail substance abuse 

treatment programs are described in this 

section. 

Multnomah County Sheriff’s

Office In-Jail Intervention

Program (Portland, Oregon) 

•Offers a specialized co-occurring mental disorders emphasis and features domestic violence services and a relapse prevention track. 

•Provides acupuncture treatment to assist 

inmates in dealing with cravings and withdrawal symptoms during the initial stage of 

treatment. 

•Offers an intensive short-term treatment 

program (22 days, 50 hours per week, 1:7 

staffing ratio) with significant emphasis on 

aftercare linkage. 

•Provides transition and linkage services, 

which includes driving inmates to community treatment providers (often residential 

services), as needed, and picking up medications and refilling prescriptions prior to 

the aftercare placement. 

•Coordinates with community treatment 

providers to share information about aftercare treatment plans and other records. 

•Plans aftercare programs that include case 

management and client needs assessment. 

•Offers a treatment curriculum shaped in 

part by results of satisfaction surveys 

administered to inmates. 

King County Jail System, 

North Rehabilitation Facility, 

Stages of Change Program

(Seattle, Washington) 

• Provides an integrated system of 

“wraparound” treatment services. 

• Partially funded through work contracts. 

• County’s Department of Public Health manages the jail. 

• Offers screening and triage for inmates 

placed in the jail for more than 1 week. 

• Provides individual sessions with counselors. 

• Offers acupuncture services. 

• Assigns all inmates to jobs that have the 

potential of developing employment skills. 

Philadelphia Prison System

OPTIONS Program

(Philadelphia, Pennsylvania) 

• Provides gender-specific programming for 

women. 

• Provides relapse prevention services, combined with modules on the “psychology of 

achievement” and entrepreneurship training, 

using motivational and action-oriented strategies of Fortune 500 companies. 

• Integrates family therapy sessions in which 

families come into the jail. 

• Program staff make home visits. 

• Program staff use videotaped material from 

jail and home-base settings for inmates and 

their families. 

• Provides aftercare followup services. 

Treatment Issues Specific to Jails 183 
Wayne County Jail Target 

Cities Jail-Based Substance 

Abuse Treatment Program

(Detroit, Michigan) 

•Diverts nonviolent prison inmates to complete 

short-term jail treatment services, followed 

by involvement in community treatment. 

•Reduces the need for prison space through 

cost-effective diversion approach. 

•Addresses parenting skills and parental 

financial responsibility for family members. 

•Uses feedback from an external evaluator to 

intensify services during the first 3–4 weeks 

of program involvement, the period in which 

many participants historically drop out. 

•Offers an “Alumni Success” group for program participants. 

Walden House and the San

Francisco Sheriff’s Office 

SISTER Project (San Francisco, 

California) 

•Prepares incarcerated women for life after 

their release to prevent relapse. 

•Encourages women to make productive use of 

their time in this 30- to 45-day program. 

•Offers a 6-week academic course that provides women with information about college 

admission and financial aid. 

•Provides five-stage testing for GED (high 

school equivalency) weekly, and holds cap 

and gown ceremony for graduates. 

•Introduces women to a variety of potential 

job options and helps them to prepare their 

resumes in a computer class. 

•Counsels women on how to keep a job after 

securing it. 

•Prepares women for treatment and places 

them in community-based programs after 

their release (Chadwick 2001). 

Research Related to 

Jail Treatment 

A survey of metropolitan jail treatment programs indicates that many jails have several 

treatment phases and endorse more than one 

therapeutic orientation (Peters and May 

1992). More than half of the jail programs 

surveyed included 12-Step groups, cognitive–behavioral groups, and relapse prevention programs. Many jail treatment programs 

have developed specialized tracks for such 

groups as juveniles charged as adults, those 

with co-occurring disorders, groups for people arrested for driving under the influence, 

and blended groups for domestic violence and 

substance abuse (Peters and Mathews 2002). 

Outcomes of Jail Treatment 

Jail treatment programs often are dependent 

on local resources or knowledge, rather than 

on consistent best practice models for this setting. While outcome studies are few and limited in scope, the therapeutic community model 

shows promise even for short-term stays. In 

particular, the Amity/Pima County Substance 

Abuse Treatment Jail Project, funded by the 

U.S. Bureau of Justice Assistance in the late 

1980s, demonstrated the efficacy of drug 

treatment in a correctional setting (Pima 

County Sheriff’s Department 1988). 

Moreover, a number of studies demonstrate 

reduced rearrest and reconviction rates, 

longer time to rearrest, and fewer arrests 

during follow-up for those participating in injail drug treatment (Peters and Matthews 

2002). 

Effects of Treatment Duration

Studies investigating the effects of duration of 

jail substance abuse treatment indicate that 

recidivism rates are related to the length of 

treatment, up to an optimal duration of 

91–150 days (Swartz et al. 1996). Successful 

treatment outcomes have been reported for 

jail programs of 1.5–5 months duration. 

Involvement in aftercare treatment services 

184 Chapter 8 
following release from jail has also been 

found to reduce criminal recidivism (San 

Francisco County Sheriff’s Office Department 

1996; Swartz et al. 1996). Offenders released 

from jail are more likely to participate in 

aftercare treatment if they have previously 

been involved in a jail treatment program 

(Taxman and Spinner 1997). 

Predictors of Treatment 

Outcomes

A number of studies have examined predictors of jail treatment outcomes—what elements help people finish treatment (“completers”) and what elements militate against 

completion (“noncompleters”). The most 

important predictor in one study examining 

rearrest during a 1-year follow-up period was 

the number of lifetime arrests, although other 

psychological indicators and living arrangements were also found to be predictors 

(Peters et al. 1993). A similar study (Peters et 

al. 1999) found that cocaine users were less 

likely to complete a treatment program than 

alcohol or marijuana users. Other factors 

predicting noncompletion were lack of a high 

school diploma, living outside a parent’s 

home, lack of full-time employment, and having been arrested for charges other than drug 

possession. It is likely that similar factors 

may influence retention in jail treatment programs, although more research is needed in 

this area. 

Importance of Aftercare 

Unfortunately, a majority of released 

detainees are not linked to aftercare services 

or treatment and the majority of jails do not 

use diversion resources such as drug courts. 

Treatment mandated by drug courts is associated with decreased recidivism, increased 

treatment retention, and better aftercare 

linkages (Leukefeld and Tims 1988). Tunis 

and colleagues (1997) found that drug treatment programs in jails provide a “behavioral 

management tool” that results in fewer behavioral problems, especially physical violence. 

However, effects of the program on recidivism 

rates were modest in the year after release. 

Inmates participated in the treatment on a 

voluntary basis in the programs they studied, 

which consisted of counseling and self-help 

groups and aftercare opportunities in the 

community were extremely limited. 

Additional training for correctional staff 

could have increased their support for 

aftercare. 

Recommendations for

Treatment Providers

The consensus panel believes that to maximize 

the benefits of substance abuse services, treatment staff working with clients in jails should 

consider the following recommendations: 

• Recognize that many people in the community frequently move back and forth from community to jail and that triage and referral to 

services can be critical. 

• For individuals in community treatment 

agencies, make staff available to provide services in jails and share expertise through 

training and consultation with jail treatment 

staff. 

• Provide ongoing consultation to jail administrators and other jail staff about substance 

abuse issues, and work to establish a continuum of services in the jail and community for 

people with substance abuse problems. 

• Develop treatment approaches that are targeted to recognized special populations, such 

as those described in this chapter. 

• Assist in conducting periodic quality assessment reviews. 

• Employ evidence-based practices such as 

motivational enhancement techniques, cognitive–behavioral interventions, relapse prevention, contingency management, and therapeutic communities. 

Treatment Issues Specific to Jails 185 
 

9 Treatment Issues

Specific to Prisons

In This
 Chapter... 

Description of the 

Population 

Treatment Services in 

Prisons 

Key Issues Affecting 

Treatment in Prison 

Settings 

What Treatment Services 

Can Reasonably Be 

Provided in the Prison 

Setting? 

In-Prison Therapeutic 

Communities 

Specific Populations in 

Prisons 

Systems Issues 

Recommendations and 

Further Research 

Overview 

The unique characteristics of prisons have important implications for 

treating clients in this setting. Though by no means exhaustive, this 

chapter highlights the most salient issues affecting the delivery of 

effective treatment to a variety of populations within the prison system. It describes the prison population as of 2003, reviews the treatment services available and key issues affecting treatment in this setting, and considers the question, “what treatment services can reasonably be provided in the prison setting?” The prison therapeutic community (TC) model is explored in depth and examples of in-prison 

TCs are described. The chapter also looks at the treatment options 

available for certain specific populations and at systems issues that 

affect all clients in prison settings. The chapter concludes with some 

general recommendations for substance abuse treatment in prisons. 

Description of the Population

Prisons differ from jails in that inmates generally are serving longer 

periods of time (1 year or longer) and the offenders have often committed serious or repeated crimes. Prisons and jails both vary in size, 

but prisons are unique in that they are separated by function and 

inmate classification. 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) 

187 
•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 special 

needs, such as people with mental illness, 

physical disabilities, or HIV/AIDS) 

(National Center on Addiction and 

Substance Abuse [CASA] 1998). 

At the end of 2003, State and Federal prisons 

in the United States housed a total of 

1,470,045 inmates. This meant that there 

were approximately 482 sentenced inmates 

for every 100,000 United States residents. 

About 1 in every 109 men and 1 out of every 

1,613 women were incarcerated by State or 

Federal authorities. The Nation’s prison population grew 2.1 percent in 2003 (Harrison 

and Beck 2004). 

The percentage of prison inmates incarcerated for parole violations has decreased in 

recent years. Between 1990 and 1998, the 

number of people in prison for parole violations increased by 54 percent, but since 1998 

the number of parole violators has increased 

less than 1 percent (Harrison and Karberg 

2004). 

Gender

Since 1995, the rate of incarceration of 

women in prisons has increased at a higher 

rate (5 percent on average) than that of men 

(3.3 percent). In 2003, the number of women 

in State or Federal prisons increased by 3.6 

percent, while the number of men in those 

institutions increased by 2 percent. Women 

accounted for 6.9 percent of all inmates in 

State and Federal prisons as of yearend 2003, 

an increase from 5.7 percent of all inmates in 

1990 (Harrison and Beck 2004). 

Race and Ethnicity

Although the total number of sentenced 

inmates increased greatly over the past 

decade, only a slight variance existed in the 

racial and ethnic composition of the inmate 

population. At yearend 2003, AfricanAmerican males (586,300) outnumbered 

Caucasian males (454,300) and 

Hispanic/Latino males (251,900) among 

inmates with sentences of more than 1 year. 

African-American inmates represented an 

estimated 44 percent of all inmates with sentences of more than 1 year, while Caucasian 

inmates accounted for 35 percent and 

Hispanic/Latino inmates, 19 percent. More 

than 9 percent of all African-American men 

between the ages of 25 and 29 were in prison 

in 2003 (Harrison and Beck 2004). 

Substance Abuse 

The lifetime incidence of substance abuse or 

dependence disorders in the prison population is roughly 75 percent (Peters et al. 1998). 

In 2001, 20 percent of State prison inmates 

were incarcerated for drug-related offenses 

(Harrison and Beck 2003). 

In a 1997 Bureau of Justice Statistics survey, 

approximately half of all State and Federal 

inmates reported that they had used drugs in 

the month before their offense, and over 

three-quarters indicated that they had used 

drugs during their lifetime (Mumola 1999). 

Almost one in three prisoners said they had 

committed their current offense while under 

the influence of drugs, and about one in six 

had committed their offense to get money for 

drugs. In addition, a quarter of State and a 

sixth of Federal prisoners had experienced 

problems consistent with a history of alcohol 

abuse or dependence. Drug offenders 

accounted for more than half the total 

increase in parole violators returned to State 

prisons (Beck 2000b). 

Offenders who use drugs are more likely to 

commit violent crimes. In a report by CASA 

(1998), almost half (43 percent) of those iden188 Chapter 9 
tified as “regular drug users” in State correctional systems were incarcerated for a violent 

offense, including murder, manslaughter, 

rape, robbery, kidnapping, and aggravated 

assault. 

Mental Illness

At midyear 1998, 16 percent of State prisoners and 7 percent of Federal inmates reported 

having a mental condition (Ditton 1999). As 

of 2000, 13 percent of State prison inmates 

(approximately 79 percent of those with mental disorders) were receiving some type of regular counseling or therapy from a trained 

professional. Approximately 10 percent of all 

inmates in State prisons were receiving psychotropic medication (Beck and Maruschak 

2001). 

According to 1998 data, State prison inmates 

who reported having a mental condition were 

more likely than other inmates to be incarcerated for a violent offense (53 percent compared to 46 percent). They were also more 

likely than other inmates to be under the 

influence of alcohol or illicit substances at the 

time of the current offense (59 percent versus 

51 percent), and more than twice as likely as 

other inmates to have been homeless within 

the previous 12 months (20 percent compared 

to 9 percent) (Ditton 1999). Approximately 78 

percent of females and 33 percent of males in 

State prisons who have a mental illness 

reported they had been physically or sexually 

abused at some point in their lives (Ditton 

1999). 

Many offenders in State or Federal prisons 

who had a mental illness reported negative 

life experiences related to drinking, including 

losing a job, getting arrested, and getting into 

a fight. Inmates with a mental illness were 

also more likely than others to be under the 

influence of alcohol or drugs while committing 

their offense; 60 percent of State prisoners 

who had a mental illness compared to 51 percent of other inmates were under the influence when they committed their offense 

(Ditton 1999). 

Communicable Diseases

Many offenders in State and Federal prisons 

have poor general health. Their access to and 

use of healthcare services may have been limited, and behaviors such as intravenous drug 

injection and unsafe sex may have exposed 

them to communicable diseases. Prisoners 

have disproportionate rates of HIV, hepatitis 

C (HVC), sexually transmitted diseases, and 

tuberculosis (TB) (Hammett 1998; HIV and 

Hepatitis Education Prison Project 2002; 

Maruschak 2004). 

HIV and AIDS 

The number of all 

State and Federal 

prison inmates with The lifetime

incidence of

substance abuse

or dependence 

disorders in the 

rison population

is roughly

75 percent.

HIV infection is estimated to be nearly 

six times higher than 

that of the general 

population 

(Hammett 1998). In 

recent years, the 

rate of infection has 

decreased somewhat 

for the general 

prison population. p The number of prisoners known to be 

infected with HIV 

was down from 2.2 

percent in 1998 to 

1.9 percent at 

yearend 2002. The 

number of State and Federal prison inmates 

known to have AIDS also decreased from 

5,754 reported cases in 2001 to 5,643 in 2002 

(Maruschak 2004). As in the general population, HIV infection rates were higher for 

racial minorities. In 1997, of all State prison 

inmates, 2.8 percent of African-American 

inmates and 2.5 percent of Hispanic/Latino 

inmates, compared to 1.4 percent of 

Caucasian inmates, reported to survey interviewers that they were HIV positive 

(Maruschak 1999b). 

Treatment Issues Specific to Prisons 189 
 

 

Hepatitis C 

Many inmates also have HVC. According to 

the HIV and Hepatitis Education Prison 

Project (2002), the rate of HCV infection is 

10 times higher than that of HIV—an estimated 17 percent of inmates, nearly 10 times 

higher than the estimates for the general population. Like HIV infection, rates are higher 

among incarcerated women. Nationally, HVC 

is about a third higher in incarcerated women 

than incarcerated men. 

Tuberculosis 

Rates of TB are also higher among State and 

Federal inmates than in the general population. Wilcock and colleagues (1996) note that 

many men who eventually enter prison are at 

risk even before they are incarcerated. 

Poverty, poor living conditions, substance 

abuse, and HIV/AIDS put them at increased 

risk. Once in prison, these offenders are at 

risk for contracting TB, as prisons present 

optimal conditions for the spread of TB. 

According to 2003 data, nationwide 3.2 percent of residents of correctional facilities had 

TB (Centers for Disease Control and 

Prevention 2004b). A 1994 study of 25 State 

and Federal inmates by Wilcock and colleagues (1996) reported that 5,609 inmates 

who did not test positive for TB when entering prisons did so 2 years later. 

Treatment Services in

Prisons

The need for prison-based substance abuse 

treatment is profound. Lo and Stephens 

(2000) examined treatment needs of Ohio 

offenders entering the State prison system. 

More than half were dependent on at least 

one substance, and 10 percent were dependent on at least two. Treatment for cocaine 

and marijuana dependence was most urgently 

needed. Young minority males were most likely to be dependent on marijuana; females 

were more likely to be dependent on cocaine 

and opioids than males. Nearly 60 percent of 

respondents said that treatment would be of 

use to them. 

Despite this need, in 1997 only 1 in 8 State 

prisoners and 1 in 10 Federal prisoners 

reported that they have participated in drug 

treatment programs since entering prison 

(Mumola 1999). In 1996, a CASA survey of 

prison facilities indicated that three quarters 

of State inmates needed substance abuse 

treatment, though less than a quarter of State 

inmates received it (CASA 1998). As Figure 9­

1 indicates, the most common reasons listed 

for the limited availability of treatment were 

budgetary constraints (71 percent) and space 

limitations (51 percent). 

Various organizations and agencies have 

developed, or are in the process of developing, guidelines for substance abuse treatment 

in correctional facilities, including the 

American Correctional Association (ACA) in 

conjunction with Therapeutic Communities of 

America, the National Institute of Corrections 

(NIC), and the Center for Substance Abuse 

Treatment (CSAT). Figure 9-2 (see p. 192) 

summarizes some of these guidelines. 

Although the extent to which State prison systems have adopted these professional guidelines is unclear, they provide a standard 

against which treatment programs can be 

measured (Peters and Steinberg 2000). 

Key Issues Affecting 

Treatment in Prison

Settings

Incarcerated prisoners are marked by considerable diversity, yet they share a common 

experience of incarceration. Prisons can be 

violent, harsh, psychologically damaging environments; incarcerated people live in an environment that is both depersonalizing and 

dehumanizing. Moreover, the social stigma 

associated with incarceration, combined with 

the depersonalizing effects of imprisonment, 

may result in a sense of hopelessness and 

powerlessness, as well as deeply internalized 

190 Chapter 9 
Figure 9-1 

Reasons for Limitations to Providing Treatment to Prison Inmates 

Reason Percentage 

Budgetary constraints 71 

Space limitations 51 

Limited number of counselors 39 

Lack of volunteer participants 18 

Frequent movement of inmates 12 

General correction problems 8 

Problems with aftercare provision 4 

Legislative barriers 2 

Source: CASA 1998. 

shame and guilt. Thus, in addition to treating 

substance abuse and other mental disorders, 

the consensus panel recommends that inprison treatment also address the trauma of 

the incarceration itself as well as a prison culture that conflicts with treatment goals. 

Trauma and Hopelessness

Inmates’ responses to prison environments 

vary, but virtually all will experience some 

degree of trauma and hopelessness. Derosia 

(1998) conducted a review of the literature and 

determined that the inmates who were most 

likely to have difficulty coping in prison 

•Have unstable family, living, work, and/or 

education histories 

•Are single, young, and male 

•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 costs (Dumond 

2000). 

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. Markers of PTSD 

include 

• Irritability 

• Hypervigilance 

• Sleep difficulties 

• Restricted range of affect 

• Feelings of detachment 

• Flashbacks and/or nightmares of traumatic 

incidents (American Psychiatric Association 

2000) 

Counselors should be able to recognize these 

symptoms and encourage clients to talk about 

their feelings related to the incarceration. 

Counselors should be especially aware of 

signs of suicidal ideation. For more information on PTSD see the forthcoming TIP 

Treatment Issues Specific to Prisons 191 
Figure 9-2 

Guidelines for Substance Abuse Treatment in Correctional Facilities 

ACA NIC CSAT 

Screening and 

assessment 

•Diagnosis of chemical 

dependency by a physician 

and determination of 

whether that individual 

requires pharmacologically 

supported care 

• Screening and assessment• Standardized screening and 

assessment 

Treatment plans •Individualized treatment 

plans 

• Development of comprehensive treatment 

services 

• Continuity of services 

across the corrections 

system 

• Individualized treatment 

plans 

Other •Referrals to community 

resources upon release 

(ACA 1990) 

• Staff recruitment 

• Staff training 

• Sanctions 

• Program accountability and evaluation 

(NIC 1991) 

• Matching to different levels 

or types of treatment services 

• Case management services 

• Use of cognitive–behavioral, 

social learning, and selfhelp approaches 

• Inclusion of relapse prevention training 

• Use of self-help groups 

• Use of therapeutic communities 

• Provision for isolated treatment units 

• In-prison drug testing 

• Continuity of services 

• Program evaluation 

• Cross-training of staff 

Sources: ACA 1990; CSAT 1993; NIC 1991. 

Substance Abuse and Trauma (CSAT in 

development f), and TIP 42, Substance Abuse 

Treatment for Persons With Co-Occurring 

Disorders (CSAT 2005c). 

Inmate Identity and Culture 

It is difficult to describe one type of “criminal” identity that is shared by all offenders. A 

more common problem is, perhaps, the lack 

of identity and accompanying hopelessness 

that many offenders face. Some offenders feel 

relatively little anxiety regarding their incar192 Chapter 9 
ceration, and many believe that being in 

prison and participating in prison culture are 

the norm. Others feel they are the victims of 

society, and still others take pride in belonging to an alternative culture (e.g., the drug 

culture, a gang) and being outside the majority culture. 

Unlike jail detainees, who are likely to be 

incarcerated for short terms, prisoners often 

learn to identify as inmates as a matter of 

survival. 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 role or persona of a prisoner. In prisons, as opposed to jails, there are 

many more people who are accustomed to the 

setting and who take the attitude that it is “no 

big deal.” The assumption of an identity as an 

inmate is an issue of survival for most offenders. The hardened demeanor and “macho” 

attitude adopted as part of the inmate culture 

can discourage offenders from participating 

in treatment. Treatment is often perceived as 

a sign of “weakness” within the inmate culture, and inmates who enroll in treatment are 

often characterized by other prisoners as too 

weak to “handle their drugs” in the community. 

Gender-Specific Issues

Gender in particular is a defining category 

for treatment and recovery in prison settings. 

Populations are segregated by gender so that 

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 divergent. 

Programs must be attuned to the differences 

inherent in treating men and women within a 

prison setting. For more information on gender-specific issues, see chapter 6 of this TIP 

and the forthcoming TIPs Substance Abuse 

Treatment: Addressing the Specific Needs of 

Women (CSAT in development g) and 

Substance Abuse Treatment and Men’s Issues 

(CSAT in development e). 

Men in prisons 

The consensus panel suggests that, where possible, programs provide specific groups and 

educational curricula that emphasize the gender-specific aspects of treatment. For example, issues related to relationships and to 

fatherhood should be explored. Fathers may 

be encouraged to participate in parenting 

education, with an emphasis on responsibilities and the impact of neglect, anger, and 

abuse on children. 

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. Treatment staff also 

should focus on gender dynamics that affect 

many male participants’ willingness to assess 

honestly their own conduct, typically including behaviors such as avoiding responsibility, 

excessively blaming others, and repressing 

feelings. 

For many incarcerated men, learning to 

express anger in healthy and constructive 

ways is vital. Many male offenders have been 

perpetrators of domestic and/or sexual violence and/or have gotten into trouble because 

of fighting or assaults. Violence prevention 

groups may help participants explore 

thoughts, feelings, and behaviors that are 

often the underpinnings of violent behavior 

and sexual aggression—issues such as a lack 

of empathy, narcissism, anger management 

problems, an overblown sense of entitlement, 

and the lack of effective thinking skills and 

sense of self-efficacy. 

Research shows that sexual offenders may be 

at greater risk for violent assaults by other 

offenders (Brady 1993). By taking a “scattershot” approach that treats all participants as 

if they have a history of violence or sexual 

offenses, rather than singling out specific 

individuals, treatment providers can address 

latent and manifest coercive behavior focusing attention on specific individuals. 

Treatment Issues Specific to Prisons 193 
 

Women in prisons 

Incarcerated women typically have a constellation of high-risk environmental, medical, 

and mental health issues as well as behaviors 

associated with continued or renewed substance abuse (CSAT 1999b). In the prison 

environment, these factors can operate as 

influences to relapse. They include antisocial 

behavior, emotional problems, the trauma of 

imprisonment, and the separation of the 

inmate from her family and loved ones, especially children. Problematic behaviors and 

the attitudes that influence them have been 

developed over many years and often have 

their roots in childhood trauma. Often, the 

trauma and related negative influences of 

imprisonment counteract the value of services 

provided by the in-prison treatment provider. 

Imprisonment also disrupts family life and 

social relationships, thereby interfering with 

female inmates’ roles as wife/partner, mother, 

sister, aunt, and daughter. Women inmates’ 

identities in most cases are tied to one or 

more of these roles. For some women, interference with these roles produces stress 

because of the loss of affection and security 

normally provided by their families, which 

can also trigger substance abuse. 

What Treatment 

Services Can

Reasonably Be 

Provided in the Prison

Setting? 

Because the prison population tends to be 

incarcerated for longer periods than jail 

inmates, treatment possibilities in a prison 

setting are more extensive, depending on 

funding and other factors. Counselors and 

prison administrators may establish programs 

that are long term and comprehensive. 

Substance abuse issues may be addressed 

along with behavioral, emotional, and psychological problems. Ideally, prisoners have 

the opportunity to abstain from substances 

and learn new behaviors before release. 

Treatment Intensity

Treatment in a prison setting can vary greatly 

in the setting and intensity of the program. 

On the most intense end of the spectrum, the 

TC is a treatment model that attempts to create a 24-hour, 7-day-a-week treatment environment that integrates community, work, 

counseling, and education activities. Ideally, 

the program activities take place apart from 

the general prison population. Complete isolation from the general population is somewhat unusual, however. 

Less intensive treatment programs may simply deliver counseling, education, and other 

treatment services in a manner similar to outpatient programs. Inmates live in the general 

population and have assignments or appointments for services. Examples include weekly 

or twice-weekly individual therapy, weekly 

group therapy, or a combination of the two in 

association with self-help activities. 

Regardless of whether treatment occurs in a 

TC or as isolated outpatient sessions, intensity generally decreases over time as the individual meets treatment goals and moves 

through the stages of recovery. 

Treatment Components

In-prison treatment incorporates several different models, approaches, and philosophies 

for the treatment of substance use disorders, 

as described in the following section. 

Counseling 

In its prison study, CASA found that 65 percent of prisons provide substance abuse counseling. Of those, 98 percent offered group 

counseling and 84 percent offered individual 

counseling. Nearly one-quarter (24 percent) 

of State inmates and 16 percent of Federal 

inmates participated in group counseling 

while incarcerated (CASA 1998). 

194 Chapter 9 
Group counseling

As the most common treatment method, 

group counseling seeks to address the underlying psychological and behavioral problems 

that contribute to substance abuse by promoting self-awareness and behavioral change 

through interactions with peers (CASA 1998). 

Although the intensity and duration of group 

therapy can vary, trained professionals typically lead groups of 8 to 10 inmates several 

times a week with the expectation that participants will commit to and engage in meaningful 

change in an emotionally safe environment. 

Group sessions typically range from 1 to 2 

hours in length. 

Cognitive–behavioral groups 

Substance abuse treatment programs in correctional settings should be organized according to empirically supported approaches (i.e., 

those based on social learning, cognitive– 

behavioral models, skills training, and family 

systems) (Cullen and Gendreau 1989).

Programs based on nondirective approaches 

or medical models or those focusing on punishment or deterrence have not been shown to 

be effective (Peters and Steinberg 2000). 

Cognitive programs include such strategies as 

“problem solving, negotiation, skills training, 

interpersonal skills training, rational–emotive 

therapy (REBT), role-playing and modeling, 

or cognitively mediated behavior modification” (Izzo and Ross 1990, p. 139). 

Cognitive/behavioral/social learning models 

emphasize interventions that assist the 

offender in changing criminal beliefs and values. Such interventions concentrate on the 

effects of thoughts and emotions on behaviors, and include strategies (e.g., behavioral 

contracting) that promote prosocial behavior 

and accountability through a system of incentives and sanctions. Examples of cognitive– 

behavioral group interventions include the 

National Institute of Corrections’ Thinking 

for a Change curricula (online at 

http://www.nicic.gov/t4c), the Criminal Conduct 

and Substance Abuse 

Treatment (Wanberg and Milkman 1998), and 

others described in chapter 5 of this TIP. 

In REBT, the client’s thinking patterns are 

also the focus of attention. Individuals who 

abuse substances tend to think automatically, 

in rigid terms, and with overgeneralizations. 

Rationalizations are also commonly used by 

offenders to justify maladaptive behaviors, 

including substance abuse and a range of 

other criminal behaviors. Clients are taught 

to be aware of their thinking patterns and to 

challenge their assumptions. Once these 

errors in a client’s thinking are pointed out, 

they can be changed. Correcting the client’s 

thoughts can lead to exploration of alternative behaviors and attitudes that do not 

involve substances. 

Specialty groups 

Specialized treatment groups are often organized around a shared life experience (e.g., 

children of alcoholics, incest survivors, people with AIDS) or common problem (anger 

management, parenting, stress reduction, or 

prerelease planning). Specialty groups offer a 

chance to work on specific issues that may be 

impeding other treatment initiatives or 

require special attention not readily available 

in the regular program. Two types of specialty groups are briefly described below. 

•Anger management groups. Anger management groups are widely used in drug treatment programs. They are especially helpful

for inmates who are either passive and

nonassertive or express anger in an explosive fashion. By careful analysis of emotional reactions to painful and threatening

experiences, treatment staff help the inmate

learn to manage anger in a more socially

acceptable manner. For example, inmates

may feel incapable of expressing negative

feelings verbally. Instead of responding

appropriately to a provocation, they allow

feelings to build up, which leads to a

delayed explosive reaction. Learning to

express angry feelings verbally and in an

appropriate manner helps inmates feel

Treatment Issues Specific to Prisons 195 
more competent about interpersonal relationships. 

•Parenting groups. Very successful groups 

have been organized around parenting 

issues. Although the perspective may differ 

for females and males, bonds to children 

can help motivate the recovery process for 

both genders and can contribute to a successful re-entry into the community. 

Practitioners have found that both men and 

women need to focus on developing parenting skills and overcoming patterns of 

neglect, abandonment, and abuse. As a 

result of parenting work, some program 

participants have tried to find their children and establish relationships with them 

upon release to the community. The process 

of becoming a responsible parent can be a 

critical component in the recovery process. 

Family counseling 

Family therapy is a systems approach that 

often focuses on large family networks. 

Family and friends can play critical roles in 

motivating individuals with drug problems to 

enter and stay in treatment. When possible, 

involvement of a family member in an individual’s treatment program can help prepare 

the individual for parole. Often caution needs 

to be exercised when involving families of 

offenders because of high degrees of antisocial 

behavior and psychological disturbance. For 

more information on using family therapy in 

substance abuse treatment see TIP 39, 

Substance Abuse Treatment and Family 

Therapy (CSAT 2004). 

Individual counseling 

Individual counseling is an important part of 

substance abuse treatment. Counselors may 

operate from many different philosophical 

and theoretical orientations and employ a 

variety of therapeutic approaches in individual therapy. The common feature of such sessions is that inmates in a private consultation 

are free to explore more sensitive issues, 

which they might not be ready to discuss in a 

group. Individual sessions also provide a 

place where a counselor can coach inmates on 

relapse prevention techniques such as how to 

recognize specific high-risk situations, personal cues, and other warning signs of 

relapse. 

Like group counseling, individual therapy 

strives to help offenders develop and maintain an enhanced self-image and accept personal responsibility (CASA 1998). It can act 

as an important adjunct to group therapy. 

Additionally, skilled psychologists and social 

workers who offer individual therapy to 

offenders play a role in the development and 

review of a client’s treatment plan. 

Self-help groups 

Self-help groups, found in a majority of State 

and Federal prisons, are frequently a crucial 

component of recovery and can provide a 

great deal of support to recovering offenders. 

Self-help groups provide peer support and 

may serve as therapeutic bridges from incarceration to the community. 

Self-help programs were founded by individuals who found conventional help inadequate 

The Benefits of Self-Help Groups 

•Support for substance abuse treatment and recovery 

•Peer support 

•Healthy peer interaction 

•Therapeutic bridges between the criminal justice system and the community 

•Crisis prevention and management 

•Personal growth 

196 Chapter 9 
or unavailable. These individuals shared 

common problems and a personal commitment to do something about their condition. 

Self-help programs are not considered “services,” which require client dependence on 

providers. Instead, they are programs based 

on a philosophy of self-responsibility. The 

philosophy involves a powerful belief system 

that requires individuals to commit to their 

own healing. For many, this approach has 

proven inspiring and successful. 

A major focus of the self-help approach is 

altering the fundamental beliefs and overall 

lifestyles of participants. By taking responsibility for their own problems, individuals can 

gain control over their situation and develop 

a new sense of self-respect and competence. 

Recovering role models provide support and 

guidance. The entire approach can result in 

far-reaching changes in personal lifestyles 

and social relationships. In general, the selfhelp movement successfully instills the more 

positive aspects of individualism—selfreliance and responsibility—while also stressing the importance of group effort in overcoming common problems. 

The concept of empowerment is perhaps the 

most central to understand the positive effects 

of self-help groups. (For other benefits, see 

previous page.) Self-help processes are geared 

to invoke and develop a sense of personal 

power among members. Empowerment can be 

derived from a “higher power,” from the 

group, or entirely from within the individual, 

where the idea of “bottom line” responsibility 

for the conditions of one’s life teaches members that they have the power to alter their 

lives and living conditions. Self-help groups 

also encourage members to use their personal 

strength to enable others to feel less helpless. 

This, in turn, enhances the power of the 

helper. Since self-help programs are peer centered, they encourage mutual support and 

offer many opportunities for leadership. 

The best known self-help groups are 

Alcoholics Anonymous (AA) and Narcotics 

Anonymous (NA). However, other self-help 

groups may be appropriate, depending on the 

offender’s beliefs, needs, and interests. Other 

groups include Survivors of Incest 

Anonymous, Secular Organizations for 

Sobriety (SOS), religious groups, women’s 

groups, and veteran support groups. One survey found that 74 percent of prison facilities 

offered self-help programs of various types. 

Of those, AA had the strongest representation 

(in 95 percent of those facilities), followed by 

NA (in 85 percent). Less than one third 

offered other types of self-help programs. 

Because of the lack of empirical evidence 

about the effectiveness of self-help programs 

in reducing recidivism and relapse, the consensus panel believes that these groups are 

best viewed as support activities that can 

enhance more structured and intense treatment interventions (CASA 1998). 

At times compulsory self-help group attendance is used as a sanction. The panel feels 

that the compulsory use of any treatment or 

supportive service as a sanction is ill advised 

and can be detrimental to other treatment 

efforts. Moreover, the constitutionality of 

mandatory participation in spiritual-based 

groups has been challenged. When compulsory attendance is a part of the treatment, secular alternatives should be made available. 

Educational and vocational 

training 

Educational and vocational training, in addition to attention to psychosocial and behavioral needs, is a critical dimension that helps 

offenders become responsible family members, employees, and community members. 

The acquisition of skills such as basic literacy, GED certification, and life skills can 

improve employment opportunities and 

improve self-esteem. Such enhancements also 

can help keep inmates from returning to substance-using subcultures and ways of life. 

These services are generally provided by the 

prison and must be closely coordinated and 

monitored by the treatment staff as part of 

case management function. 

Treatment Issues Specific to Prisons 197 
Therapeutic Techniques

Specific therapeutic techniques can be especially helpful in treating the prison population. As 

discussed below, role-playing and video feedback can help offenders improve awareness of 

how others experience and perceive their 

behavior. Other models that have received 

increased attention include motivational interviewing, faith-based initiatives, token economy 

models, and the resurgence of a more traditional medical–pharmacological model that 

includes the development of medications to 

remove the organic effects of cocaine (i.e., 

craving-based treatment interventions). 

Typically, therapeutic techniques are not used 

as standalone interventions but rather blended 

into a treatment approach or model that 

addresses multiple needs with multiple techniques. Also, evaluation studies usually test the 

efficacy of program models such as the TC and 

rarely test the effectiveness of individual treatment techniques. However, the following interventions have been widely used in correctional 

treatment and have gained clinical validity 

among many practitioners. 

Role playing 

Role playing exercises have been used with 

incarcerated populations since the 1950s, 

particularly in residential treatment settings. 

These exercises take advantage of the fact 

that inmates are experienced at playing roles 

negatively and direct that skill toward a positive end. Prior to participation in guided role 

playing, inmates learn the rules and purpose 

of this technique. This approach has been 

Advice to the Counselor: 

Prison Treatment Approaches

• Treatment in prison environments should be organized 

according to empirically supported approaches, such as 

social learning, cognitive–behavioral models, skills training, and family systems. 

• Nondirective approaches, some medical models, and 

those focusing on punishment or deterrence have not 

been shown to be effective. 

particularly effective with perpetrators of violence, as these individuals often remove themselves emotionally from their victims. Using 

role play, inmates often take turns acting as 

both victims and perpetrators. Destructive 

behavior patterns, frequently rooted in childhood, can be evoked and re-experienced. 

This process helps the individual understand 

old patterns to avoid repeating them. Roles 

can also be reversed so that perpetrators 

experience the emotions and thoughts of their 

victims. Habitual offenders typically feel 

remorse not for the crime committed but for 

being caught. Experience of appropriate guilt 

and desires to make restitution for their 

crimes are major goals of role playing 

exercises. 

Video feedback 

Video feedback can be a valuable therapeutic 

tool in correctional rehabilitation. Video feedback allows inmates to “see themselves as others see them.” For example, viewing a tape of 

their intake interview helps inmates cut 

through denial as a result of witnessing their 

own body postures, gestures, and facial 

expressions. Video sessions can also help 

inmates identify different behavior patterns, 

attitudes, and self-images. Inmates who have 

spent their lives on the streets may change 

their self-perception by seeing themselves in a 

video, perhaps dressed in a suit, speaking 

and behaving differently than before. 

Watching tapes of group sessions and of other 

activities, inmates can begin to view themselves differently. This is especially valuable 

for those with poor self-images. 

Inmates may have no access to 

visual images of themselves, 

since full-length mirrors are not

typically available in jail or prisons. Lacking important information for forming an accurate selfimage, an inmate’s problem may 

be less a matter of poor selfimage than of no self-image. In 

such cases, videotapes can play 

an important role in treatment. 

198 Chapter 9 
“Blended” approaches 

The “blended model” recognizes that a melding 

of different approaches and techniques can 

prove effective in prison-based treatment. 

More subtly, the corrections environment itself 

already incorporates a blended approach, simply because the nature of prisons requires 

adaptation of existing structural and security 

concerns. 

Blended approaches expand in-prison treatment offerings to include more innovative 

techniques and treatment modalities. These 

require creativity, the imaginative use of 

available resources, proper identification of 

inmate problem severity (i.e., the more severe 

the inmate’s problem, the more intensive the 

treatment services), support for programming, adequate physical plant and design, 

attention to the impact of activities on classification and movement, cost, monitoring, and 

continued professional development of correctional staff. 

One example of a blended approach program 

is the Residential Substance Abuse Treatment 

located at the South Idaho Correctional 

Institution. It offers a combination of three 

treatment strategies, including cognitive– 

behavioral and 12-Step programming set 

within a TC (Stohr et al. 2001). A unique feature is its target population: parole violators 

who abuse substances. Using qualitative and 

quantitative data collection techniques, an 

initial evaluation team determined it to be 

sound in content and service delivery. 

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 who are 

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. 

Surveys of the membership of Therapeutic 

Communities of America (Melnick and 

DeLeon 1999) and the residential TC programs in the Drug Abuse Treatment Outcome 

Survey (De Leon 2000; Melnick and De Leon 

1999) show high levels of agreement among 

TCs as to the nature of the essential treatment elements including the treatment 

approach, the role of the community as a 

therapeutic agent, the use of educational and 

work activities, the formal elements of TC 

treatment, and the TC process. The standards have undergone field testing conducted 

by the Therapeutic Communities of America 

and the Office of National Drug Control 

Policy. The more than 120 revised standards 

cover 11 domains, from theoretical basis and 

administration to staffing, stages of treatment, and aftercare. 

Goals

The core beliefs and practices of the TC have 

been described in the literature (Bell 1994; 

De Leon and Rosenthal 1989; De Leon 1997, 

2000; Kooyman 1986; Sugarman 1986; 

Wexler 1995; Wexler and Williams 1986). The 

general goals of TCs are (1) decline in or 

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. 

Structure 

Although there is some variation in the structure of these programs, 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 establish routines 

Treatment Issues Specific to Prisons 199 
•Group and individual counseling to work on 

issues of recovery 

•Maintaining recovery and relapse prevention 

•Reentry planning (Peters and Steinberg 2000) 

There is also evidence that prison-based TC 

programs may provide their best results for 

those whose residency extends from 9 to 12 

months (Wexler et al. 1990). Relapse can be 

relatively high, however, if there is no continuity of care provided after release from custody. Research has clearly shown that aftercare in the community is essential to prevent 

relapse and recidivism (Knight et al. 1999b; 

Martin et al. 1999; Wexler et al. 1999a). One 

study found that offenders who were in treatment for 12 to 15 months while in prison, 

combined with 6 months of aftercare, were 

more than twice as likely to be drug-free 18 

months after release than offenders who 

received prison-based treatment alone 

(Inciardi 1996). Offenders who receive aftercare are also less likely to be rearrested in the 

18 months after their release than offenders 

who receive only in-prison treatment (71 and 

48 percent, respectively). 

Program Elements of a TC 

Components

The TC’s daily regimen involves the resident in 

a variety of work, educational, therapeutic, 

recreational, and community activities. Main 

program components are 

• Community meetings, events, and ceremonies 

• Seminars 

• Group encounters 

• Group therapy 

• Individual counseling (both from staff and 

peers) 

• Tutorial learning sessions 

• Remedial and formal education classes 

• Client job-work responsibilities 

• Explicit treatment phases that are designed to 

provide incremental degrees of psychological 

and social learning 

TCs differ from self-help groups, such as AA, 

in that they are structured, hierarchical, and 

highly intense intervention programs while 

AA provides peer support only. The TC treatment experience promotes a sense of camaraderie, safety, and communication as keys to 

transformation from degradation to dignity. 

One of the most complex treatment models to 

implement and operate in a prison, TCs 

require significant changes in the norms, valRod Mullen, founder of the Amity prison TC program, has attempted to define the program elements needed for a TC and suggests that programs that do not meet this standard be identified simply as “residential” 

to avoid indiscriminate use of the TC identification: 

• Twenty-five to 50 percent of the staff should have a substance abuse history and at least 2 years of continual sobriety. 

• The program must emphasize peer leadership and a structure of peer responsibilities and authority. 

• The program must have a defined structure of community ceremonies that occur daily (as well as at other 

intervals), which reinforce the beliefs and mission of the community. 

• Regular encounter groups are held for all participants and confidentiality of the group is a paramount 

community value. 

• All staff members participate in community activities. 

• The emphasis of the community is on the healthy, positive development of all aspects of its members. 

200 Chapter 9 
 

ues, and culture of the environment and a 

great deal of commitment and cooperation 

from prison administration and staff to properly structure and control that environment. 

While residents must take responsibility for 

their own recovery process, treatment staff, 

including ex-offenders, act as role models and 

provide support and guidance. Individual 

counseling, encounter groups, peer pressure, 

role models, and a system of incentives and 

sanctions form the core of treatment interventions in a TC. Residents of the community 

must live together, participate in groups, and 

study together. In the process, inmates learn 

to control their behavior, become more honest with themselves and others, and develop 

self-reliance and responsibility. 

TCs are most often implemented in a residential structure isolated from the general population to provide enough safety and sense of 

belonging to begin the process of change. 

States of anxiety, secrecy, fear, and alienation—conditions permeating the antisocial 

inmate subculture of the general prison population—are antithetical to positive change. In 

fact, separation from the prison subculture 

during treatment has been found to be most 

conducive to achieving major changes in attitudes and behavior. However, the safe TC 

environment, coupled with gains in interpersonal skills, helps offenders relate to the general prison population with the inner strength 

needed to combat the negative cues of the 

prison environment. 

Practitioners note that there can be no 

“watchers” in a TC, only active participants. 

TCs demand the participation of the inmates 

in the emotional, physical, and intellectual 

work required for the process of change and 

personal growth. Work in a TC, as a part of 

treatment, involves an increasing set of 

responsibilities designed to build self-confidence and coping skills. As active participants 

in their own recovery process, inmates learn 

self-sufficiency and competence. Practitioners 

often cite an old maxim that captures the 

essence of the TC philosophy: “Give people a 

fish and they have food for a day. Teach them 

to fish and they can obtain food for a lifetime.” 

TCs depend on the staff and participants’ 

community-building capabilities. The degree 

and intensity of confrontation with participants tends to correspond to the strength of 

the supportive atmosphere of the program. 

Confrontation in prison, for example, may be 

less intense than in a community-based environment, since confrontation can be a threat 

to prisoner codes of acceptable behavior. The 

success of the TC also depends on the collaboration between treatment and corrections 

staff in classification of inmates who are 

appropriately assessed and placed in treatment as well as in the delivery of sanctions 

and removal from the treatment unit. 

Successful Prison-Based TC

Programs

The TC is widely recognized as an effective 

approach that is highly intensive in nature and 

scope, deals effectively with issues related to 

implementation and maintenance, and addresses many of the more important treatment 

issues. Some examples of successful in-prison 

TC programs are described below along with 

references that provide further information. 

Stay’n Out in New York 

The Stay’n Out program was implemented in 

July 1977 as a modified hierarchical TC. 

Stay’n Out began at a time when many other 

in-prison TC programs were closing. Program 

capacity was 120 inmates at the time this 

research was conducted. Residents lived in 

two housing units segregated from the rest of 

the prison population. They had contact with 

prisoners in the general population only when 

off the TC unit (e.g., at the cafeteria, infirmary, library). The Stay’n Out staff comprised mostly persons in recovery with TC 

experience. 

Treatment Issues Specific to Prisons 201 
Figure 9-3 

Stay’n Out Program Outcomes 

Male Graduates Males with No 

reatment 

Femate Graduates Females with No 

T Treatment 

Rearrest 

27 percent 41 percent 18 percent 24 percent 

Source: Wexler et al. 1988, 1990. 

The results of a 3-year outcome study of the 

Stay’n Out prison TC indicate that this program is effective in reducing recidivism rates 

(Wexler et al. 1988, 1990). As summarized in 

Figure 9-3, program completion also 

decreased the likelihood of rearrest. 

Research also found a strong relationship 

between time spent in the program and treatment outcomes. For male inmates who participated in Stay’n Out, the percentage of those 

who had no parole infractions during community supervision rose from 50 percent for 

those who remained less than 3 months, to 

almost 80 percent for parolees who were in 

the program between 9 and 12 months while 

in prison. Similar findings were obtained for 

the females, although the percentages of those 

discharged positively from parole were higher 

than for their male counterparts (79 percent 

for females in treatment less than 3 months, 

92 percent for the 9 to 12 month group) 

(Wexler et al. 1988, 1990). 

Delaware KEY-CREST 

programs 

The KEY-CREST programs, evaluated by the 

Center for Drug and Alcohol Studies at the 

University of Delaware, represent a treatment 

continuum that mirrors the offenders’ custody status (Inciardi et al. 1997). Prisoners 

with a history of drug-related problems are 

identified and referred to the KEY TC program. Following prison release, parolees then 

go to the CREST program, a TC-based workrelease program. Six-month postrelease 

relapse and recidivism rates for graduates of 

both KEY and CREST were significantly 

lower than for program dropouts and a nontreatment comparison group (Martin et al. 

1995; Nielsen et al. 1996). A followup study at 

18 months showed that among those who completed both the prison-based and the workrelease aftercare programs, fewer used drugs 

and were rearrested compared with an 

untreated comparison group (Inciardi et al. 

1997). Outcomes at 3 years were similar, 

although somewhat attenuated (Martin et al. 

1999). A recent study by the Delaware 

Sentencing Accountability Commission has 

confirmed the positive results (SENTAC 

2002). 

Amity prison TC 

Originally established as a demonstration 

project funded by the California Department 

of Corrections in 1989, the Amity TC is located at R.J. Donovan Correctional Facility in 

San Diego, a medium security prison. (See 

Graham and Wexler 1997 and Winnett et al. 

1992 for detailed program descriptions.) The 

prison houses approximately 4,000 men in 

five self-contained living areas. All aspects of 

daily living (e.g., housing, education, work, 

etc.) are accommodated within the confines of 

the prison. One 200-man housing unit is designated for Amity project occupancy. The 

men residing in the unit participate in daily 

programming conducted in two trailers located near the housing unit. 

The program uses a three-phase treatment 

process (DeLeon 1995; DeLeon and Rosenthal 

1989; Wexler and Williams 1986). The initial 

202 Chapter 9 
phase (2 to 3 months) includes orientation, 

clinical assessment of resident needs and 

problem areas, and planning interventions 

and treatment goals. Most residents are 

assigned to prison industry jobs and given 

limited responsibility for the maintenance of 

the TC. During the second phase of treatment 

(5 to 6 months), residents are provided 

opportunities to earn positions of increased 

responsibility by showing greater involvement 

in the program and by focusing on emotional 

issues. Encounter groups and counseling sessions address self-discipline, self-worth, selfawareness, respect for authority, and acceptance of guidance for problem areas. During 

the reentry phase (1 to 3 months), residents 

strengthen their planning and decisionmaking 

skills and work with program and parole staff 

to prepare for their return to the community. 

Upon release from prison, graduates of the 

Amity prison TC may elect to participate in a 

community-based TC treatment program for 

up to 1 year. Residents at this Amity 

Aftercare TC have responsibility for maintaining this facility (under staff supervision) 

and continuing the program curriculum. The 

aftercare TC also provides services for the 

wives and children of residents. 

An evaluation conducted by the Center for 

Therapeutic Research at the National 

Development and Research Institutes, Inc., 

assessed 36-month recidivism outcomes for a 

prison TC program with aftercare using an 

intent-to-treat design with random assignment. Outcomes for 478 felons at 36 months 

replicated findings of an earlier report on 12­

and 24-month outcomes, showing the best 

outcomes for those who completed both inprison and aftercare TC programs (Wexler et 

al. 1999a). For those who completed the TC 

aftercare program, 27 percent had been reincarcerated at a 36-month followup, compared 

to 75 percent for the other groups. 

Researchers also noted a significant positive 

relationship between the amount of time spent 

in treatment and the time until return for the 

parolees who recidivated. However, the 

reduced recidivism rates for in-prison treatment at 12 and 24 months were not maintained at 36 months (Wexler et al. 1999b). 

Texas Kyle New Vision 

Program 

The Kyle New Vision program was the first 

in-prison TC (ITC) developed under 1991 

State legislation that outlined plans for several corrections-based substance abuse treatment facilities in Texas (Eisenberg and Fabelo 

1996). It is a 500-bed facility that provides 

treatment to inmates during their final 9 

months in prison. After release, parolees are 

mandated to attend 3 months of residential 

aftercare in a transitional TC (TTC), followed 

by up to another year of supervised outpatient aftercare. An evaluation conducted by 

the Institute for Behavioral Research at 

Texas Christian University revealed that 3 

percent of those who completed both ITC and 

TTC programs were rearrested within 6 

months of their release from prison, compared to 15 percent of those who only completed the ITC and 16 percent of an untreated comparison group (Knight et al. 1997). 

Furthermore, results from hair specimens 

collected during a 6-month followup indicated 

that fewer of those who completed both the 

ITC and TTC tested positive for cocaine (the 

primary drug of choice for those in the sample), compared to those who completed only 

the ITC and a comparison group (Knight et 

al. 1998). A recently completed study showed 

that TTC completion following the ITC was 

the strongest predictor of remaining arrestfree for 2 years following release from prison. 

Aftercare completion was strongly associated 

with parolee success (Hiller et al. 1999a). A 3­

year outcome study revealed that high-severity aftercare completers recidivated only half 

as often as those in the aftercare dropout and 

comparison groups. These results indicate 

that intensive treatment can be effective when 

it is integrated with aftercare and that the 

benefits of intensive treatment are most 

apparent for offenders with more serious 

crime and drug-related problems (Knight et 

al. 1999b). 

Treatment Issues Specific to Prisons 203 
Federal Bureau of Prisons While not technically a TC program, the 

Federal Bureau of Prisons offers voluntary 

residential treatment programs, or Drug 

Abuse Programs (DAPs), for alcohol and 

drug problems that use some of the features 

of the TC model. Inmates participate in a 

total of 500 hours of treatment over a 9­

month period and programs have 1 staff 

member for every 24 inmates. Program goals 

are to identify, confront, and alter the attitudes, values, and thinking patterns that led 

to criminal behavior and substance abuse. 

This is accomplished through a unit-based 

approach (whereby program participants are 

segregated from the general population to 

build a treatment community), and also 

through standardized program content that 

includes 450 hours of programming using 

modules devoted to a variety of subject areas. 

Though initially implemented without incentives, the passage of time saw the introduction 

of financial achievement awards; consideration for a full 6 months in a halfway house for 

successful DAP program completion; and tangible benefits such as shirts, caps, and pens 

with program logos. The passage of the 

Violent Crime Control and Law Enforcement 

Act of 1994 allowed eligible inmates with successful completion rates to reduce as much as 

a year from their statutory release dates. 

The second component is graduate maintenance, an 8-week program for those who completed the initial component. Skills are reinforced from the first component and transition plans are initiated. The third and final 

component, aftercare, provides services from 

completion of graduate maintenance to 

release from department custody. This component attempts to reinforce attitudinal and 

behavioral changes that occurred during the 

first three phases. Transition plans are regularly reviewed, placements for inmates in 

community-based programs are completed, 

and tracking occurs for all inmates at regular 

intervals. 

Specific Populations in

Prisons

Co-Occurring Substance Use 

and Other Mental Disorders

Despite the high incidence of co-occurring 

mental and substance use disorders, few programs for inmates with co-occurring mental 

and substance use disorders currently operate in prisons. Edens and colleagues (1997) 

found fewer than 10 operational programs 

that were designed for this population (see 

next page for a description of one such program), although several State correctional 

systems reported that similar programs were 

being planned. A number of common elements of these programs included phased program interventions, a focus on destigmatizing 

mental disorders, the use of psychoeducational interventions, involvement of mental health 

staff in major program activities, and the use 

of relapse prevention approaches. 

Sex Offenders

In 1999, nearly 9 percent, or 100,800, of the 

1.2 million inmates in State prisons were 

incarcerated on sex-related offenses: 2.6 percent (29,600) for rape and 6.2 percent 

(71,200) for other sexual assault (Burdon et 

al. 2001). Among incarcerated sex offenders, 

two of every three have a history of alcohol or 

substance use, abuse, or dependence (Peugh 

and Belenko 2001). 

Given their prevalence in the prison population, as well as the high rate of substance 

abuse, in-prison substance abuse treatment 

programs are likely to be treating a number 

of sex offenders. Burdon and colleagues 

(2001) identified several barriers to successful 

treatment of sex offenders in correctional 

institutions: 

•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 

204 Chapter 9 
San Carlos Correctional Facility—A TC Modified for 

Offenders With Mental Illness 

In response to the increasing number of inmates with co-occurring substance use and other mental disorders, the Colorado Department of Corrections contracted with a private not-for-profit agency to 

develop the Personal Reflections Therapeutic Community program at the San Carlos Correctional 

Facility in Pueblo (Sacks et al. 2001). Based on evidence of the effectiveness of the TC approach for cooccurring disorders implemented in a community-based setting (De Leon et al. 2000), the San Carlos 

program, a Modified Therapeutic Community (MTC), uses TC principles and methods as the foundation 

for recovery. Modifications from traditional TCs include smaller caseloads, shortened and simplified 

meetings, and minimized confrontation. In addition, the MTC contains components to address criminal 

thinking and to provide medication education. 

The goal of the program is to use a positive peer culture to foster personal change and to reduce the 

incidence of return to a criminal lifestyle. The inmates progress through program stages, typically moving from orientation to primary treatment (“family” phase) and then preparation for re-entry to the 

community at large. Upper level inmates in the MTC program function as a positive peer leadership 

group, or “structure,” to guide and support newer members as they begin to develop and apply new values, beliefs, and skills to their daily lives. Thus the San Carlos TC, modified for the mentally ill population, functions as a healthy family for its members, reinforcing affiliation with the recovery community. 

A NIDA-funded evaluation of MTCs showed significantly better outcomes on self-reported crime and 

arrests for the MTC group as compared to standard mental health and nontreatment groups. The best 

outcome was for the MTC group that also received TC aftercare. In response to such results, a CSAT 

Community Action grant supported an initiative to improve services for released offenders with histories 

of substance abuse and severe and persistent mental illness (Wexler 2001). Preliminary cost analysis 

indicates that the incremental (or additional) costs of prison MTC programs for offenders with co-occurring disorders are low compared to both the overall costs of incarceration and the additional cost of services for people with co-occurring disorders in the general prison population (Sacks et al. 2001). 

treatment staff. This leads to extreme secrecy and fear of self-disclosure based on a 

legitimate fear for their own safety. 

•Untrained and inexperienced staff. Most 

treatment staff members 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 or special certification, 

although it will entail increased treatment 

costs associated with compensation to 

ensure their longevity. 

•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 

clinical sex offenders. The different classifications of those who have committed sexrelated offenses and those diagnosed with 

sex-related disorders makes identification 

more difficult for providers. Currently, the 

sole criterion for identification is the 

inmate’s criminal record. Because some 

individuals are likely to be recommended 

for highly specialized treatment and may 

not need it, this criterion may result in an 

inefficient use of resources. 

One proposed model is to provide effective 

treatment by differentiating between legal and 

clinical offenders and then offering treatment 

to clinical sex offenders. Steps in this process 

include identifying those sex offenders suitable for treatment, identifying the appropriTreatment Issues Specific to Prisons 205 
 

ate treatment modality, and maximizing success by providing needed aftercare (Burdon 

et al. 2001). More detailed information on sex 

offenders is in chapter 5, Major Treatment 

Issues and Approaches. 

Older Inmates

In recent years, the number of inmates in 

State and Federal prisons aged 55 and older 

has increased dramatically. Between 1995 and 

2003 that number has increased approximately 85 percent, so that as of 2004 there were 

27,700 prison inmates over the age of 55 

(Harrison and Beck 2004). Many, though not 

all, of these inmates have spent much of their 

lives in prison. The 1994 Crime Bill ratifying 

the “three strikes and you’re out” provision 

could increase these numbers substantially as 

it becomes a more fully utilized sentencing 

option. 

As a distinct cultural subgroup, lifers have 

spent much of their adulthood in “total institution” environments with unique features. 

Among them are the physical barriers to the 

outside world, the development of a unique 

way of life, or “prison culture,” which precludes “normal” interactions and social activities found on the “outside.” This stressful, 

unnatural situation can produce what 

Goffman (1961) termed “disculturation,” 

wherein prison rules and mores have outweighed those of the outside world. Over prolonged periods, the implications for inmate 

self-concept and autonomy may be more pronounced. 

Additional “disculturative” changes can occur 

relating to family, employment, and sexual 

identity. Although all inmates face these challenges upon incarceration, the aging inmate 

faces the imminent probability that a traditional life cycle will be seriously altered. 

“Time that might have been spent in 

Use of “Lifers” as Peer Counselors at Amity 

In 1990, the Amity prison TC at the R.J. Donovan Correctional Facility, a medium security facility, began 

to accept offenders who were under life sentences (i.e., “lifers”) as counselors in its substance abuse treatment program. It remains one of a handful of programs in the country to do so. 

Lifers were accepted as members of the counseling staff because they could provide stability to the program and ensure its continuity. They are available to program participants 24 hours a day, unlike staff 

from outside the prison, and can have a vital role in keeping a community alive and helping to hold its 

members responsible for their behavior. Because these are individuals who have considerable respect in 

the prison community, they are able to help keep participants in the program safe and out of situations 

that can cause them trouble. 

The program is selective about who can become a counselor; all counselors have to be graduates of the 

program and then complete a 2-year internship. They must be individuals who have the respect of their 

peers and demonstrate high levels of motivation. The program also ensures that this group represents 

the racial demographics of the prison population. 

Programs that are considering using lifers should already have trained staff who are experienced working with this particular subpopulation. The culture of lifers is unique within the prison system, and the 

problems they face are also often different. These are individuals whose home, for much (if not all) of 

the rest of their lives is the prison. Becoming a counselor enables lifers to make personal restitution for 

past acts by helping others, which they may never have the opportunity to do so outside the prison environment. During followup interviews, many of the successful program participants mentioned that lifers 

had been important influences in their recovery (Wexler et al. 1999a). 

206 Chapter 9 
 

courtship, marriage, raising children, career, 

education, travel, pursuit of personal talents, 

and activities with friends never can be reestablished” (LaMere et al. 1996, p. 27). The 

usual milestones to measure success and adult 

rites of passage are systematically denied the 

aging inmate, thus producing a sense of social 

disconnection. 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 (see previous 

page) is an example of a treatment approach 

that can be beneficial to both the aging prison 

population and its younger peers. 

Systems Issues

Coerced Treatment 

In prison, coerced treatment may come as a 

result of a sentence mandating treatment or 

as a result of a prison policy mandating treatment for inmates identified as having substance use disorders. Still, prison-based programs generally do not have significant incentives for parolees or probationers who enter 

treatment as a means to avoid prison. 

Research indicates that treatment adherence 

and outcomes are the same among those 

coerced into treatment and those who entered 

treatment voluntarily (Miller and Flaherty 

2000). In terms of prison-based treatment 

programs, Wexler and colleagues (1996) 

reported that these programs are often the 

only (emphasis added) treatment opportunities for offenders. Two key issues regarding 

treatment of offenders are time spent in treatment and engagement in the process. Coerced 

treatment can force inmates to begin a treatment episode, but the program must be able 

to engage them in a meaningful rehabilitation 

process. The longer the inmate remains in 

treatment, the greater the likelihood for success (Hubbard et al. 1988; Simpson 1984; 

Wexler 1988). Without treatment, the likelihood of continued drug use and criminality 

after release increases considerably (Lipton 

1994). 

Sanctions and Incentives

A hierarchy of specific sanctions (that notes 

the type and duration of each sanction) can 

be used in conjunction with treatment incentives and rewards to improve treatment outcomes. TIP 12, Combining Substance Abuse 

Treatment With Intermediate Sanctions for 

Adults in the Criminal Justice System (CSAT 

1994a), gives a more detailed overview of 

sanctions and their effective use. 

Offenders need to be responsible to their individual treatment plans and held accountable 

to the treatment program’s rules. They must 

know the consequences of noncompliance and 

poor progress and understand that treatment 

programs have certain unbreakable or “cardinal” rules (e.g., no violence or intimidation). The penalties for breaking rules that 

are intended to guide behavior can include 

dismissal from the program or revocation of 

privileges. Sanctions should be applied consistently for positive drug tests, no-shows for 

treatment, prohibited behavior, or broken 

program rules. Penalties should be specifically spelled out, so there is no doubt in the 

client’s mind regarding the consequences of 

specific misbehavior. Accountability also 

includes objective measures and monitoring 

as a basis for measuring the client’s progress 

and determining the need for reassessment. 

Rule infractions (other than “cardinal rules”) 

are best seen as opportunities to learn more 

appropriate and effective behaviors. This 

treatment or learning perspective is in contrast to the traditional correctional view of 

adjudication and punishment. It is important 

to provide opportunities for “failed” clients to 

reapply to the program when possible. Often, 

a program failure can be a learning experience that leads to increased motivation and 

desire for a “second chance.” Given that 

addiction is a chronic, recurring condition, 

multiple treatment episodes are more the 

norm than the exception. 

Just as sanctions clearly establish a series of 

consequences for designated behaviors, incentives should be offered to inmates who adhere 

Treatment Issues Specific to Prisons 207 
to the program rules, to recognize small 

accomplishments. Possible incentives include: 

•Recognition ceremonies 

•Awards 

•Preferred meals 

•Special desserts 

•T-shirts, coffee mugs, or other small gifts 

•Modified uniforms (which contributes to a 

positive environment) 

•Deviations from the standard curriculum 

including seminars, music, and sports 

•Financial rewards 

•Increased privileges 

•Safe housing units 

•Additional recreation time 

•Positive parole board review 

•Return of children to their mothers 

Wherever possible, problems of attrition and 

noncompliance should be anticipated early 

enough in the treatment process to avert 

them. The panel believes that coordination 

and communication between the treatment 

counselor and criminal justice staff are crucial in this process. For example, the treatment counselor can use a proactive attitude 

and alert the criminal justice representative 

when noncompliance occurs, long before a 

client is actually expelled from a program, if 

it appears that a situation leading to this outcome is developing. It is also helpful if the 

treatment counselor and criminal justice representative discuss certain general trends in 

advance. Such particulars as retention rates, 

the most likely dropout points, and relapse 

rates in various stages of treatment can be 

used to alert case managers in other systems 

to potential problem periods and when they 

are likely to occur. 

Disincentives for Inmate 

Participation

Despite these incentives, there are factors— 

both perceived by the inmate and inherent in 

the system—that the panel believes may discourage involvement in a residential treatment 

program: 

•Increased surveillance on the job and in the 

treatment program. This includes the justification for increased urinalysis during 

treatment and posttreatment phases. 

•The requirement and pressure to stop using 

drugs. Although prevalence levels are lower 

in prison than the general population, there 

is still substance use and when enrolled in 

treatment, the offender must confront the 

necessity of having to stop using drugs. 

•Loss of relationships. Women especially may 

resist treatment because they have the perception that participation could result in 

the loss of in-prison intimate relationships. 

•Loss of income. Often it is a requirement to 

give up prison jobs in order to enter treatment. 

•Peer (or yard) pressure. Offenders can face 

physical threats of violence if they participate in treatment. 

•Lack of treatment continuum. Intensive 

treatment inside the prison is of limited use 

if there are no services available upon 

release. Furthermore, it is critically important to build upon previous treatment 

rather than forcing a newly released inmate 

graduate to start over in the community 

program. 

•Treatment length and modality. If treatment is not linked to inmates’ needs, 

inmates are more likely to drop out. For 

example, often an offender who has serious 

substance abuse problems and is in need of 

a structured environment is placed in a 12­

Step program on a voluntary basis, whereas 

a person who only occasionally uses substances is inappropriately placed in a longterm TC or other residential program. 

•Lack of desire to help one another. For 

many offenders, the key to doing prison 

time is to get through it without any extra 

output of energy to help others (e.g., “I’m 

doing my time. I’m not doing his time.”). It 

is not selfishness per se but rather part of 

prison culture. 

208 Chapter 9 
Advice to the Counselor: 

Heading Off Noncompliance 

• Counselors can take a proactive attitude and alert the 

criminal justice representative when noncompliance 

occurs before a client is expelled from a program. 

• The treatment counselor and criminal justice representative can identify the most likely program dropout points 

to alert case managers to potential problems in the 

system. 

The consensus panel encourages 

treatment providers to understand the operational responsibilities of the justice system, the 

importance of public safety, and 

the security concerns that are at 

the heart of criminal justice. 

Criminal justice personnel should 

understand the dynamics of substance abuse treatment and its 

potential to reduce recidivism and 

relapse. Without these training 

•Limited treatment resources. There are 

often problems associated with convincing 

inmates to engage in treatment. One problem is the lack of trained staff and available 

modalities. Additionally, treatment programs often do not offer incentives. In fact, 

some incentives (e.g., work furloughs) are 

removed, which acts as a disincentive to 

enter treatment. 

•Stigma. Many inmates want treatment, but 

do not necessarily want to be put in programs that may cause them to have low status in the inmate culture. 

•Mandatory sentences that prohibit early 

release. Increasingly, in an effort to appear 

ever tougher on crime, politicians and policymakers are removing early release opportunities by legislating mandatory sentences 

that require inmates to serve their full 

terms, reducing or eliminating good time 

credits, or being more stringent in Parole 

Board decisions. Without the incentive of 

early release, inmates are less likely to voluntarily enter and remain in prison treatment programs. 

Staff Training and

Cross-Training 

Cross-training for both criminal justice and 

substance abuse treatment staff can improve 

the effectiveness of program administration 

(Farabee et al. 1999). Treatment providers 

and custody staff often become familiar with 

the philosophy, approach, goals, objectives, 

language, and boundaries of both systems. 

safeguards in place, the custody 

concerns of the correctional facility will often 

overwhelm the concerns of the treatment program (Farabee et al. 1999). Some of the training issues include confidentiality, relapse prevention, infectious diseases, co-occurring disorders, and cultural competence. 

Other concerns regarding recruitment and 

training of staff include the difficulty of hiring qualified staff in the remote areas where 

prisons are built; the lack of experience in 

criminal justice settings on the part of most 

counselors; and the perennial concern about 

high turnover rates and the lack of experienced counselors, especially given the limited 

ability to hire individuals in recovery as 

counselors (Farabee et al. 1999). In addition, 

Department of Corrections contracts frequently have restrictions based on criminal 

history that narrow the eligible pool of 

employment applicants. 

Gender-specific training 

The panel stresses that training should review 

the latest theories and findings on men’s and 

women’s issues in treatment. For counselors 

working with men, special focus should be on 

anger management and relational violence. 

Staff should learn theories of male development and explore key issues influencing men’s 

substance abuse—societal gender roles, family, relationships, rage and violence, abuse 

and trauma, and educational and vocational 

issues. In addition, staff need to become 

familiar with the prison culture specific to the 

Treatment Issues Specific to Prisons 209 
program’s geographic location, for example, 

race and gang issues, “the convict code,” and 

prison slang. Knowledge and understanding 

about these issues ensures greater impact and 

provides staff deeper insight into incarcerated 

men’s barriers to recovery. 

Staff working with incarcerated women 

should be familiar with theories of female 

development and consider ways that treatment programs can address the central 

importance of relationships for women. 

Training should also 

explore key issues 

influencing women’s 

Criminal justice 

personnel should 

understand the 

dynamics of 

substance abuse 

treatment and its 

potential to 

reduce recidivism 

and relapse. 

substance abuse— 

family, parenting, 

relationships, self-

sufficiency and life 

skills, anxiety and

depression, grief 

and loss, abuse and

trauma, educational 

and vocational 

issues, and societal 

gender roles. 

Expertise in these 

areas will help 

develop a quality 

program focused on 

helping incarcerated

women recover and 

successfully re-enter

their communities. 

Further information 

on gender training is 

in chapter 6. Two forthcoming TIPs will also 

provide detailed information on gender training, Substance Abuse Treatment and Men’s 

Issues (CSAT in development f) and 

Substance Abuse Treatment: Addressing the 

Specific Needs of Women (CSAT in development g). 

Recommendations and

Further Research

The following are the consensus panel’s recommendations regarding treatment in prisons: 

Recommendations

• In-prison treatment for substance abuse can 

reduce recidivism. 

•In general, treatment programs based on 

social learning, cognitive–behavioral models, skills training, and family systems 

approaches are more effective than nondirective programs or those using punishment 

or deterrence. 

•Successful programs provide a variety of 

intensive services that use several 

approaches and create a prosocial environment. 

•Nine to 12 months of treatment in a TC is 

the recommended duration for reducing 

recidivism, although a noticeable improvement in recidivism is noted after 3 months. 

•To sustain the gains achieved in in-prison 

TCs requires supervision in an aftercare 

program in the community. 

•TCs can be adapted to make them more 

appropriate for female inmates. 

•Quality assurance models are needed for 

assessing prison treatment. 

•The needs of incarcerated women (and their 

children) have to be better understood, 

with an emphasis on reintegrating the family when appropriate and developing marketable skills. 

•As the number of people with co-existing 

substance use and other mental disorders in 

prisons expands, treatment models that 

integrate the best mental health and substance abuse treatment practices need to be 

developed and tested. 

•The mental health and substance abuse literature on co-occurring disorders has identified the modified TC as a promising treatment model. 

210 Chapter 9 
•Issues of aftercare and continuity of care 

are especially relevant to offenders with cooccurring disorders, who are particularly in 

need of continuing treatment to stabilize 

their positive gains and to promote integration with the mainstream community. 

•Restructuring the prison environment to 

address education and employment, particularly for inmates with longer sentences, 

can dramatically improve prison security, 

programming, and outcomes. 

•Providers should develop innovative aftercare programs that incorporate recovery, 

employment, and educational best practice. 

Continuity of vocational goals should be 

identified early on and followed throughout 

the various phases of client reintegration 

from prison to community residential and 

aftercare outpatient treatment. 

Further Research

In-prison substance abuse treatment, particularly when followed by community-based continuing care, has been credited with reducing 

short-term recidivism and relapse rates 

among offenders who are involved with illicit 

drugs. More recently, the sustained effects on 

longer-term outcomes have been documented 

by studies conducted in California, Delaware, 

and Texas. There is a growing credibility of 

the idea that “treatment works,” which is 

replacing the older belief that “nothing 

works” in prison rehabilitation. 

However, the benefits of treatment can vary 

greatly depending on the inmate being treated 

and the services being provided. The consensus panel believes it is critical that research 

now focus on determining which inmates benefit the most from the different types of treatment programs being offered in prison. For 

example, should intensive treatment programs such as TCs give admission priority to 

inmates with the most severe problems? Are 

better educated inmates best treated with a 

cognitive–behavioral approach? Is it better to 

develop stand-alone in-prison treatment facilities? 

There is considerable research that shows 

that at least 3 months of community treatment and 9–12 months of prison treatment 

are needed to produce significant improvement and reductions in recidivism and 

relapse. The critical need for adequate treatment duration has been demonstrated. What 

is not known is whether postprison treatment 

alone can be effective and how much time in 

aftercare following prison treatment is needed. Currently, in-prison drug treatment programs vary considerably in length: from 4 

months to 2 years. Also, given the importance 

of aftercare, can similar outcomes be 

obtained with a shorter duration in-prison 

treatment program if inmates are mandated 

to a comprehensive postrelease aftercare program? 

Treatment and aftercare 

research questions 

•A clear understanding of the treatment 

“black box” remains elusive; models that 

describe effective treatment processes need 

to be developed and tested. 

•The organizational and system dimensions 

of treatment need to be studied and understood to foster the implementation and 

maintenance of treatment networks within 

complex correctional systems. 

•Researchers should examine the contribution of pharmacotherapy to treatment outcomes among prisoners. 

•Although prison evaluation studies of 

women have shown positive treatment 

effects, more research is needed to study 

treatment engagement, process, and costs 

versus benefits for this population. 

•Consideration needs to be given as to 

whether aftercare alone is capable of significantly reducing recidivism and relapse following prison. 

•Researchers should investigate the effect of 

shorter term prison treatment with and 

without aftercare. 

Treatment Issues Specific to Prisons 211 
•Researchers should consider the optimum 

combination of duration of both in-prison 

and aftercare treatment. 

•Researchers need to determine what the 

best treatment models are for dealing with 

the inherent geographic dispersion of 

offenders after their release from prison. 

•Research is needed to evaluate the costs and 

cost-benefits of prison treatment and aftercare. 

212 Chapter 9 
 

10 Treatment for

Offenders Under

Community

Supervision

In This
 

Chapter... 

The Population 

Levels of Supervision 

Treatment Levels and 

Treatment Components 

What Treatment Services 

Can Reasonably Be 

Provided for People 

Under Community 

Supervision? 

Treatment Issues for 

People Under Community 

Supervision 

Treatment Issues Specific 

to People on Parole 

Treatment Issues Specific 

to Probationers 

Strategies for Improving 

System Collaboration 

Sample Programs 

Conclusions and 

Recommendations 

Overview 

Substance abuse treatment for parolees and probationers differs from 

treatment for people in jail or prison. Although their freedom is curtailed, they have greater access to drugs and alcohol than the incarcerated population, and hence more opportunities to relapse. Moreover, 

securing basic needs such as food and shelter is often of paramount 

importance, especially for parolees attempting to reintegrate into 

society. 

After describing the population under discussion in this chapter, the 

text takes up levels of supervision and treatment. Next, the discussion 

provides a broad look at the services needed by probationers and 

parolees and examines the treatment issues that are specific to offenders 

under community supervision. The chapter then suggests strategies that 

are helpful in improving collaboration between the substance abuse 

treatment and criminal justice systems. Finally, the chapter presents 

descriptions of sample programs. 

The offenders discussed in this chapter also are discussed elsewhere in 

the TIP. Probationers, for example, are often sentenced through the 

drug courts described in chapter 7, Treatment Issues in Pretrial and 

Diversion Settings. Indeed, much of the material in chapter 7 is applicable to the probation population. Many probationers also have spent 

time in jail, as discussed in chapter 8, Treatment Issues Specific to 

Jails. Chapter 9, Treatment Issues Specific to Prisons, describes the 

prison culture that parolees left upon release. In order to acquire an 

understanding of the full range of issues that affect the treatment of 

offenders under community supervision, the reader is advised to consult these other relevant chapters. 

213 
The Population

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. 

Despite their differences, parolees and probationers often share a history of drug or alcohol use. Approximately two thirds of probationers can be characterized as alcohol- or 

drug-involved offenders (Mumola and 

Bonczar 1998), while almost 74 percent of 

State prisoners expected to be released 

between 2000 and 2001 were drug- or alcoholinvolved (Beck 2000c). Parolees and probationers also are alike in that their freedom is 

conditional; both groups must meet certain 

conditions in order to avoid incarceration or 

reincarceration. Often, treatment for drug or 

alcohol dependence is one of those conditions. 

The number of people under community 

supervision has increased over the past 

decade. More than 4.8 million individuals 

were under community supervision in 2003, 

compared to 3.8 million in 1995. The parole 

population has been the slowest growing since 

1995, with an average annual rate of 1.7 percent; however between 2002 and 2003, the 

growth rate nearly doubled to 3.1 percent 

(Glaze and Palla 2004). 

Despite the shared experience of individuals 

under community supervision, as Figure 10-1 

indicates, parolees and probationers differ 

considerably. 

Levels of Supervision
 While both probationers and parolees are 

under community supervision, the level of 

supervision varies according to individual circumstances. These differences are described 

below. 

Intensive Supervision

Intensive supervision generally involves frequent contact with supervising officers, frequent random drug testing, strict enforcement of probation or parole conditions, and 

community service. The level and type of 

supervision that are labeled intensive vary 

widely but usually require closer supervision 

and greater reporting requirements than regular probation. Contacts can range from 

more than five per week to fewer than four 

per month. Conditions usually include having 

a job or attending school, and participating in 

treatment. Intensive supervision parole has 

similar requirements and variations for 

offenders completing their sentences in the 

community. 

Intermediate Supervision

Compared to traditional supervision, intermediate supervision can include increased 

drug testing, short jail stays, increased 

reporting to criminal justice staff, referral to 

day reporting centers, attending 12-Step 

meetings, community service requirement, 

curfews, work release centers, electronic 

monitoring, and more frequent home visits. 

Treatment Levels and

Treatment 

Components

Chapter 3, Triage and Placement in 

Treatment Services, provides detailed information on selecting an appropriate treatment 

level. This section builds on the material in 

chapter 3 to provide information specific to 

offenders under community supervision. 

Placement will depend on a number of factors, including the duration and severity of 

the offender’s substance use as well as the 

crimes committed. The level of treatment services recommended for the offender should be 

individualized and based on a multidimensional, diagnostically driven assessment; clini214 Chapter 10 
Figure 10-1 

Comparison of Probationers and Parolees 

Probationers Parolees 

Number (as of December 31, 2003) 4,073,987 774,588 

Gender (as of December 31, 2003) 77 percent male 

23 percent female 

87 percent male 

13 percent female 

Race/Ethnicity (as of December 31, 

2003) 

African American 

Hispanic/Latino (can be of any 

race) 

Caucasian 

30 percent 

12 percent 

56 percent 

41 percent 

18 percent 

40 percent 

Crimes 24 percent for drug law violation 

17 percent for driving while 

intoxicated 

40 percent for drug offenses 

24 percent for violent offenses 

Drug or alcohol involved 83 percent (based on State prisoners expected to be released by the 

end of 1999) 

74 percent (based on State prisoners expected to be released 

between 2000 and 2001) 

Mental illness 13.8 percent 14.3 percent 

Parole/probation violations led to 

incarceration/reincarceration in 

1998 

17 percent incarcerated 42 percent reincarcerated 

Drug/alcohol treatment as condition of release 41 percent N/A 

Mandatory drug testing 32.5 percent N/A 

Sources: Beck 2000b; Ditton 1999; Glaze and Palla 2004; Hughes et al. 2001; Mumola 1998; Office of 

National Drug Control Policy (ONDCP) 2003. 

cal judgment; and availability of resources in 

a given community. 

Residential

Residential treatment for those supervised in 

the community incorporates several 

approaches involving cooperative living for 

people receiving treatment. The most used 

residential model is the therapeutic community (TC), which provides a well-controlled, 24­

hour, structured treatment environment. (See 

chapter 9 for a discussion of prison-based 

TCs.) 

Some programs provide services for 8 or 

more hours a day, 5–7 days a week, with clinical staff available days and evenings. Other 

residential programs are recovery homes for 

employed offender-clients, with evening and 

weekend treatment and limited onsite staff. 

Facilities may include hospitals or hospitalTreatment for Offenders Under Community Supervision 215 
based programs, institutional housing, sections of apartment complexes, and dormitorylike 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. Residents collaborate on chores, laundry, and meal preparation with the aim of 

participation in problemsolving, goal setting, 

and improving cooperation and communication skills. Residential treatment should be 

followed by continued care in an outpatient 

setting. 

Outpatient 

Outpatient treatment for probationers and 

parolees can be provided to many more 

offenders for the same level of funding as residential treatment. It ranges from traditional 

outpatient services provided by treatment 

professionals in regularly scheduled sessions 

in a group or individual setting, to intensive 

outpatient treatment several hours per week. 

Because outpatient treatment tends to be 

more intense in community settings than in 

correctional institutions, offenders may be 

receiving more intense treatment than during 

incarceration. Intensive outpatient treatment 

includes day or evening programs in which 

clients engage in a full spectrum of services 

while living at home or in a special residence. 

For more details on this level of care, see 

chapters 3 and 5 of this TIP, as well as the 

forthcoming revised TIPs, Substance Abuse: 

Clinical Issues in Intensive Outpatient 

Treatment for Alcohol and Other Drug Abuse 

(Center for Substance Abuse Treatment 

[CSAT] in development d) and Substance 

Abuse: Administrative Issues in Intensive 

Outpatient Treatment (CSAT in development c). 

Within a treatment continuum, intensity 

decreases over time as the individual meets 

treatment goals. Offenders may initially be 

placed in residential settings, followed by 

intensive outpatient treatment and continuing 

care. With institution-based treatment as a 

foundation, outpatient services in the community can help offenders to continue working 

on their problems and developing social and 

work skills in group processes familiar to 

them from their earlier treatment experience. 

Halfway Houses

Halfway houses are transitional facilities 

where clients are involved in schoolwork, 

work, training, and other activities that do 

not necessarily include any drug abuse treatment when run by the criminal justice system. 

The 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). Some 

clients need halfway houses that can help 

them stabilize or maintain recovery as they 

enter society. Usually these programs provide 

individual counseling along with group, family, or couples therapy. Offenders can leave 

the facility for work, school, or therapy but 

are otherwise restricted to the halfway house, 

Dallas County Judicial Treatment Center: A Sample 

Community-Based Substance Abuse Treatment Program 

Dallas County, Texas, established a residential substance abuse treatment program for probationers to 

relieve prison overcrowding. Based on a modified therapeutic community with a 12-Step component, it 

included basic substance abuse treatment, life-skills training, drug education, and group counseling. 

After 1 year, arrests for program graduates were one half of those for probationers who were expelled 

or transferred. Those who participated in a residential aftercare program had even lower arrest rates 

(Knight and Hiller 1997). 

216 Chapter 10 
which is in the community but can be 

attached to a jail or other correctional institution. House responsibilities are shared and 

rules must be followed. The length of stay 

may be related to sentence length and depend 

on individual progress toward specific goals. 

Day Reporting 

Day reporting centers are facilities to which 

offenders must report in person or by phone 

from a job or treatment site as part of their 

larger supervision plan. The regular reporting back to probation or parole officers mandated under this intermediate sanction is 

aimed at monitoring offender movements or 

incapacitating them. Reporting must be done 

at specified times, often throughout the day. 

Day centers may include assessment for special needs and such services as anger management, drug testing, General Equivalency 

Exam (GED) preparation, drug and medical/mental health treatment, violence prevention, community service, and vocational 

training. 

Some day centers primarily function as staging areas from which offenders are sent out in 

work crews to perform manual labor in the 

community: cleaning highways, painting 

schools, etc. Others offer chiefly educational 

opportunities. In many jurisdictions, day centers have become day treatment centers 

whose primary mission is to provide outpatient alcohol and drug abuse treatment of 

various intensities. Public or private treatment agencies or correctional agency staff 

may provide the treatment. 

Treatment Components

Substance abuse is a chronic, relapsing disorder influenced by numerous interacting biological, psychological, and social factors. To provide treatment addressing these factors, the 

consensus panel believes that a full range of 

services should be available, which might 

include components from the following list: 

•Screening and assessments—medical, psychiatric, and substance abuse (see also 

chapter 2, Screening and Assessment) 

•Detoxification (see also the forthcoming TIP 

Detoxification and Substance Abuse 

Treatment [CSAT in development a]) 

•Medical assessment—pregnancy tests and 

treatment for HIV and AIDS, other sexually transmitted diseases, and tuberculosis 

(see also chapter 2, Screening and 

Assessment) 

•Full-range medical treatment 

•Treatment planning—medical, psychiatric, 

and substance abuse (see chapter 4, 

Substance Abuse Treatment Planning) 

•Counseling—group, individual, family, couples (see chapter 5, Major Treatment Issues 

and Approaches) 

•Residential treatment for substance abuse 

•Substance abuse education—didactic lectures, interactive groups, videos, reading 

assignments, and journal-writing assignments 

•Relapse prevention services 

•Crisis intervention 

•Drug testing and monitoring 

Salt Lake City, Utah: A Sample Day Reporting Center 

The day reporting center in Salt Lake City, Utah, has been operating since 1994. It serves high-risk/highneed offenders who abuse substances and who have had technical violations or committed new offenses 

while on probation or parole. Program activities are designed to reduce recidivism and enhance recovery by 

improving coping skills, preventing relapse, improving job and employment skills, and promoting a smooth 

reentry to the community. A study of offenders who attended and were discharged from the program during 

a 1-year period showed that these individuals had fewer property crime offenses, fewer criminal charges, 

and less substance use in their first year after discharge. A longer stay was associated with better positive 

outcomes up to 120 days, after which the effect diminished (Bureau of Justice Assistance 2000). 

Treatment for Offenders Under Community Supervision 217 
 

 

•Self-help education and support 

•HIV/AIDS education, testing, and counseling 

•Comprehensive pregnancy management— 

prenatal care and parenting classes and/or 

childbirth classes 

•Mental health services—medications when 

indicated 

•Social and other support services for the 

offender and family members 

•Vocational and educational training 

•Family services unrelated to substance 

abuse treatment 

•Assistance in managing entitlements (e.g., 

food stamps, veterans benefits) 

•Acupuncture and other nontraditional 

adjuncts 

•Housing assistance 

Additional services may be needed to address 

sexual abuse, child abuse, domestic violence, 

victimization, guilt and remorse, and family 

problems. These can be coordinated on an 

individual basis through case management and 

collaboration among system practitioners. 

What Treatment 

Services Can

Reasonably Be 

Provided for People 

Under Community

Supervision? 

Parolees and probationers receive similar services in community supervision. This section 

highlights the panel’s recommended treatment 

options for both populations. 

Basic Needs

Parolees and probationers often cannot meet 

their basic needs. In some situations, treatment 

cannot begin until such fundamental needs as 

housing and employment are met. In other 

cases, such as when the client cannot maintain 

prolonged abstinence or when detoxification is 

needed, the client should be engaged in treatment before he or she receives assistance in 

locating housing or a job. 

Housing 

A lack of housing for offenders under community corrections supervision is a major problem in most jurisdictions; yet stable living 

arrangements are crucial to treatment. 

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 a halfway house, a 

“sober house,” or recovery house are better 

alternatives than the offender-client’s home. 

Attention to residential resources for clients 

should be a critical factor in case planning by 

corrections supervisors. Probation and 

parole officers should be required to visit and 

evaluate client residences promptly. 

Reintegration With Family

Members and Social Support 

The offender’s home environment often is not 

helpful for encouraging adherence to treatment. Treatment providers should explore the 

family’s dynamics promptly during a home 

visit and make alternative living arrangements if the environment threatens to undermine treatment progress. Negative family 

dynamics take many forms. The offender may 

be the scapegoat for family problems, making 

his or her return to the home counterproductive. Also, other family members may be 

actively using drugs or involved in criminal 

activities. 

Domestic violence and child abuse situations 

present additional issues, including the personal safety of family members. To determine 

how healthy the home is, counselors need to 

make frequent home visits. Generally, community corrections supervisors assess levels of 

safety in the home when there is a question, 

218 Chapter 10 
although there are some substance abuse 

treatment programs that also perform this 

function. 

To supplement the support an offender may 

be receiving from family members, the treatment plan should include recreational opportunities and other outlets to build healthy 

social relationships. 

Vocational Training and

Employment 

Although highly important to an offender’s 

recovery, vocational training and employment 

can create problems when they are mandated 

by the community supervision agency before 

the offender has been engaged in treatment. 

If the client has not undergone treatment, 

there is a high risk that money earned will be 

spent on drugs or alcohol. Another common 

result of mandating employment before treatment is that the offender may lose his or her 

job because of behavior related to substance 

abuse. Achieving and maintaining abstinence 

depends on structured, phased programming. 

Vocational training should occur before 

employment to enable the offender to retain a 

job or obtain a better one. Wexler (2001a) 

suggests beginning vocational training at the 

start of treatment rather than introducing it 

at the end. Integrating vocational assessment, 

counseling, training, placement, and followup 

throughout treatment is a challenge and 

requires consistent collaboration within and 

outside of agencies. However, actuating vocational treatment goals can serve as the matrix 

holding all other goals of reintegration into 

the community. For additional information 

about vocational issues and offenders, see 

chapter 8 in TIP 38, Integrating Substance 

Abuse Treatment and Vocational Services 

(CSAT 2000c). 

Case Management 

Case management is the process of linking the 

offender with appropriate resources, tracking 

his or her progress through required programs, reporting this information to supervising authorities, and monitoring court-imposed 

conditions when requested. It should provide 

the following functions for offender-clients: 

• Assessment of the client’s strengths, weaknesses, needs, and ability to remain crimeand drug-free 

• Planning for treatment services and fulfillment of criminal justice obligations, such as 

restitution, community service, or regular 

contacts with probation officers or other 

criminal justice officials 

• Brokering treatment and other services and 

ensuring continuity as the client moves along 

criminal justice and treatment continuums 

• Monitoring and 

reporting progress Attention to

residential

resources for clients 

should be a critical 

factor in case planning by 

corrections 

supervisors.

• Providing client 

support, such as 

identifying problems and advocating with legal, 

social service, and 

medical systems in 

response to needs 

• Monitoring urinaly- 

sis, breath analysis, or other chemical testing for substance use 

Case management 

tests the ability of 

the criminal justice 

and treatment systems to work collaboratively and is based on 

two types of agreement: the agreement 

between the client and the two systems laying 

out protocols and consequences of infractions, and the agreement between the two 

agencies, a memorandum of understanding 

(MOU) that defines how each will manage the 

caseload of offender-clients in the jurisdiction. There can be one or two case managers 

representing each system. If two case managers are involved, they must coordinate 

efforts, working to encourage a multidisciplinary response that takes advantage of a 

Treatment for Offenders Under Community Supervision 219 
wide range of treatment and rehabilitation 

options. For more on MOUs see chapter 11, 

Key Issues Related to Program Development. 

For more on case management see TIP 27, 

Comprehensive Case Management for 

Substance Abuse Treatment (CSAT 1998a). 

Relapse Prevention

When an offender experiences relapse, it is 

crucial to gauge the seriousness of the “slip” 

to determine appropriate interventions. One 

positive urine test or one drink after a long 

abstinence should not be viewed as failure but 

as a signal for stepped-up treatment and closer monitoring. Because resumption of drug 

abuse can lead to 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. Repeated relapses 

must trigger consequences based on danger to 

the community and the offender’s treatment 

progress. 

The rate of relapse is high among offenders, 

and relapse prevention training must be provided at the beginning of and throughout 

treatment, and stressed prior to release. 

Personal relapse plans should be developed 

for all parolees receiving treatment. Relapse 

prevention skills should be part of each 

offender-client’s treatment plan, addressing 

how clients can refuse drugs and identify and 

manage triggers for craving. When relapse 

occurs, clients must be helped to understand 

it is part of the recovery process, rather than 

a personal failure, so they can rededicate 

themselves to success. If properly handled, 

relapse can lead to increased motivation for 

recovery, strengthening an individual’s 

knowledge of his or her limitations, the dangers of stressors, and awareness of what could 

be lost by leaving the treatment process. 

In negotiating the MOUs, treatment and criminal justice officials need to collaborate and 

must support sanctions consistent with treatment so that relapse is not simply punished as 

a criminal offense. Criminal justice decisionmakers at all levels, including judges and 

court personnel, should be aware that relapse 

is a characteristic feature of substance use 

disorder that must be anticipated, prevented, 

and addressed. Sanction possibilities include 

• House arrest 

• Assignment to halfway house 

• More frequent drug testing 

• Electronic monitoring 

• Day treatment 

• Brief jail stays 

• Assignment of community service hours 

Treatment Issues for

People Under

Community

Supervision

The point at which an individual acknowledges the need for drug treatment varies by 

personal circumstance. What is a crisis for 

one person is not a crisis for another. 

However, at a number of junctures many 

offenders indicate readiness to accept substance abuse treatment. These include the 

point of arrest, the point of release back to 

the community, any point at which there is a 

diversion decision, sentencing, after certain 

periods of incarceration, on entering probation, or when there is a choice between entering a residential treatment program or a jail. 

Other critical choice points include changes in 

one’s social position in the community or personal crises such as the death of a loved one, 

loss of a job, or suicide attempt. 

Because of the diversity of offenders under 

community supervision, treatment issues vary 

widely. A parolee recently released after a 20­

year sentence will, for example, have different issues and needs than a probationer who 

has spent minimal time in a correctional facility and who has more immediate ties to the 

community. Still, there are treatment issues 

220 Chapter 10 
 

that are common to both 

parolees and probationers. This 

section addresses those issues. 

Treatment issues unique to probationers and parolees are 

addressed in separate sections. 

Self-Esteem and

Identity

Shame and stigma are tremendous obstacles for offenders to 

overcome after an arrest or in 

making the transition between 

incarceration and the community. One effective approach to 

overcoming this stigma involves 

encouraging offender-clients to 

become active as volunteers in 

support of a community activity. 

Providing an opportunity for 

individuals to make a positive 

contribution to the community— 

to “give back”—may reduce 

feelings of alienation and build 

self-regard. 

Stories abound of ex-offenders 

who experienced a successful 

recovery from substance use disorders through inspirational 

interventions and became mentors to young people, playing 

key roles in steering them 

toward law-abiding lives. 

Successful programs recognize 

the importance of building the 

client’s sense of worthiness. 

Program success also depends on the quality 

of the staff, the treatment approach, and 

individual client motivation. Given the critical importance of self-esteem to recovery, the 

panel recommends that training in developing 

client self-esteem be mandatory for community corrections personnel. 

At the same time, self-esteem is not always a 

useful treatment target or goal with offenders. 

Feelings of shame and stigma are sometimes 

missing, especially in those having antisocial 

Advice to the Counselor: 

Recommended Treatment Services for

People Under Community Supervision

• Help the client address basic needs, such as housing or 

employment. 

• A client’s living arrangements are crucial to treatment. 

Counselors should be aware of residential resources and 

collaborate with corrections supervisors and probation 

and parole officers on finding appropriate housing for 

clients if needed. 

• A client’s treatment plan should include recreational 

opportunities and other outlets to help them build 

healthy social relationships in addition to the support 

clients may be receiving from their family. 

• Try to start vocational training for clients at the begin 

ning of substance abuse treatment rather than at the 

end of treatment. 

• Case management is an opportunity for the criminal jus 

tice and substance abuse treatment systems to collaborate to take advantage of a wide range of treatment 

and rehabilitation options for clients. 

• Relapse prevention skills should be part of each offender 

treatment plan, and personal relapse prevention plans 

should be developed for all parolees receiving treatment. These plans address how clients can refuse drugs, 

identify triggers, and manage cravings. 

• One positive urine test or one drink after a long abstinence should not be viewed as a failure but as a signal 

for stepped-up treatment and closer monitoring. 

• Graduated sanctions for relapses should be specified in 

the treatment plan because resumption of drug abuse 

can lead to resumption of criminal activity. 

traits and psychopathy. Targeting self-esteem 

without also increasing sense of personal 

responsibility and empathy for others may 

only result in a more confident criminal. 

Community service serves to reconnect the 

offender with the community and allows for 

retribution. 

Financial Concerns

Many offenders have multiple financial 

responsibilities—child support, family obligaTreatment for Offenders Under Community Supervision 221 
als under community supervision.

Some communities 

have recognized the

obstacles and stress 

presented by competing assignments 

and schedules

imposed on offenders, which often

necessitate expensive and time-consuming travel 

between sites. On 

Maryland’s Eastern 

Shore, Tyson’s 

Food, a major 

chicken producer, 

Establishing an 

offender’s 

motivation to 

change is an 

essential first step 

in substance abuse 

treatment. 

has given parole officers an office on-site at 

the processing plant so that employees do not 

need to miss work to meet reporting requirements. Drug courts impose numerous reporting responsibilities, but officials can make a 

reasonable attempt to accommodate the logistics of offenders’ job, treatment, and family 

responsibilities. 

Barriers to Treatment 

Probationers and parolees may live in fear of 

the system; their freedom is conditional, and a 

mistake is likely to lead to reincarceration. 

Among the many internal barriers that can 

inhibit treatment success for offender-clients 

are 

tions, job requirements, restitution, and 

treatment schedule—which can be major 

obstacles to successful treatment. A client 

burdened with overwhelming responsibilities 

sometimes gives up, saying, “I just couldn’t 

handle it.” Criminal justice and treatment 

professionals need to plan realistic requirements for individu­

•A history of failure 

•Alienation from and cynicism about the 

social structures and governmental agencies 

that typically have had a major impact on 

them 

•A sense of hopelessness that anything can 

make a difference in their lives 

•A culturally supported belief that treatment 

is for weak people 

•The perception that treatment is further 

punishment 

Those working with probationers and 

parolees need training to address each of 

these barriers. It is important for professionals working with offenders under community 

supervision to learn that offenders often do 

not realize that the goal of community corrections is to prevent them from being reincarcerated. Another treatment component 

should address the realities of incarceration 

and the impact of being a felon. Offenders 

being supervised in the community need to be 

informed of what they stand to lose by violating supervision requirements. 

Motivation for Treatment 

Establishing an offender’s motivation to 

change is an essential first step in substance 

abuse treatment. It cannot be skipped. 

Generally, clients lack focus or goals, which 

must be established to permit motivation. 

Those working with probationers and 

parolees need to be familiar with techniques 

of motivation and how to create and/or support the offender’s desire to break a pattern 

of criminality. Without genuine motivation on 

the part of the offender-client, treatment 

problems can be guaranteed. Clients need to 

feel hope and counselors need to plan a continuum of events that can begin to generate 

hope. During early stages of treatment, the 

offender-client should be oriented toward 

small accomplishments. 

Flexibility on the part of community corrections officials is important. Both treatment 

programs and corrections agencies can work 

together to build opportunities for success— 

keeping an appointment, having a clean urine 

test, or completing homework—small, structured steps that clients can take with relative 

ease and derive confidence from as they 

222 Chapter 10 
 

progress. When the client completes one goal, 

the provider should be ready to suggest the 

next. Incentives can be built into the system 

as well. For example, the more frequent the 

negative drug test results, the less frequent 

the mandatory testing. 

Those who abuse substances often are gifted 

manipulators with long histories of manipulative behavior in many systems. They may be 

able to simulate motivation but lack any real 

emotional investment in changing behavior. 

Clear, consistent, and uniform messages promote recovery and prevent the two systems 

from being used against one another. If the 

word “on the street” is that staff can be 

manipulated, treatment providers will face an 

uphill battle with many clients. 

Motivational interviewing is one of the most 

frequently used strategies for enhancing motivation. The technique assumes the client’s 

ambivalence about change and produces cognitive dissonance by eliciting the negative consequences of the addictive behavior. 

Motivational interviewing has been effective 

in the treatment of alcoholism (Bien et al. 

1993; Galbraith 1989; Miller and Rollnick 

1991) and methadone treatment for opioid 

abuse (Saunders et al. 1995; Van Bilsen and 

Van Emst 1986). For more on motivational 

interviewing, see the section on brief treatment in chapter 8 and TIP 35 Enhancing 

Motivation for Change in Substance Abuse 

Treatment (CSAT 1999b). 

Negative Counselor Attitudes

Treatment is impeded when counselors have a 

negative perception of the client’s desire to 

change, believe there is a poor prognosis for 

recovery, or are reluctant to serve offenders 

in general. Clients easily pick up on a 

provider’s negative attitude, which often confirms their own feelings about the futility of 

attempts to give up drugs. The cross-training 

of professionals helps build an understanding 

of offender-clients’ needs and potential, but 

professionals in both systems must acknowledge that the very nature of substance abuse 

means that maintaining recovery is a longterm goal. 

Lifestyle Changes

The kinds of changes community corrections 

professionals ask drug offenders to undertake 

are extraordinarily challenging and difficult 

to contemplate on a personal level. Many 

offenders have had limited experience with 

success and few opportunities to test their 

ability to succeed. A drug court or prison 

may be the first setting in which some offenders have a genuine chance to discover the 

capacity to change their lifestyles. 

A counselor who is a role model of courage or 

compassion can often be very effective in persuading clients to reevaluate their lifestyles. 

On the other hand, counselors should also be 

prepared for setbacks, lapses, and slow 

progress, as offenders come to terms with the 

extent of lifestyle change that is being asked 

of them. 

Self-Help Groups

Self-help groups frequently are a crucial component in recovery; they can provide peer 

support and nurture positive change. As 

bridges between incarceration and community, they can help with crises and personal 

growth. Probation and parole officers often 

advise clients to attend well-known programs 

like Alcoholics Anonymous or Narcotics 

Anonymous, saying, “Don’t take my word. 

I’m not the expert. Listen to the folks who’ve 

been there.” Other self-help groups may be 

appropriate depending on a client’s beliefs, 

needs, and interests, such as Survivors of 

Incest Anonymous, Secular Organizations for 

Sobriety, church or feminist groups, or veteran organizations. Practitioners need to 

remember, however, that although self-help 

groups are not a substitute for counseling, 

they can be an important adjunct to it. 

Treatment for Offenders Under Community Supervision 223 
Adherence to Supervision

Conditions

Both parole and probation officers need to be 

attuned to treatment needs, the dynamics of 

substance use disorders, and the changes 

required to maximize an offender-client’s 

chance to succeed. Training needs to be provided to them on how to craft requirements 

that support a client’s potential for success. 

Flexibility must be built into the requirements, given the complex pressures on most 

offenders in the community. Cross-training is 

necessary to facilitate information sharing 

among the entire range of professionals 

involved from presentence to probation or 

parole. While public safety is always a priority, training for probation and parole officers 

should emphasize that the offender’s longterm treatment will bring sustained improvements in public safety. 

Revocations because of technical violations of 

probation or parole requirements are a major 

barrier to completion of successful treatment. 

Required expectations for offender behavior 

need to be realistic. Cross-training can be 

helpful in fostering a shared vision of success. 

Such training should have specific goals. For 

example, the consensus panel suggests that 

training for probation officers working with 

drug offenders could include education on 

what treatment is and is not. Generic models 

of treatment should be presented. Similarly, 

treatment professionals working with drug 

offenders should be trained on the role of 

parole and probation in the criminal justice 

system. Probation and parole are frequently 

the most misunderstood element of the system, considered to be “law enforcement” by 

treatment professionals and “social work” by 

law enforcement. Often the breakdowns in 

communication between probation, parole, 

and treatment professionals are the result of 

a lack of understanding of each other’s roles. 

Vulnerability to Relapse 

Both parole and probation officers, who may 

have a supportive role before the client enters 

treatment, are likely to move into supervisory 

mode once treatment is underway to reduce 

public safety and liability risks. Zero tolerance and “three strikes” policies make it difficult for officers to overlook drug lapses and 

contradict knowledge that substance use disorder is a chronic disease. Relapse is not necessarily a failure. The common belief that 

treatment does not work is often based on the 

fact that most people recovering from substance use disorders relapse from time to 

time. 

Roles as Workers and

Taxpayers

Not only have arrests and imprisonment 

removed many young men and increasing 

numbers of young women from their communities and families, the majority have no 

financial resources to cushion their return. 

Their length of time away from the job world 

and lack of skills or experience to enter the 

marketplace leave many offenders low on the 

job ladder and further unable to support 

families or meet social expectations. Simply 

having a job, and particularly paying taxes, 

can be a completely foreign experience for 

many offenders. If parole or probation 

reporting and other multiple requirements 

are inflexible, they can prevent clients from 

being able to earn a living and contribute as 

tax-paying citizens. 

Increasingly, vocational training, GED programs, and job readiness training are being 

added to treatment. If programs do not offer 

these services, they can link to community 

agencies that can provide them. Offenders 

need specific preparation for responding to a 

prospective employer’s questions about their 

past. Lying is often a first choice, given the 

prospect that admitting to a criminal history 

will likely bar them from the job. A felon may 

224 Chapter 10 
 

 

be legally obligated to disclose a 

criminal past. 

Treatment for

Specific Populations

Both probationers and parolees 

with substance use disorders are 

likely to have additional treatment needs. Model programs 

described at the end of this chapter include comprehensive services to address a range of issues. 

This section briefly highlights the 

treatment issues of specific populations. For more detailed information, see chapter 5, Major 

Treatment Issues and 

Approaches. 

People with 

co-occurring 

disorders 

Of the 74 percent of probationers and parolees identified as 

having drug and/or alcohol 

problems, 11.4 percent were 

also identified as having mental 

illness (Beck 2000c). The prevalence of co-occurring disorders 

among these populations means 

that many offenders will need 

assistance with their mental illness as well as their drug or 

alcohol problems. Treatment for 

co-occurring mental disorders 

should be tailored to the particular treatment plan, and 

revised according to ongoing assessment. 

Coordinated (integrated when possible) services are especially important for offenders 

with mental illness. An example of one model 

for treating offenders with mental illness is 

highlighted on the next page. 

The National GAINS Center for People with 

Co-occurring Disorders in the Justice System 

Advice to the Counselor: 

Treatment Issues for People Under
 

Community Supervision
 

• Counselors can help offenders overcome the stigma of

past incarceration by encouraging them to become

active as volunteers in support of a community activity.

• For some clients financial stresses can be an obstacle to

successful treatment. Counselors can work with criminal

justice personnel to help plan realistic financial requirements for clients.

• Counselors need to help clients address any internal barriers clients may be experiencing, such as a history of failure, sense of hopelessness, or the perception that treatment is further punishment. Counselors can help offenders understand that the goal of community corrections is

to prevent them from being reincarcerated.

• An essential first step for treatment is to establish a

client’s motivation to change. Counselors should be

familiar with motivational techniques (such as motivational interviewing) and how to create or enhance a

client’s desire to break a pattern of criminality.

• Counselors should be careful not to project negative attitudes, which might be picked up by clients and reinforce 

their feelings of futility about substance abuse treat 

ment. 

• Being a role model of courage or compassion can be

effective in persuading clients to reevaluate their 

lifestyles and make positive changes. 

• Self-help groups can be a crucial component in a client’s

recovery by providing peer support and nurturing posi 

tive feelings. 

• Counselors can help clients applying for employment

prepare for responding to a prospective employer’s questions about their past. 

provides an online information source of value 

to those who work with offenders. The GAINS 

Center collects and analyzes information, and

develops materials specifically for people who 

work with offenders with mental illness, and 

provides technical assistance to help localities 

plan, implement, and operate appropriate, 

cost-effective programs. For further information go to http://gainscenter.samhsa.gov. 

Treatment for Offenders Under Community Supervision 225 
PACT (Programs for Assertive Community Treatment) 

The PACT model targets individuals with severe and persistent mental illness (which may include 

schizophrenia and other psychotic disorders, bipolar disorder and severe and recurrent depressive disorders, and occasionally severe personality disorders or severe anxiety disorders). Many if not most 

PACT clients have co-occurring addictive disorders, medical problems, and more than one psychiatric 

illness. The hallmark of PACT is low caseload size (15 clients per staff person) and an integrated team 

approach that includes people with medical, psychiatric, nursing, social work, psychology, case management, addictions, and other expertise who view the clients as a shared responsibility. Typically these 

programs will follow the client across locations. They do outreach into homeless shelters and street locations, they work with other providers when the client is hospitalized, and they will work with jails to 

advocate for good treatment. 

Research indicates that PACT is effective in reducing hospital recidivism and, less consistently, in 

improving other client outcomes (Drake et al. 1998a; Wingerson and Ries 1999). Another study compared a PACT with a standard case management approach at 3-year followup. The results indicated 

that the PACT adapted for clients with co-occurring disorders produced greater improvements on measures of quality of life and clinician ratings of alcohol use and substance abuse (McHugo et al. 1999). 

Female clients and children 

Nearly a million women were on probation in 

2003, and nearly 100,000 were on parole 

(Glaze and Palla 2004). Women under community supervision accounted for 85 percent 

of females in the criminal justice system in 

1998. About 45 percent of women whose 

parole ended in 1996 were back in prison or 

had absconded. Women who successfully finished parole were incarcerated for an average 

of 15 months and on parole for an additional 

20 months (Greenfeld and Snell 1999). 

Mothers who are to be incarcerated often lose 

custody of their children because of neglect 

and/or abuse, but the loss of children is 

extremely difficult for them to accept. If children are removed, criminal justice and treatment providers need to 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 reentering 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 on reunification 

issues, when appropriate. 

Clients with HIV/AIDS or 

other illnesses 

Offenders face additional challenges when 

they are unable to work because of illness. 

Access to medical help is essential. The consensus panel believes that comprehensive 

assistance to offenders should include prevention education, medical and social service 

support, grief counseling, and other psychological services. Services should include infectious disease risk assessment and screening, 

medical interventions such as primary care, 

and family counseling. Continuing care 

should include followup and hospice care. 

Case managers can assist in coordinating care 

for such infectious diseases as HIV, hepatitis 

C, tuberculosis, and sexually transmitted diseases. For more on infectious diseases in 

criminal justice clients, see chapters 2 and 6. 

Treatment Issues

Specific to People on

Parole 

Prisoners released into the community face a 

sometimes bewildering transition. Nearly 80 

percent of prisoners returning to the commu226 Chapter 10 
nity are released on parole under conditional 

release (Petersilia 2000). A successful transition from offender to citizen often depends on 

successful treatment. Successful treatment 

helps individuals to be more realistic about 

their strengths and weaknesses, more skilled 

and willing to endure obstacles encountered 

in maintaining a job or obtaining an education, and more confident about meeting family and work responsibilities. 

Continuum of Care 

Because substance use disorders are longterm, relapsing illnesses, a crucial aspect for 

reentry is to develop and sustain an integrated continuum of care between substance 

abuse treatment providers, the parole officer, 

and social service agencies that can assist the 

inmate’s reintegration into the community. 

Ideally, cross-system integration for offender 

transitional services contributes to cost benefits as a result of reduced recidivism (Inciardi 

1996; National Institute of Justice 1995; 

Swartz et al. 1996). However, the parolee 

does not exist in a discrete, well-coordinated 

system, but rather in a cluster of independent 

agencies and entities with separate justice 

responsibilities. Some entities collaborate 

closely; others do not. Most operate under 

separate funding streams, with differing organizational missions that may or may not share 

philosophical orientations toward public safety and offender rehabilitation. Boundary 

spanners and case managers can sometimes 

help maintain continuity. TIP 30, Continuity 

of Offender Treatment for Substance Use 

Disorders From Institution to Community 

(CSAT 1998b), discusses this topic in depth. 

Aftercare and Continuing Care 

Several studies have supported the long-term 

efficacy of postprison aftercare and treatment 

services in the reduction of recidivism and 

relapse. For example, Wexler (1995) found 

that those who participated in prison- and 

community-based therapeutic community 

treatment committed fewer crimes than their 

counterparts who did not receive aftercare 

services. Inciardi (1996) reported similar 

findings: lower rates of drug use and recidivism than those enrolled only in institutional 

treatment programs. 

Residential aftercare contributes to improved 

postprison outcomes. For optimal results, the 

offender should remain in treatment in the 

community. Studies show, for example, that 

the most effective treatment lasts a minimum 

of 3–6 months, and outcomes improve with 

additional time in treatment. This is true for 

all treatment modalities and particularly for 

treatment of offenders (Hubbard et al. 1988; 

Simpson 1984; Wexler 1988). 

Case Management 

Case management is the crucial function that 

links the offender with appropriate resources, 

tracks progress, reports information to supervisors, and monitors conditions imposed by 

the supervising agency. These activities take 

place within the context of an ongoing relationship with the client. The goal of case management is continuity of treatment, which, for 

the offender in transition, can be defined as 

the ongoing assessment and identification of 

needs and the provision of treatment without 

gaps in services or supervision. Accountability is an important element of a transition 

plan, and case management includes coordinating the use of sanctions and incentives 

among the criminal justice, substance abuse 

treatment, and possibly other systems. 

Ideally, case management activities should 

begin in the institution before release and 

continue without interruption throughout the 

transition period and into the community. 

Reassessments should be conducted at various stages throughout the incarceration and 

community release process. These periodic 

assessments should form the basis for ongoing 

case management and service delivery. 

Ancillary services are needed before and after 

release to prepare the offender for the return 

to family, employment, and the community. 

Treatment for Offenders Under Community Supervision 227 
Studies (Knight et al. 1999a; Martin et al. 

1999; Wexler et al. 1999b) have revealed the 

importance of aftercare for the maintenance 

of treatment effects. Foremost among needs 

for ancillary services are drug-free housing or 

other living arrangements, employment, family support, transportation, education, and 

primary health care. Others include literacy 

training, HIV/AIDS education, and prosocial 

support networks (Belenko and Peugh 1998; 

Hiller et al. 1999b). Offenders may need help 

learning basic life skills such as budgeting, 

using public transportation, and parenting. 

Improving clients’ likelihood of obtaining a 

job through GED preparation, enrollment in 

an educational program, vocational training, 

or job-seeking skills classes increases their 

chances of success after release. 

This array of services reflects the multiple 

psychosocial needs of offenders and takes into 

account the likelihood that they may experience periods of relapse, requiring more intensive levels of treatment and supervision. 

Other needs are training to improve interpersonal skills within families and among peers 

and training in anger management to learn 

new methods for resolving conflicts. Family 

members should be involved whenever possible, and participation in self-help groups 

should be encouraged. 

Recidivism

Parole failures now account for 35 percent of 

all prison admissions. Two-thirds of all 

parolees are rearrested within 3 years 

(Petersilia 2000), many on technical revocations, but most rearrests occur in the first 6 

months. Offenders with mental illness are especially likely to be rearrested. 

Given the importance of aftercare in the 

reduction of recidivism, several Federal and 

State Initiatives have sought to provide integrative treatment. One such program, the 

Serious and Violent Offender Reentry 

Initiative, is highlighted below. 

Serious and Violent Offender Reentry Initiative 

In conjunction with several Federal partners, the U.S. Department of Justice, Office of Justice 

Programs, created a comprehensive program to reduce violent crime by helping high-risk offenders prepare for reentry to society. The Initiative provides funding for the development, implementation, and 

enhancement of reentry programs. Programs funded under the Initiative will be tailored to address the 

three phases of reentry: 

•Phase 1—Protect and Prepare. Institution-based programs will provide services to prepare the

offender for reentry, including education, mental health and substance abuse treatment, job training

mentoring, and diagnostic and risk assessment.

•Phase 2—Control and Restore. These community-based transition programs will assist offenders prior

to and immediately following their release by providing education, monitoring, mentoring, life skills

training, assessment, job skills development, and mental health and substance abuse treatment.

•Phase 3—Sustain and Support. In this phase, community-based, long-term support programs help

offenders who have successfully completed their criminal justice supervision to connect with social services agencies and community-based organizations that provide ongoing services.

Further information on the Serious and Violent Offender Reentry Initiative is available at the Office 

of Justice Programs Web site: http://www.crimesolutions.gov/ProgramDetails.aspx?ID=167

228 Chapter 10 
Treatment 

Issues Specific 

to Probationers

Compared to parolees, probationers are less likely to have 

spent extended time in a correctional facility, and their ties to 

the community are relatively 

intact. The latter is both a benefit and a detriment in terms of 

substance abuse. On the one 

hand, offenders on probation 

may have the support of their 

Advice to the Counselor: 

Treatment Issues for People on Parole 

• Counselors can collaborate with parole officers and social 

service agencies to assist a client’s reintegration into the 

community and help maintain the continuity of services. 

• Counselors can help clients with securing postprison 

aftercare and treatment services, which have been 

shown to reduce recidivism and relapse. 

• Ancillary services (e.g., drug-free housing, employment, 

family support, transportation, education, health care) 

are needed before and after release from prison to prepare the client for return to the community. 

families and their communities. 

They may be able to maintain some consistency in their employment, their residence, and 

their family lives. On the other hand, probationers face a more immediate return to the 

surroundings and influences associated with 

their drug or alcohol use. For example, the 

offender with alcohol dependence is likely to 

return to the same neighborhood with the 

same bars, liquor stores, and friends. 

As with parolees, in order to be effective 

treatment must necessarily focus on changing 

ingrained patterns of behavior and thinking 

and avoiding the people, places, and things 

that the offender associates with drug or alcohol use. Unlike people on parole, however, 

the issue is not so much to reintegrate into 

society, but rather to learn new ways to live 

in that society. Much of the information presented in chapter 7 is also applicable to probationers, since many probationers have been 

sentenced through drug courts. 

Strategies for

Improving System

Collaboration

Initiatives such as cross-training, coordinated 

and comprehensive planning, and followup 

interdisciplinary meetings can help justice 

and treatment system partners to develop a 

shared, client-centered mission and a coordinated response. Figure 10-2 (next page) provides an example of how the goals of the 

treatment and criminal justice systems can be 

viewed as similar, although on the surface 

they appear disparate. 

Memorandum of 

Understanding 

When a substance abuse treatment program 

and a criminal justice agency collaborate, an 

MOU will outline the objectives of each partner, the expectations each partner has about 

the obligations of the other, and communications between the program and the criminal 

justice agency. For programs treating offenders, it is crucial to identify who will make certain decisions and what kinds of information 

will be reported. For example, will the program or the criminal justice agency decide 

when an offender’s relapse into alcohol or 

drug use will be handled as a violation of the 

conditions of probation? How detailed are the 

program’s reports to the criminal justice 

agency? Matters such as these can be resolved 

upfront between the program and criminal 

justice agency. An MOU or letter of agreement makes explicit the responsibilities 

agreed upon by each system. 

Treatment for Offenders Under Community Supervision 229 
 

Figure 10-2 

Paradigm of Collaboration 

Goals of Treatment System Goals of Treatment System Goals of Supervision System Goals of Supervision System Shared Goals Shared Goals 

• Reduce recidivism/criminal 

behavior. 

• Provide evaluation and treatment services. 

• Practice social skills. 

• Develop working alliance. 

• Prevent secondary pathology. 

• Collaborate/consult with other 

providers. 

• Honor confidentiality. 

• Reduce recidivism/criminal 

behavior. 

• Maximize the use of databases on 

the offender. 

• Enhance supervision. 

• Rely on third party expertise. 

• Focus on public safety. 

• Respond to court mandates. 

• Minimize risk to public. 

• Obtain adherence to treatment 

plan and abstinence from substance use. 

• Alleviate symptoms of illness. 

• Promote successful community 

reintegration with the goal of 

abstinence. 

• Encourage family/social support. 

• Support employment efforts. 

Information-Sharing and

Confidentiality Issues

To develop effective treatment plans that 

respond to individual needs and problems, 

community-based organizations need information from the paroling institution about the 

offender’s previous substance abuse treatment. Obtaining such information often is 

problematic because of ethical considerations 

about client privacy and Federal laws guaranteeing strict confidentiality of information 

about all people receiving substance abuse 

prevention, assessment, and treatment services. For more detailed information on confidentiality and privacy, see chapter 7. 

(Additional information on confidentiality can 

be found INæCSAT 2004.) 

Program Violations

Ideally, program violations should be 

addressed in the context of treatment needs 

before legal sanctions are considered, 

depending on the severity of the violation. 

However, this is realistic only if the supervising agent and the provider of care agree on 

how to make it work; it is not realistic if there 

is not a solid agreement between the two systems. When possible, this understanding can 

be established by an initial agreement 

between the offender-client’s probation or 

parole officer and treatment provider. 

Personnel and Training 

While some States do not require licensing for 

treatment providers, it is undesirable to have 

unaccredited, unlicensed people providing 

treatment. The consensus panel feels strongly 

that individuals providing treatment to 

offender populations should meet minimum 

standards of recognized accrediting authorities in addition to receiving specialized training in substance use disorders and relapse 

prevention. Special attention needs to be paid 

to the training of recovering staff who are 

essential counseling resources for therapeutic 

communities and other programming. Their 

credibility with clients and role modeling 

potential cannot be underestimated. 

Programs that include opportunities for 

clients to begin counselor training while in 

custody enrich programs and offer increased 

hope for participants. However, careful 

guidelines are needed concerning crime-free 

and sober years, in addition to other standard professional counselor requirements. 

Whenever possible, training should be carried out across criminal justice and substance 

230 Chapter 10 
abuse treatment systems and should integrate 

personnel from both. The curriculum should 

cover needs and approaches to specific populations in the jurisdiction, such as women, 

minorities, those with co-occurring mental 

disorders, and clients with special needs, and 

incorporate input from each of these groups 

to ensure the training’s relevance, accuracy, 

and sensitivity. General topics to consider 

include 

•A broad overview of how each system works 

•Common ground shared by substance abuse 

treatment and criminal justice systems 

•Education on the language and jargon of the 

systems so that providers understand each 

other’s language 

•Clarification of system roles and personnel 

roles within each system 

•Ways in which the two systems can communicate, work together, and manage conflicts 

•Cultural competence issues 

•Confidentiality requirements 

•Effective case management for the offenderclient 

•Rationales for intermediate sanctions programs for drug offenders 

•Eligibility requirements for intermediate 

sanctions programs and how they can be 

applied to individual cases 

•Reporting requirements and agreements 

•Pharmacotherapy 

Participants in training for this type of community supervision program should include 

•Judges 

•Prosecutors 

•Probation and parole officers 

•Treatment program administrators 

•Counselors 

•Public treatment-funding agencies 

•Defense attorneys 

•Ancillary program staff 

Special presentations can be made to policymakers (e.g., State and local legislators or advisors to the State or county) that focus more on 

systems and legislative issues. For more on 

training on screening and assessment, see chapter 2. For general information on treating 

offenders, see chapter 5. 

Sample Programs

Treatment Accountability for

Safer Communities

For a description of TASC, see chapter 7. 

The Amity Project 

The Amity Project was a collaboration 

between Amity, Inc., and the Pima County, 

Arizona, Department of Probation and funded by The Center for Substance Abuse 

Treatment, U.S. Department of Health and 

Human Services, in 1990. The program targeted offenders who were at high risk of having their probation revoked because of their 

substance abuse. By incorporating the key 

elements of a therapeutic community into a 

day and evening program, the unique structure escalated sanctions, including urine 

screens and varying supervision levels, case 

management, educational and vocational 

training, family support and counseling, coordination of medical services, and intensive 

aftercare. After 2 years, drug use relapses 

among probationers declined, positive urine 

screens decreased by more than 50 percent in 

the first year, and job placement increased. 

Because of the success of the employment 

component, the project had to extend its 

activities to nights and weekends to accommodate the employed offenders. The program 

ended when funding was not renewed, despite 

its promising start (Healey 1999). 

Treatment for Offenders Under Community Supervision 231 
Breaking the Cycle 

A joint project of the ONDCP and the 

National Institute of Justice, U.S. 

Department of Justice, Breaking the Cycle is 

designed to interrupt the downward spiral of 

drug use, crime, imprisonment, and recidivism and is currently being tested by three 

adult justice systems nationwide. The goal of 

the program is to reduce drug use and crime 

through increased collaboration between justice system practitioners and treatment 

providers. The Breaking the Cycle model 

encourages a change in the way both systems 

respond to offenders who use drugs and 

includes the following initiatives: 

•Drug testing of all arrestees before the initial 

court hearing 

•Placement of people who use drugs in appropriate treatment and monitoring programs 

•Intensive pretrial and post-sentence case 

management 

•Appropriate, graduated sanctions and incentives to address offender behavior 

•Judicial oversight of offender compliance 

(National Institute of Justice 2001) 

Probationers in Recovery

An intensive probation program in San Diego 

County, California, Probationers in Recovery 

requires offenders to participate in intensive 

drug treatment and drug testing. The program has made a strong effort to combine 

substance abuse treatment with the heightened surveillance of intensive supervision. 

The program targets high-risk offenders and 

excludes people with psychotic disorders and 

excessive criminal or violent histories. The 

requirements for program completion are 

comparatively high, including self-help, group 

and individual therapy, job club, drug education, social skills development, and life skills 

components lasting a minimum of 6 months 

(Curtis et al. 1994). 

KEY–CREST

Located in Wilmington, Delaware, KEYCREST has an in-prison therapeutic community, and a 6-month residential, communitybased TC with a work release program for 

inmates with histories of substance abuse. 

The program includes an aftercare stage, 

where clients are under community supervision. Data from a 3-year followup indicate 

that the group in aftercare shows the most 

powerful effects of the earlier treatment 

(Martin et al. 1999). For additional information, see chapter 9. 

Special Offender Services

Program

One model program for the treatment of 

offenders who have developmental disabilities 

or at least three deficits in essential adaptive 

skills or behaviors was developed in the mid1980s by Lancaster County, Pennsylvania. 

This program, known as Special Offenders 

Services (SOS), helps qualified offenders who 

have been placed on probation or parole. 

SOS works in a number of areas to help this 

group by educating criminal justice personnel, facilitating the use of social services 

(through case management), building client 

self-esteem (which it does by rewarding small 

successes and not placing unreasonable 

demands on its clients), educating clients 

about their rights and responsibilities, and 

providing skills training in areas such as 

recreational activities (since many offenders 

who are cognitively challenged may not know 

how to spend their free time). The program’s 

success is demonstrated by the extremely low 

recidivism rate of its clients, which, as of 

1992, was only 5 percent (Wood and White 

1992). 

232 Chapter 10 
Conclusions and

Recommendations

Based on their knowledge and experience, 

consensus panel members offer the following 

conclusions and recommendations regarding 

treatment for probationers and parolees: 

•Offenders can be effectively controlled and 

managed by a combination of treatment and 

surveillance while on probation at a far 

lower cost than if they are in jail or prison. 

•Offenders under community supervision 

who have substance use disorders need services from multiple systems. Services should 

be accessible on an as-needed basis to 

ensure positive outcomes and smooth transitions. 

•Cross-training of probation and parole officers, case managers, and substance abuse 

counselors is vital for the delivery of coordinated services. 

•Community supervision should be based on 

the recognition that relapses are unavoidable and not necessarily indicative of failure. Intensification in the level of supervision should be matched by an intensification of the level of treatment. Likewise, the 

intensity of supervision should decrease 

over time as the individual meets treatment 

goals. 

•Probationers who have avoided incarceration should receive education on the realities of incarceration and the impact of being 

a felon on the offenders’ lives. 

•Ideally, case management activities for 

parolees should begin in the institution 

before release and continue throughout the 

transition period for a minimum of 3 

months of treatment after release. 

•Reassessment should be conducted throughout the period of community supervision. 

•All residential treatment should be followed 

by continued care in an outpatient setting. 

•Optimally, probation and parole officers 

should visit and assess the client’s residence 

and place of employment periodically in the 

course of community supervision. 

•Vocational programming should be ongoing 

and integrated with substance abuse treatment. 

•Community supervision staff should be 

involved in treatment planning and treatment team activities whenever possible, 

particularly when issues of sanctions and 

placement in community treatment are 

reviewed. 

Treatment for Offenders Under Community Supervision 233 
 

 

 

In This
 

Chapter... 

Reconciling Public Safety 

and Public Health 

Interests 

Interdependence of 

Criminal Justice and 

Treatment Systems 

Program-Level 

Coordination 

Research and Evaluation 

Cost Issues 

Key Goals of SAMHSA 

Conclusions 

11 Key Issues Related
 

To Program

Development 

Overview 

An important thread running throughout this TIP is the interdependence of criminal justice and substance abuse treatment systems, 

which influences what program activities are undertaken and how 

they are implemented. The members of the TIP consensus panel feel 

strongly that effective collaboration between the criminal justice and 

substance abuse treatment systems can result in better treatment for 

offenders and, ultimately, a reduction in crime. When available and 

effectively implemented, substance abuse treatment programs can 

reduce recidivism, reduce substance use, and help offenders to change 

their lives. The guiding notion in this chapter is to provide thoughtful 

consideration of key issues that frame effective programming and 

coordination. 

This chapter is primarily aimed at program administrators, although 

counselors will benefit from reading it as well. The chapter presents 

information on issues such as reconciling the goals of the criminal justice and substance abuse treatment systems; the interdependence of 

the two systems and how to collaborate effectively; program-level 

coordination, including barriers to coordination and solutions, and 

integrating criminal justice and substance abuse treatment; research 

and evaluation issues; cost issues; and conclusions. 

Reconciling Public Safety and

Public Health Interests

Any discussion concerning the effectiveness of substance abuse treatment for clients under criminal justice supervision needs to address 

the historic differences between the criminal justice and public health 

systems. These differences influence the nature and quality of services 

provided at both the program and policy levels. A basic difference is 

the primary focuses of the two fields. The responsibility of the criminal justice system is to protect the public safety, with a focus on activi235 
ties designed to isolate, and supervise individuals who threaten the lives and well-being of 

others (Office of the Federal Register 2004). 

The substance abuse treatment system’s focus 

is on restoring individuals to productive lives 

and minimizing the consequences of alcohol 

and drug dependence on people with substance use disorders, their families, and communities. 

Because of these differences in focus, the two 

systems sometimes operate at cross-purposes. 

The perceived need to “get tough” on crime 

and the rehabilitation of the offender have 

fueled the continued debate. 

Offenders are 

sometimes viewed 

as less deserving 

competitors for 

scarce substance 

abuse treatment 

services compared 

to nonoffending citizens. For some, 

punishment is the

primary goal; treatment—if available

at all—is secondary. 

The missions of 

public health 

departments and 

correctional 

agencies are 

complementary. 

At the same time, 

security and public safety issues may not be a 

primary consideration for substance abuse 

treatment professionals. Counselors may forget that offenders are there because they have 

committed crimes, sometimes violent ones, 

and that not all offenders will become lawabiding citizens, even if they are not under 

the influence of drugs or alcohol. Moreover, 

some treatment programs may not address 

the additional needs of criminal justice 

clients, such as issues underlying criminal 

activity (e.g., criminal belief systems and 

criminal peer groups). 

Despite these differences, the missions of public health departments and correctional agencies are complementary. An important common ground—a goal that is critically important to both systems—is the reduction of 

crime. The remainder of this chapter 

addresses ways to build on that common 

ground to create systems that habilitate 

offenders, prevent crime, and protect the 

public. 

“Good treatment is good public safety.” 

—Claire McKaskill, former 

county prosecutor in Missouri 

Interdependence of 

Criminal Justice and
 

Treatment Systems
 The criminal justice and substance abuse 

treatment systems can work together to 

improve the results of both systems. The 

Criminal Justice Treatment Planning Chart 

prepared by the Center for Substance Abuse 

Treatment (CSAT) might serve as a frame of 

reference (CSAT 1994b). In the chart (Figure 

11-1, pp. 238–239), specific connections 

between the criminal justice and substance 

abuse treatment systems are targeted. 

It is vitally important that these two systems, 

and the people who work within them, agree 

that treatment must be tailored to the particular criminal justice setting and to the client’s 

stage in the recovery process. Steps to promote integration between the criminal justice 

and the substance abuse treatment systems 

are discussed below. 

Effective Collaboration

Between Criminal Justice and

Treatment Systems

Several conditions must exist for effective relationships between different groups or systems 

(Argyris 1970), such as the treatment and criminal justice systems. These conditions include 

• Investment in the system’s effectiveness 

• Confidence in their own system 

• Belief in the interdependent nature of the 

systems 

236 Chapter 11 
•Willingness to accept or develop common 

goals to link the systems 

•Willingness to work collaboratively with other 

systems on joint projects 

The consensus panel recommends the following 

basic principles, which are used to promote 

change in different organizations and systems 

but can be applied to the criminal justice and 

substance abuse treatment systems: 

•Development of leadership and goals 

•Endorsement from system leaders 

•Establishment of common goals and objectives 

•Identification of stakeholders 

The following section describes how these recommended principles can be used to strengthen 

coordination between criminal justice and substance abuse treatment systems. 

Development of leadership 

and goals 

Small groups of individuals who have endorsement of leadership within the criminal justice 

and substance abuse treatment systems can 

help develop an agenda for action. Preliminary 

goals that link the two systems can then be 

established. It is important that preliminary 

goals identified are specific and attainable. 

Building on small successes at the beginning of 

the process is important. 

Endorsement from system 

leaders 

Formal endorsement should be obtained for 

collaborative projects from both systems’ 

leaders. Endorsement may be implicit if leaders are part of the group or may be obtained 

from a more formalized process if they are 

not. This endorsement can take the form of 

an executive order from the governor, mayor, 

or commissioner; a legislative declaration for 

the group’s work; or simply a memorandum 

of understanding from those who hold power 

in the criminal justice and substance abuse 

treatment systems. Whoever commissions the 

collaborative project activities must be kept 

informed about progress and goals at every 

stage, preferably in an informal, uncomplicated way. A systems audit may be an effective way to measure the starting point and 

level of collaboration. This may be conducted 

internally by project staff or by external evaluators. 

Establishment of common 

goals and objectives 

For systems collaboration to be effective, a 

unifying goal must be identified and pursued. 

The planning group should set a unifying goal 

that encompasses the needs of both the substance abuse treatment and criminal justice 

systems. For example, a goal to reallocate 

money from current treatment programs in 

order to treat other groups of offenders may 

be divisive rather than unifying. However, a 

goal of finding new funding for offender treatment that focuses on the most dangerous 

offenders is an example of a superordinate or 

unifying goal. The process of articulating 

goals will help to clarify and resolve differences among group members and to expedite 

project development. As soon as the goals 

have been determined, objectives should be 

described. A series of concrete objectives 

should be accompanied by an action plan to 

achieve the goals. The objectives should then 

be assigned to individual group members for 

followup. 

Identification of 

stakeholders 

Everyone has a vested interest in preventing 

and addressing crime related to substance 

abuse. As the example of Portland’s Regional 

Drug Initiative (see text box on page 240) 

demonstrates, when systems and individuals 

work together the results can be impressive. 

Key Issues Related to Program Development 237 
238 Chapter 11 
Figure 11-1 

CSAT Criminal Justice Treatment Planning Chart 

Key Issues Related to Program Development 239 
Regional Drug Initiative, Portland, Oregon 

In 1987, citizens and leaders in Portland, Oregon, and surrounding communities united to form a coalition, the Regional Drug Initiative (RDI). Although the RDI was dissolved in June 2002, it continues to 

serve as a national model for community coalitions. Join Together hosts an archival Web site 

(HTTPWWWDRUGFREEORGJOIN
TOGETHERFUNDINGMODEL
COMMUNITY
COALITIONS) that contains basic 

documents describing RDI, its approach, and how to replicate its work. 

RDI’s purpose was to substantially reduce alcohol and drug abuse in Portland and Multnomah County. 

It worked to coordinate networking efforts of the criminal justice system, treatment and prevention 

agencies, healthcare and education systems, community organizations and advocates, youth, the faith 

community, businesses, and the media. RDI aimed to increase the number of drug-free workplaces, 

strengthen youth and adult leadership to reduce alcohol and drug use among youth, and educate community leaders and the public on actions and policies needed to reduce substance abuse. 

The Drug Impact Index was an annual compilation of indicators that highlighted the severity of the drug 

problem in Oregon and Multnomah County. The last volume of the Index (2001) showed that approximately one fifth of those needing substance abuse treatment in Oregon received it in any one year. 

The Index also showed that that when stakeholders cooperate, treatment can work. For example, every 

dollar invested in public substance abuse treatment returned over $5 in direct costs to taxpayers. Other 

significant findings from the report included: 

•In the Multnomah County, Oregon STOP (Sanction Treatment Opportunity Progress) program, which 

provided court-monitored outpatient treatment, graduates averaged 0.4 re-arrests 2 years following completion of the program, versus 1.5 re-arrests for people who were eligible to participate in the program 

but did not. 

•Due to court-mandated treatment, for every dollar spent, $2.50 was saved in direct State and local 

government costs. Total savings including theft and costs to victims amounted to $10 per dollar spent. 

•Positive drug tests in the workplace had increased since 1997, after they had decreased by almost half 

from 1993 to 1997. 

•The percentage of adult arrestees testing positive for drugs was 67 percent in 2000. The percentage 

testing positive for drugs was similar across a wide variety of offenses. 

•Alcohol-involved traffic deaths declined 28 percent statewide and 43 percent in Multnomah County 

between 1998 and 1999. Alcohol-related deaths are at their lowest level in over 20 years. 

•Drug-related deaths dropped in 2000, both statewide (by 15 percent) and countywide (by 35 percent). 

Eighty percent of drug-related deaths in Multnomah County were heroin related. 

Source: Regional Drug Initiative 2001. 

The following groups can be targeted to garner support for initiatives designed to provide 

substance abuse treatment for offenders. 

The public. As taxpayers, voters, and residents, the public can influence what happens 

at every point along the criminal justice treatment continuum. As such, they are primary 

stakeholders who should be kept informed of 

relevant issues. For example, officials might 

consider releasing an annual community 

progress report, similar to a corporate annual 

report that includes facts such as the number 

of people who have successfully completed a 

treatment program. When members of the 

public participate in planning, an ongoing 

educative process is initiated. Public involvement also can address fears associated with 

240 Chapter 11 
proximity to offenders who use drugs and 

help the public recognize the benefits of treatment programs (e.g., jobs in the community, 

reduced crime, etc.). 

Victims. Those victimized by a crime include 

the crime victim and family members—especially children and significant others. Several 

States have passed constitutional amendments 

that protect the rights of victims and that 

usually provide an opportunity for the victim 

to take part in the criminal justice process. 

Additionally, community-based victims’ rights 

groups have been established in many communities, and some prosecutors’ offices 

employ victim advocates. 

Victims have a variety of interests, depending 

on the circumstances of their cases. Most victims want to see a combination of punishment, restitution, and protection, while others may be interested in having the offender’s 

substance abuse problem addressed. There 

are a number of “indirect” victims of drugrelated crime who are not readily identified 

by law enforcement or the courts, such as 

individuals who live near “crack” houses and 

whose main goal is to close them down. As 

stakeholders, these victims should have the 

opportunity to represent their own interests. 

Recovering criminal justice clients. Offenders 

in recovery are the “consumers” of treatment 

services. Although their criminal behavior 

creates public safety problems, often they are 

also the victims of abuse and other crimes. It 

is important to include criminal justice clients 

who are in recovery as stakeholders, since 

they are well informed about issues related to 

coordination between the justice and treatment systems. It is also important to reference the statements, writings, achievements, 

and testimonials of recovering criminal justice 

clients. 

Media. The media play a major role in shaping public attitudes toward the criminal justice system, especially attitudes about how to 

handle substance-involved offenders. Avenues 

of communication between the media and the 

criminal justice and substance abuse treatment systems must be kept open. Continual 

efforts should be made to communicate to the 

media a full picture of the multifaceted issues 

surrounding crime, substance use disorders, 

and substance abuse treatment. When media 

representatives are involved in planning, they 

may begin to see the positive side of joint 

efforts of the criminal justice and substance 

abuse treatment systems. 

Legislators. Legislators should be consulted 

and provided up-to-date information about 

offenders who use substances and are 

involved with the criminal justice system. It is 

important that they also become aware of 

“success” stories, so that the influence of 

failed cases does not dominate their policy 

decisions. The political stance of being “tough 

on crime” and “waging war on drugs” has 

resulted in legislation requiring mandatory 

sentences for drug offenses, which must be 

tempered with information regarding positive 

treatment outcomes, the availability of effective alternatives to incarceration, and the 

consequences of punitive approaches for drug 

offenders. Tough crime bills (e.g., “three 

strikes” laws) have resulted in high criminal 

justice expenses that often shift limited funds 

from social services and education to construction and operation of correctional facilities—actions that tend to exacerbate the 

crime problem and reduce the availability of 

needed services for citizens. In some cases, 

this type of punitive sentencing reform has 

been developed in reaction to a particularly 

heinous crime, with inadequate consideration 

provided to the public policy consequences. 

Community organizations. Community groups 

include local boards, recreational programs, 

church groups, neighborhood watches, and 

other community associations that address, 

either directly or indirectly, the issues of substance abuse and criminal behavior. These 

groups can play a role in prevention, treatment, and referral. Advocacy groups such as 

Mothers Against Drunk Driving and other 

special interest groups also can work effectively at the community level to address prevention issues. Their agendas often are conKey Issues Related to Program Development 241 
sistent with those of other community groups 

that can be helped to understand the importance of reaching offenders with effective 

treatment. 

Businesses. Local businesses and business 

groups, such as Kiwanis, Rotary, and downtown business associations, have a strong 

interest in preventing crime, since they may 

be targets, and often take an active role in 

their communities. Employers also are interested in preventing substance abuse by their 

employees. Businesses are a vital component 

of the larger community and should be 

involved in planning for substance abuse 

treatment in the criminal justice system. 

Business leaders can provide invaluable assistance in planning training programs and providing opportunities for job placements. 

Vocational training is a critical component of 

the transition and reintegration process for 

offenders with substance use disorders reentering communities (see also chapter 8 in TIP 

38, Integrating Substance Abuse Treatment 

and Vocational Services [CSAT 2000c]). 

The consensus panel believes that leaders 

from the criminal justice and substance abuse 

treatment systems can do the hard work of 

planning substance abuse treatment for 

offenders in all parts of the criminal justice 

system continuum. Policy, procedures, relationships, and shared responsibilities should 

be developed to operationalize effective substance abuse treatment within the criminal 

justice system. 

Program-Level
 

Coordination
 Federal, State, and local policies have a 

tremendous effect on the quality and availability of substance abuse treatment for offenders, 

as do policies and procedures within individual 

programs. The following sections address the 

barriers to effective program coordination and 

integrating substance abuse treatment into 

criminal justice at the program level. 

Barriers to Program

Coordination

Farabee and colleagues (1999) identified six 

major barriers that prevent effective implementation of substance abuse treatment in the 

criminal justice system. These barriers and 

their suggested solutions are summarized in 

Figure 11-2. 

Program Components

Effective programs include case management 

along with procedures to coordinate the flow of 

information and to serve the best interests of 

the offender. 

Case management 

Case management is the process of linking the 

offender with appropriate resources; tracking 

the offender’s participation and progress in 

the referred programs; reporting this information to the appropriate supervising authority and, when requested, to the court; and 

monitoring the conditions imposed by the 

court. Effective case management often 

requires supplementary funding and reallocation of resources. 

Case management activities optimally begin at 

the pretrial period, continue throughout the 

treatment process, and provide a means to 

coordinate the requirements of the justice 

system with treatment goals and other immediate concerns. Case management activities 

focus on coordination of services during transitions between different stages of the justice 

system. When clearly defined, accountability 

guidelines established across the two systems 

ensure that information regarding criminal 

activity, infractions, and other critical incidents are reported in a timely and effective 

manner. 

242 Chapter 11 
Problem Area Description of Problem Solution(s) 

Assessment Assessment uses broad definitions of drug abuse and applies 

criteria unrelated to addiction. 

As a result, inmates are not 

always matched with the appropriate level of services, and some 

inmates who do not have substance abuse problems are placed 

in treatment. 

Expand treatment options by 

establishing larger numbers of 

carefully targeted programs at 

more institutions. 

Staff training Many newer prisons have been 

constructed in rural areas where 

local communities have a smaller 

pool of treatment professionals 

and fewer people in recovery as 

potential staff members. 

Offer better wages; recruit and 

train offenders who are serving 

life sentences; and orient and 

train treatment staff and correctional staff together. 

Staff redeployment Effective correctional officers 

and treatment counselors often 

move “up and out.” 

Change rotation policies; certify 

and reward officers who wish to 

work in jail- or prison-based 

treatment programs. 

Overreliance on institutional 

sanctions 

In successful treatment programs, noncompliant participants face peer pressure and 

eventually develop internal controls. Often, however, institutional sanctions are imposed before 

peers can have a positive impact. 

Treatment and correctional staffs 

cooperate to determine conditions for imposing both therapeutic and institutional sanctions. 

Aftercare Many participants drop out of 

treatment as soon as they can; 

many providers in the community hesitate to work with ex-prisoners, especially those sentenced 

for violent or sexual offenses. 

Establish treatment programs in 

the community that cater to or 

willingly accept parolees, probationers, and others under community supervision. 

Coercion Often inmates do not volunteer 

for treatment because peers 

attach stigma to it, programs 

demand more rules and structure, and participants often lose 

seniority and job opportunities in 

the facility. 

Focus on rewarding good behavior. Remove disincentives and 

add such inducements as early 

release, better living quarters, 

and better job opportunities. 

Figure 11-2 

Barriers to Effective Treatment 

Source: Farabee et al. 1999. 

Key Issues Related to Program Development 243 
Procedures to coordinate the •Establish consistent definitions of the data

flow of information 

Information management is the key to identifying treatment needs and can provide treatment and related services more effectively. 

Basic information gathered about the defendant should follow the offender through subsequent stages of the criminal justice system 

and substance abuse treatment system. 

Agencies from both systems should decide 

what information is necessary and useful and 

should develop methods for sharing that 

information. However, the defendant’s civil 

liberties and rights of confidentiality must be 

considered whenever information is shared. 

Procedures to improve information flow 

include the following: 

•Establish methods for timely collection and 

reporting of information. 

•Implement regular quality control procedures to maximize completeness, accuracy, 

and consistency of data. 

elements between the different participating 

agencies. 

•Ensure that information flows in both directions: from treatment providers to criminal 

justice staff, and from criminal justice staff 

to treatment providers. 

•Increase sensitivity to the confidentiality 

requirements and political concerns of 

criminal justice agencies and treatment 

providers. 

•Create a designated central repository for 

appropriate client information. 

Integrating Public Safety and

Treatment at the Program

Level

Good substance abuse treatment programs 

contribute heavily to enhancing safety and 

security, as program participants usually present the fewest safety and security-related 

problems (Belenko 2001). Treatment and 

security can be thought of as two sides of the 

same coin, rather than as opposites. For 

Information Sharing: Maricopa County Data Link Project 

An innovative approach to sharing information between the jail and community services is reflected in 

the Maricopa County (Arizona) Data Link Project (National GAINS Center 1999c). Computer experts 

developed an electronic data link between the Maricopa County Jail and the public mental health system 

to identify clients who have previously received mental health services. This link identifies mental health 

clients regardless of their charges, time of jail booking, or mental health status at the time of booking. 

All jail admissions are electronically routed to the management information system (MIS) operated by 

the public mental health system, with the MIS automatically matching clients based on demographic and 

other identifying information. Clients identified as matches with the mental health system are immediately “flagged” for the jail diversion program—an initiative funded by the Substance Abuse and Mental 

Health Services Administration (SAMHSA) to provide triage, case management, and treatment services 

for nonviolent inmates who have co-occurring substance use and mental disorders. The jail diversion 

team then evaluates potential candidates for its program, based on public safety risk factors, current 

mental status, availability of community mental health and treatment resources for those with co-occurring disorders, and prior history in treatment services. Clients accepted into the jail diversion program 

may be released from jail under pretrial or deferred prosecution arrangements to participate in treatment as a condition of community supervision. The Data Link Project has enabled the jail to increase 

the number of inmates identified for diversion and treatment involvement by approximately 100 percent 

within the first year of operation. 

244 Chapter 11 
example, substance abuse treatment significantly enhances offenders’ accountability 

through additional monitoring and communication with the courts, community supervision, and other criminal justice staff. 

Accountability also is provided by drug testing and by behavioral and skills-oriented 

interventions that are provided by treatment. 

The consensus panel believes that the following conceptual model is helpful in understanding how the justice system is strengthened by substance abuse treatment involvement. 

Supportive environment with 

accountability 

A key issue for criminal justice programs is 

how treatment and justice system staff can 

work together to maintain a positive atmosphere that supports offenders’ recovery 

efforts while confronting and managing 

offender “games” and manipulative coping 

strategies. Programs that focus exclusively on 

either supportive or confrontational 

approaches generally are not effective within 

the criminal justice system. Criminal justice 

treatment programs run smoothly and successfully only when staff employ both supportive and accountability procedures. 

“Confrontation” as used here does not mean 

a hard and aggressive verbal interchange, but 

rather assertively pointing out misbehavior 

and discrepancies between goals and behavior. 

Some programs are successful in implementing only half of this formula. Supportiveness 

without accountability leads to the appearance that staff are trying to be “friends” with 

clients, leaving staff vulnerable to offender 

manipulation. The staff relationship with the 

client is better represented as that of a teacher and student, with staff modeling adaptive 

skills, behaviors, and attitudes. Conversely, 

accountability procedures that are developed 

in a nonsupportive environment often lead to 

an atmosphere characterized by hostility and 

punitiveness. Criminal justice system programs with this type of atmosphere are not 

typically successful in engaging offenders in 

treatment recovery. 

Justice system programs flourish when all 

staff contribute to both the supportive environment and accountability of the clients. 

Keys to success include staff appreciation of 

the need to set limits supportively and to 

establish clear personal boundaries with 

clients. A final point for all staff who are integrating the work of criminal justice staff and 

treatment staff is that good treatment is good 

public safety. Treatment staff should demonstrate to justice system staff how their program might enhance safety and security. 

Substance abuse treatment programs can 

quickly demonstrate their worth by effectively managing clients’ difficult behavior, supporting the work of criminal justice staff, and 

holding themselves and criminal justice staff 

accountable for following through with their 

respective commitments to the program. 

Personnel needs 

Training and professional and workforce 

development issues are of paramount concern 

in implementation of treatment programs with 

the criminal justice system. Because the criminal justice system affects the environment in 

which treatment occurs and provides the 

structure to which the client must respond, 

substance abuse treatment counselors need to 

become familiar with the criminal justice system, its unique terminology, and methods of 

balancing client treatment needs with safety 

issues. Treatment professionals working with 

criminal justice clients should be knowledgeable about criminogenic risk factors, the most 

effective strategies and approaches for use 

with offender populations, and the need for 

professional boundaries. 

By the same token, criminal justice staff 

should understand the goals of substance 

abuse treatment, the effects of frequently 

abused drugs, and the types of treatment that 

are available. Treatment knowledge is particularly important for criminal justice staff, 

Key Issues Related to Program Development 245 
since treatment is increasingly affecting all 

aspects of diversion, community supervision, 

court monitoring, and incarceration. Crosstraining activities can encourage employees to 

work together. Training is also needed to 

address the wide variety of “special needs” 

populations under criminal justice supervision and the impact of managed care systems and tiered placement criteria (e.g., 

American Society of Addiction Medicine criteria) on publicly funded treatment systems. 

Given that the rapid growth of treatment programs within the criminal justice system has 

not been matched by equal growth in organizational and staff resources, the system has 

been strained. Staff turnover, burnout, and 

other occupational hazards can be addressed 

through efforts to increase professionalism, 

such as developing 

•A clear hierarchy of staff positions with 

increasing responsibilities at each level 

•Clear requirements for advancement in the 

hierarchy 

•Incentives for additional training, made readily available 

•Incentives for working on units that are considered more difficult or are higher security 

•Merit pay 

Training resources 

CSAT launched a network of Addiction 

Technology Transfer Centers (ATTCs) in 1993 

to increase the knowledge and skills of substance abuse treatment professionals; to facilitate access to state-of-the-art research and 

education; heighten the awareness, knowledge, and skills of all professionals who may 

be in a position to help people with substance 

use disorders; and to foster alliances among 

stakeholders. Information on and links to 

ATTC’s 14 Regional Centers and National 

Office can be accessed online at 

http://www.attcNETWORK.org. 

The ATTCs have extensive resources of value 

to professionals working with offenders who 

abuse substances, a few of which are highlighted below: 

Working with Criminal Justice Clients. 

Designed to familiarize substance abuse treatment counselors to work with criminal justice 

clients, the curriculum includes material on 

intersystem teamwork and relapse issues. 

Training for Professionals Working with 

MICA (Mentally Ill Chemical Abusing) 

Offenders. This 1-day course module serves 

as cross-training for staff in law enforcement, 

mental health, and substance abuse settings. 

Orientation to Therapeutic Community. 

Developed to introduce administrators and 

ancillary staff to the history, theory, and current research on the therapeutic community 

model, this training provides a fundamental 

framework for therapeutic communities. This 

training curriculum is not intended for frontline workers. 

Therapeutic Community Experiential 

Training. Intended for frontline staff of startup therapeutic communities, this 5-day intensive experiential training provides participants with the knowledge, expertise, and attitudes that have been used effectively by professionals in the field. 

Criminal Justice/Substance Abuse Cross 

Training: Working Together for Change. This 

program is designed to help administrators 

and professionals integrate criminal justice 

and substance abuse services systems to coordinate treatment and recovery services and 

overcome barriers to collaboration. 

246 Chapter 11 
Research and

Evaluation

Research and evaluation is a critical dimension of substance abuse treatment programs 

in the criminal justice system. Evaluations 

are needed for program monitoring and for 

decisionmaking by program staff, prison 

administrators, and policymakers. 

Evaluations provide accountability, identify 

strengths and weaknesses, and provide a 

basis for program revision. In addition, evaluation reports are useful learning tools for 

others who are interested in developing effective programs. Many treatment programs in 

the criminal justice system have operated 

without evaluations for many years, only to 

find out later that key outcome data are needed to justify program continuation. 

Conducting an adequate evaluation requires 

one to clearly formulate the treatment model 

and reasonable program goals and specific 

objectives related to client needs. General 

goals must be translated into measurable outcomes. The evaluator generally works closely 

with program administrators to translate 

their evaluation guidelines into operational 

components. For example, general goals of 

helping program participants become drug 

and crime free can be operationalized into 

intermediate goals of changing behavior (e.g., 

reductions in rule infractions and fewer positive drug test results) while in a program. 

There are three basic types of evaluations: 

1. Implementation 

2. Process 

3. Outcome 

While implementation and process evaluations can begin when the program is initiated, 

outcome evaluation should not begin until the 

program has been fully implemented. 

Outcome evaluations are generally more costly than other types of evaluation and are warranted for programs of longer duration that 

are aimed at modifying lifestyles (such as 

therapeutic communities), rather than drug 

education interventions that are less intensive 

and less likely to produce long-term effects. 

Implementation Evaluation

While programs often look promising in the 

proposal stage, many fail to materialize as 

planned in the security-oriented correctional 

environment. Other 

programs are rigidly 

implemented as Research and

evaluation is a 

critical dimension 

of substance abuse

treatment 

programs in the

criminal

justice system.

planned and without 

adjustments for the 

realities of prison, 

often rendering 

them less effective. 

Implementation 

evaluations are 

aimed at identifying 

problems and 

accomplishments 

during the early 

phases of program 

development for 

feedback to clinical 

and administrative 

staff. Such evaluations involve informal and formal 

interviews with correctional administrators, 

officers, and inmates to ascertain their degree 

of satisfaction with the program and their 

perceptions of problems. 

In order to initiate an evaluation, in addition 

to having a clear, detailed proposal that 

describes the planned program, evaluators 

will need to know 

• The model or theory the program is based on 

• Criteria for participation 

• Program components 

• Planned treatment duration 

• Staff qualifications 

• Plans for staff orientation and training 

• The schedule for implementation 

These elements provide the basis for assessment. Periodic implementation feedback 

Key Issues Related to Program Development 247 
reports to program and institutional administrators can be very useful in identifying problems and planning corrective measures. 

Process Evaluation

Traditionally, process evaluation refers to 

assessment of the effects of the program on 

clients while they are in the program, making it 

possible to assess the institution’s intermediary 

goals. Process evaluation involves analyzing 

records related to 

•Type and amount of services provided 

•Attendance and participation in group meetings 

•Number of clients who are screened, admitted, reviewed, and discharged 

•Percentage of clients who favorably complete 

treatment each month 

•Percentage of clients who have infractions or 

rule violations 

•Number of clients who test positive for substances (this can be compared to urinalysis 

results for the general prison population) 

Effective programs produce positive client 

changes. These changes initially occur during 

participation in the program and ideally continue upon release into the community. The 

areas of potential client change that should be 

assessed include 

•Cognitive understanding (e.g., mastery of 

program curriculum) 

•Emotional functioning (e.g., anxiety and 

depression) 

•Attitudes/values (e.g., honesty, responsibility, 

and concern for others) 

•Education and vocational training progress 

(e.g., achievement tests) 

•Behavior (e.g., rule infractions and urinalyses results) 

Within corrections it is also important to evaluate program impact on the host institution. 

Well-run treatment programs often generate an 

array of positive developments affecting the 

morale and functioning of adjacent cellblocks 

and entire prisons. Areas to examine include 

•Inmate behavior. Review the number of 

rule infractions, the cost of hearings, court 

litigation expenses, and inmate cooperation 

in general prison operations. 

•Staff functioning. Assess stress levels, which 

may become manifest in the number of sick 

days taken and the rate of staff turnover. 

Generally, the better the program, the 

lower the stress, and the better the attendance, the involvement, and the commitment of staff. 

•Physical plant. Examine the physical properties of the program. Assess general vandalism apparent in terms of damage to furniture or windows, as well as the presence 

of graffiti. Assess structural damage, for 

example, to walls and plumbing. 

Institutional impact can be evaluated by comparing the status of the environment before 

and after program implementation (pre/post 

comparison), as well as by comparing the current status of similar cellblocks that do not 

have treatment programs. Careful cost assessment of institutional impact can help provide 

convincing information regarding program cost 

benefits to administrators, funding sources, 

and policymakers. 

Outcome Evaluation

Outcome evaluations are more ambitious and 

expensive than implementation or process 

evaluations. Outcome evaluations involve 

quantitative research aimed at assessing the 

impact of the program on long-term treatment 

outcomes. Such evaluations are usually carefully designed studies that compare outcomes 

for a treatment group with outcomes for other 

less intensive treatments or a no-treatment 

control group (i.e., a sample of inmates who 

meet the program admission criteria but who 

do not receive treatment), complex statistical 

analyses, and sophisticated report preparation. 

248 Chapter 11 
Followup data (e.g., drug relapse, recidivism, 

employment status) are the heart of outcome 

evaluation. Followup data can be collected 

from criminal justice and substance abuse 

treatment agency records or from face-to-face 

interviews with individuals who participated 

in prison programs. Studies that use agency 

records are less expensive than locating former inmates and conducting followup interviews. Outcome evaluations can include costeffectiveness and cost-benefit information 

that is important to policymakers. 

Because outcome research usually involves a 

relatively large investment of time and money, 

as well as the cooperation of a variety of people and agencies, it must be carefully 

planned. A research design may be very simple and easy to implement or it may be more 

complex. In the case of more complex studies 

it is usually advisable to enlist the assistance 

of an experienced researcher. The kinds of 

outcome information that might be collected 

are summarized in Figure 11-3 (next page). 

There is a hierarchy of evaluation approaches 

ranging from simple outcome monitoring to 

nonrandom or quasi-experimental designs to 

experimental research studies that use random assignment. The selection of a research 

design depends on available funding and 

available comparison groups. 

Any claims to a program’s effectiveness rest 

on comparisons that demonstrate it is superior to nontreatment groups or to groups that 

have received another type of treatment. The 

power of a research design is related to how 

defensible study results are against potential 

criticisms. Although simple outcome monitoring studies are relatively economical to conduct, they lack the comparison groups needed 

to show the specific effects of a program. 

While specific program outcomes can be compared with national and State norms or with 

published outcomes of another program, such 

comparisons are limited because of the many 

uncontrolled potential differences between 

the program group being monitored and the 

comparison groups. 

The defining characteristic of a pure research 

design is random assignment of inmates to 

treatment and control groups. Random 

assignment may be done by using a lottery 

type procedure that ensures that there are no 

systematic pretreatment differences between 

the groups (such as motivation or background 

characteristics). The concern is that any 

important preprogram difference in program 

and control groups may bias the results and 

compromise any claims for program effectiveness. Random assignment is difficult to implement in prisons because of ethical and legal 

implications of denying inmates treatment. If 

a program has a substantial waiting list it may 

be feasible to implement a lottery procedure 

as a fair method to control program admission, thus creating a random assignment situation. 

Nonrandom assignment is an attempt to 

approximate the power of the pure experimental design. A popular quasi-experimental 

design uses a comparison group that is 

matched to the program group on as many 

pretreatment factors as possible. Often, statistical methods are employed to control pretreatment group differences that might influence outcomes. 

Locating criminal justice clients for outcome 

studies is a very difficult and expensive 

undertaking. Collection of extensive locator 

information at program intake will assist 

interviewers in the locating task. Examples of 

useful locator information include social security number, driver’s license number, mother’s maiden name, aliases, names and locations of family members and friends, and 

locations of favorite hangouts. 

Large samples are needed in outcome studies 

to demonstrate significant results and to 

study the effects of multiple variables. For 

example, an analysis of the role of ethnicity 

(African American, Caucasian, and 

Key Issues Related to Program Development 249 
Figure 11-3 

Outcome Information 

Drugs • Urinalysis results 

• Drug-related parole infractions 

• Drug-related arrests 

Crime • Parole rule infractions 

• Time until parole rule infraction 

• New misdemeanor arrests of any type 

• New felony arrests for non–drug-related crimes 

• New felony arrests for drug-related crimes 

• New felony arrests for violent crimes 

• Time until arrest 

• Re-incarceration 

Social adjustment • Employment and education 

• Family (e.g., support, child rearing, marital, etc.) 

• Substance abuse treatment 

• Community involvement (e.g., community service) 

HIV risk behaviors • Intravenous drug injection 

• Sexual behavior 

• HIV test results 

Cost information • Cost estimates of substance use 

• Cost estimates of crimes 

• Cost estimates of social services to family (e.g., welfare) 

• Criminal justice processing and detention costs 

Tracking information • Tracking locator information (e.g., social security and license numbers, addresses of family and friends, etc.) 

Hispanic/Latino) reduces group size by a 

third. When reporting results it is generally 

best to use less complex statistics such as percentages and averages so that they are clear 

and understandable to nonstatisticians. 

Often, showing results in figures and charts is 

helpful. It is advisable to keep reports concise 

and clear for policymakers who may have little time or patience to study complex material. Finally, the credibility of outcome studies 

is often enhanced when conducted by outside 

researchers who have fewer vested interests 

in the outcomes. 

The consensus panel provided several recommendations for improving evaluation efforts 

within criminal justice programs: 

• Management information systems should be 

coordinated for use by substance abuse treatment and justice system professionals. This 

can lead to greater sharing of information 

and ensure that information is available for 

evaluation purposes. 

• Quality assurance and quality improvement 

measures should be applied across all criminal justice program settings. 

250 Chapter 11 
•Monitoring and evaluation should be part of 

all major treatment initiatives established 

within the criminal justice system. 

Cost Issues

Another critical area in program development 

is that of program costs, including cost savings and cost-benefit/cost-offset information. 

Program administrators are routinely 

required to provide evidence that monies are 

spent effectively. The literature indicates that 

treatment has cost benefits in certain settings. 

Positive cost-offset results (savings down the 

road) have been demonstrated from treatment through specific approaches, such as 

drug courts (Belenko 2001). Similar results 

have been shown for treatment in prison settings (McCollister and French 2001). 

Cost analyses (see Figure 11-4 below for definition) are important in determining how to 

allocate funds within a program and for 

understanding the relationship between costs 

and outcomes. Examining costs for the program as a whole (or for parts of it) is a basic 

form of cost analysis. Cost analyses can be 

provided as a monthly or quarterly report 

and costs generally vary over time. Costs provided at several levels include: 

•Total cost of the program for the average 

treatment 

•Cost of each part of the program each day 

• Total monthly or annual cost per offender 

The major types of cost analyses include 

“cost,” “cost-effectiveness,” and “cost benefit,” 

and are described below in Figure 11-4. 

Some treatment program evaluations measure 

direct monetary outcomes, such as a reduction in the use of health services. Other treatment program evaluations can measure indirect costs, such as reduction in crime-related 

costs, reduced recidivism, and the costs of 

incarcerating offenders. 

Other ways to report the relationship between 

costs and benefits include 

•The net benefit of a program can be shown 

by subtracting the costs of a program from 

its benefits. 

•The ratio of benefits to costs is found by 

dividing total program benefits by total program costs. 

•The time to return on investment is the time 

it takes for program benefits to equal program costs. 

•The present value of benefits takes into 

account the decreasing value of benefits 

attained in the distant future. 

•Because neither net benefits nor cost-benefit 

ratios indicate the size of the cost (initial 

investment) required for treatment to yield 

the observed benefits, it is important to 

report this as well. 

Figure 11-4 

Definition of Terms 

Name Definition 

Cost analysis A thorough description of the type and amount of all resources 

used to produce substance abuse treatment services. 

Cost-effectiveness analysis The relationship between program costs and program effectiveness, that is, patient outcome. 

Cost benefit analysis The measurement of both costs and outcomes in monetary terms. 

Source: Yates 1999. 

Key Issues Related to Program Development 251 
How Politics and Policy Can Affect Treatment: California’s 

Proposition 36 

In November 2000, by a 60 percent majority, California passed Proposition 36 (the Substance Abuse 

and Crime Prevention Act [SACPA], see chapter 7 for more information). Its passage has been interpreted, in part, as an expression of public dissatisfaction with the increasing share of State budgets allocated to expansion of correctional facilities at the expense of other public services, such as education. 

Under the SACPA initiative, offenders who are convicted of nonviolent drug-related offenses are eligible 

for diversion to community treatment programs. Diversionary program eligibility is also provided for an 

estimated 9,500 parole violators annually. Offenders may apply to have their charges dismissed after 

successful completion of probation and treatment. Proponents of this law suggest that treatment saves 

money and enhances public safety and public health by reducing crime and substance abuse. Opponents 

countered that the proposition offers a quick fix that lacks safeguards, compromises public safety, and 

invites ineffective treatment. The law became effective July 1, 2001. In its second year (July 2002 to 

June 2003), about 50,000 offenders were referred for substance abuse treatment. Of those, about 71 

percent (35,947) went on to enter treatment (Longshore et al. 2004). 

Key Goals of SAMHSA
 SAMHSA is committed to serving justiceinvolved populations and shares that responsibility with other agencies. In 2004 SAMHSA 

began a 2-year action plan to create a strategy 

to facilitate development and management of 

mental health and substance abuse prevention, 

early intervention, clinical treatment, and 

recovery support policies, programs, strategies, 

and practices for adults and juveniles in contact with or involved with the justice system. 

Following are some of the key activities that are 

underway: 

•Develop and implement a Recovery 

Management Framework that will foster 

resiliency and manage recovery among 

adults and juveniles involved in the criminal justice system. 

•Examine the gaps within SAMHSA’s criminal and juvenile justice activities and identify key efforts that could be implemented. 

•Provide training and technical assistance on 

best practices and evidence-based programs 

for persons in the criminal justice system. 

•Support mechanisms that promote sciencebased policies, programs, and models to 

ensure that services are provided at all 

points in the criminal justice system. 

•Support knowledge synthesis and information dissemination efforts to help change 

attitudes of and reduce stigma among service providers who work with clients in the 

justice system. 

•Engage in targeted collaborations at local, 

State, and Federal levels to promote effective, integrated systems approaches. 

•Inform communities, policymakers, and 

other stakeholders of the importance of 

substance abuse and mental health services 

for people in the criminal justice system. 

For more information about SAMHSA’s 

efforts regarding substance abuse and mental 

health services for adults and juveniles in the 

criminal justice system go to 

http://www.samhsa.gov. 

Conclusions

The consensus panel draws conclusions and 

makes recommendations as follows: 

• A goal that is critically important to both the 

substance abuse treatment and correctional 

systems is the reduction of crime. 

252 Chapter 11 
•It is vitally important that these two systems 

recognize that treatment must be tailored to 

the particular criminal justice setting and to 

the client’s stage in the recovery process. 

•The following basic principles can be used to 

promote change in the criminal justice and 

treatment systems: developing leadership, 

obtaining endorsement from systems leaders, 

establishing common goals and objectives, 

identifying stakeholders, and encouraging 

collaboration among stakeholders. 

•Good treatment programs contribute to 

enhancing safety and security, as program 

participants usually present the fewest safety 

and security-related problems. 

•Substance abuse treatment professionals 

should be trained in criminal justice issues, 

and criminal justice personnel should be 

trained in substance abuse issues. Crosstraining activities can encourage employees’ 

willingness to work with each other more and 

can help personnel manage the wide variety 

of “special needs” populations under criminal justice supervision as well as the impact 

of managed care systems and tiered placement criteria. 

• Research and evaluation are a critical dimension of substance abuse treatment programs 

in the criminal justice system. Evaluations 

provide feedback related to key issues and 

also can identify major problems related to 

program implementation. 

• Program costs are another critical area. Cost 

analyses can help a program determine how 

to allocate funds and understand the relationship between costs and outcomes. 

Key Issues Related to Program Development 253 
 

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290 Appendix A
Appendix B: 

Glossary

Acquittal

Judicial deliverance from a criminal charge on a verdict or finding of 

not guilty. 

ADAM 

Arrestee Drug Abuse Monitoring Program; a program sponsored by 

the National Institute of Justice that periodically administers drug 

tests and short research interviews to samples of new arrestees in 

selected cities. 

Addiction

Drug craving accompanied by physical dependence that motivates 

continuing use, resulting in a tolerance to the drug’s effects and a syndrome of identifiable symptoms. 

Addiction Severity Index (ASI) 

A standardized assessment tool used to conduct a comprehensive drug 

evaluation and to match offenders’ drug problems with treatment 

approaches. (See also Offender Profile Index.) 

Adjudication (for adults) 

The process of resolving a criminal case through the determination of 

guilt or innocence and determining a sentence if the person is convicted of the crime. 

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. 

Aftercare 

Treatment that occurs after completion of inpatient or residential 

treatment. 

291 
Alcoholics Anonymous

The best known of self-help support 

groups, which serves as an important 

adjunct to treatment. 

Ancillary treatment services

These include education about substance 

abuse, self-help groups (Alcoholics 

Anonymous, Narcotics Anonymous), and 

skills training. 

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. 

Assessment 

Evaluation or appraisal of a candidate’s 

suitability for substance abuse treatment 

and placement in a specific treatment 

modality/setting. This evaluation includes 

information on current and past use/abuse 

of drugs; justice system involvement; medical, familial, social, educational, military, 

employment, and treatment histories; and 

risk for infectious diseases (e.g., sexually 

transmitted diseases, tuberculosis, 

HIV/AIDS, and hepatitis). (See also 

Screening.) 

Bail

Security (usually financial) provided as a 

guarantee that an arrested person will 

appear for trial; release from imprisonment 

based on that security. (See also Financial 

bail and Nonfinancial conditions.) 

Behavior contracts

An agreement between counselor and client 

about the sanctions and incentives that are 

to be applied when specified when the 

client performs specified behaviors. 

Bond hearing 

Proceeding before a judge to determine 

what (if any) conditions to set for a 

detainee’s release pending trial. 

Booking facility

A secure lockup usually operated by the 

local police or sheriff’s department. New 

arrestees are taken to and held in booking 

facilities for paper processing, fingerprinting, criminal records, and warrant checks, 

pending the initial appearance before a 

judge. 

Boot camp

Typically, a sentence to a boot camp (also 

called shock incarceration) is for a relatively short time (3–6 months). These camps 

are characterized by intense regimentation, 

physical conditioning, manual labor, drill 

and ceremony, and military-style obedience. 

Boundary-spanner

An individual with knowledge of both substance abuse treatment and criminal justice 

systems who can facilitate the interaction of 

the two for the purpose of obtaining substance abuse treatment for offenders under 

criminal justice supervision. 

Center for Substance Abuse Treatment 

CSAT is a Federal agency within the 

Substance Abuse and Mental Health 

Services Administration (SAMHSA). 

SAMHSA is part of the Public Health 

Service, under the Cabinet-level 

Department of Health and Human 

Services. 

Changing the Conversation 

CSAT’s National Treatment Plan Initiative, 

published November 2000, which is a consensus document on how to improve substance abuse treatment and how those 

changes can be accomplished. 

Classification

The process by which a jail, prison, probation office, parole, or other criminal justice 

agency assesses the security risk of an individual offender and the individual’s need 

for social services. 

292 Appendix B 
 

 

Clinical formulation

The process of integrating information 

obtained through assessment into larger 

patterns or processes. 

Clinicians

(See Counselors and clinicians.) 

Coercion

The use of incentives and sanctions to 

encourage participation in substance abuse 

treatment. 

Cognitive–behavioral therapy

Treatment that focuses on learning and 

practicing coping skills, some of which are 

cognitive in nature. 

Community corrections

A model of corrections that has a primary 

goal of reintegrating the offender into the 

community. Typically will consist of judicial dispositions that involve alternatives to 

incarceration, such as diversion program, 

house arrest, electronic monitoring, probation, and parole. 

Community notification laws

Laws that allow law enforcement to inform 

the public of the whereabouts (in some 

jurisdictions the specific home address) of 

offenders. The laws generally apply to sex 

offenders and typically include the “risk” 

level of the offender. Community notification laws are in effect in 50 States and the 

District of Columbia. 

Community reintegration planning 

Preparation and strategy for each prisoner’s release from custody. The plan prepares for the prisoner’s return to the community in a law-abiding role after release. 

Community supervision or

Community-supervised activities

These are outside the formal criminal justice system. Such activities include, for 

example, drug testing, programs to promote sobriety and prevent relapses, and 

day reporting centers. 

Community treatment 

This is a program outside the formal criminal justice setting. It may be run by public 

or private organizations (nonprofit or 

profit-making). Treatment may take place 

in a residential group (e.g., a halfway 

house) or a nonresidential activity (e.g., 

required attendance at Alcoholics 

Anonymous meetings). Treatment methods 

may vary. Both community treatment and 

community supervision are usually mandated by a court. An active partnership 

between these two should be built into 

planning activities for both. 

Conditional release 

Release from custody under specified conditions. 

Confidentiality

The right of privacy for a client’s/offender’s personal information, except in certain 

law-enforcement situations. 

Continual interagency communication

The ongoing cooperative effort among 

treatment/criminal justice/public health 

personnel needed to successfully treat and 

supervise offenders involved with drugs. 

Communication among these systems facilitates a united approach. 

Co-occurring disorders

TIP 42, Substance Abuse Treatment for 

People With Co-Occurring Disorders, uses 

the term to specify the co-occurrence of a 

mental disorder and a substance use disorder. Other uses of the term include substance abuse accompanied by one or more 

physical or psychological conditions. 

Sometimes referred to as dual disorders. 

Corrections system

Includes jails and detention centers, prisons, and community supervised settings. 

Counselors and clinicians

Treatment professionals serving clients who 

abuse substances and are involved in the 

criminal justice system. 

Glossary 293 
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. 

Cultural competence 

A set of academic and interpersonal skills 

that helps individuals increase their understanding and appreciation of cultural differences and similarities within, among, and 

between groups. It requires a willingness 

and ability to draw on community-based 

values, traditions, and customs and to work 

with knowledgeable people from the community in developing focused interventions, 

communication, and support. (See TIP 12, 

appendix C, for more on this topic, such as 

the “Continuum of Competence.”) 

Curfew 

In the criminal justice context, a rule or 

condition applied to individuals on probation or parole, requiring them to be in their 

residence and remain there by a specific 

time. An individual sentenced to house 

arrest will have a curfew. 

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. 

Denial breaking 

An intervention strategy designed to confront thought processes that prevent the 

individual from acknowledging problems 

related to his or her use of alcohol or illicit 

substances. 

Detention

Holding a defendant in jail or other facility 

pending trial or determination of guilt. 

Detention center

For adults, a holding facility such as a jail. 

Determinate sentence 

A sentence in which the length of incarceration is fixed by the court. 

Deterrence 

Being deterred from criminal activity 

because of fear of involvement in the criminal justice system or other punishment. 

Detoxification

A structured medical or social milieu in 

which an individual is monitored for withdrawal from the acute physical and psychological effects of addiction. 

Developmental interagency

coordination

Collaboration among personnel from criminal justice, treatment, and public health to 

form expert justice/treatment/public health 

systems. For example, developmental interagency coordination is essential in the 

assessment of the drug-involved offender 

and in the development of referral procedures and reporting policies, as well as in 

understanding each system’s definition of 

success and failure. 

Disposition

The final resolution of a criminal case (e.g., 

in a case in which an individual is found 

not guilty, the disposition is an acquittal 

and release). 

Diversion

The process whereby a defendant’s prosecution is deferred or dropped if certain 

conditions are met. Diversion also is the 

judicial option to refer prison-bound cases 

to a review board, which in turn may recommend that the original sentence be modified or suspended and that the offender be 

placed in a residential or nonresidential 

program. 

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 

294 Appendix B 
 

 

support services. They often operate with 

probation supervision and services. 

Drug testing 

Technical examination of urine samples to 

determine the presence or absence of specified drugs or their metabolized traces. 

Drug use forecasting 

Arrestee urinalysis data based on studies 

conducted under the Drug Use Forecasting 

(DUF) System of the National Institute of 

Justice. 

DSM-IV 

Diagnostic and Statistical Manual, 4th edition, published by the American 

Psychiatric Association, a standard manual 

used to categorize psychological or psychiatric conditions. 

Due Process (of Law) 

Legal proceedings established to protect 

individual rights and liberties. 

DUI, DWI

Driving under the influence or driving 

while intoxicated. 

Duty to warn

A treatment professional’s duty to report a 

patient’s threat to harm another or to commit a crime (does not apply to knowledge of 

a client’s past offenses). 

Electronic monitoring 

A sanction in which an electronic device is 

worn by an offender that can alert corrections officials to the unauthorized absence 

from the house of a person under 

curfew/house arrest. (See also House 

arrest.) 

Financial bail

An amount of money, set by a judge, that is 

used to ensure the defendant’s appearance 

at court. (See also Bail and Nonfinancial 

conditions.) 

Habilitation

Training in social problemsolving skills for 

people with mental illness requiring the 

client to: (1) define the problem; (2) generate alternative solutions; (3) choose the best 

solution, (4) make a plan, and execute it; 

and (5) evaluate the outcome. 

Halfway house 

A transitional facility where a client is 

involved in school, work, training, etc. The 

client lives onsite while either stabilizing or 

reentering 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. (See also Work release.) 

House arrest 

The restriction of offenders to their homes 

for various periods of time. (See also 

Electronic monitoring.) 

Incarceration

Holding a person in a detention center, jail, 

or prison (State or Federal) because of suspected or actual involvement in criminal 

activity. 

Indeterminate sentence 

A prison sentence in which the amount of 

time to be served is indeterminate and is 

usually determined by a Parole Board after 

a minimum period of incarceration. Judges 

generally impose a minimum and maximum 

incarceration term in indeterminate sentences. 

Infectious diseases risk assessment 

Evaluation of a person’s risk for sexually 

transmitted diseases, tuberculosis, 

HIV/AIDS, and other infectious diseases 

including information regarding current 

and past history, screening, and treatment 

of such diseases. Testing and referral for 

treatment are recommended for those with 

Glossary 295 
 

 

substance use disorders who are assessed 

as at high risk for such diseases. Those 

with substance use disorders who are 

assessed as at low risk should be reassessed 

intermittently. Thus, collaboration between 

criminal justice personnel, treatment personnel, and public health personnel must 

be developed in order to ensure interagency coordination in the assessment and 

treatment of the drug-involved offender at 

various stages throughout the criminal justice continuum and in the development of 

referral procedures and reporting policies, 

as well as in understanding each system’s 

definitions of success and failure. 

Intermediate sanctions

Community-based programs providing 

increased surveillance, tighter controls on 

movement, more intense treatment for a 

wider assortment of maladies or deficiencies, increased offender accountability, and 

greater emphasis on payments to victims 

and/or corrections authorities. Intermediate sanctions are less punitive than 

incarceration but more punitive than simple probation. (See also Sanctions.) 

Interpersonal issues

Those between the client and counselor in 

the therapeutic relationship. Includes 

boundaries, training, the need for peer role 

models and cultural sensitivity, respect for 

confidentiality and privacy, and the counselor’s duty to report certain client crimes. 

Intrapersonal issues

Those stemming from an individual’s psychological makeup and/or physical conditions (including co-occurring disorders), as 

well as one’s social skills, educational status, and personal support system. 

Jail

A place for holding a person in lawful custody, usually while he or she is awaiting 

trial. In some jurisdictions, jails are used 

punitively for offenders serving short-term 

sentences or those involving work release 

or weekends in incarceration. Jails range 

in size from small rural ones with a dozen 

or so cells to urban settings with thousands 

of cells. Jails usually are operated by cities 

or counties. 

Linkages

The provider establishes working relationships with various agencies and facilities in 

order to refer clients with multiple life 

problems to accessible, appropriate vocational training, medical, assisted living, and 

legal assistance services. 

Management Information System (MIS) 

A computer system that assists in organizing information for the purposes of planning and maintaining a business or other 

organization. 

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. 

Methadone treatment 

Medically supervised outpatient treatment 

that provides counseling while maintaining 

a client on the drug methadone (used mainly for heroin or other opioid addiction). 

Monitoring for compliance 

Surveillance of an offender to ensure that 

the conditions imposed on an individual 

are being adhered to. 

Narcotics Anonymous

A self-help and support group similar to 

Alcoholics Anonymous. 

National Treatment Plan Initiative 

Developed by CSAT, this initiative is a 

blueprint for improving substance abuse 

treatment. 

Negative predictive value 

The proportion of offenders identified by a 

screening or assessment instrument as not 

296 Appendix B 
 

having substance abuse problems, compared to the total number not having substance abuse problems. 

Nonfinancial conditions

Release requirements set by a judge that do 

not include monetary payment (e.g., 

required participation in supporting services, such as substance abuse treatment). 

(See also Bail and Financial bail.) 

Nonresidential treatment of 

incarcerated people 

In this form of treatment, prisoners receive 

treatment either through day care programs, regularly scheduled therapeutic 

groups, or other nonresidential programs. 

“No Wrong Door” 

This key component of CSAT’s National 

Treatment Initiative indicates that no matter where they enter the health or social 

service system, people should be able to get 

treatment for substance abuse, either 

directly or through appropriate referral. 

Offender Profile Index 

A standardized assessment tool used to 

conduct a comprehensive drug evaluation 

and to match offenders’ drug problems 

with treatment approaches. (See also 

Addiction Severity Index.) 

On recognizance 

Release on one’s own responsibility (e.g., 

with an obligation to appear in court, but 

the release is not secured by financial bail). 

Overall accuracy

The extent to which a screening or assessment instrument classifies respondents correctly. 

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. 

Peer staff 

Individuals in recovery from substance 

abuse disorders who have been trained for 

work in the treatment or criminal justice 

areas. 

Personal bond

Release from court on one’s own promise to 

appear in court, without financial conditions. Similar to release on recognizance. 

Pharmacotherapies

Treatment of disease with drugs. In substance abuse treatment, these include 

methadone, naltrexone, and buprenorphine. 

Placement 

Assigning substance abuse treatment program participants with appropriate community substance abuse treatment facilities 

when such individuals leave the correctional facility at the end of a sentence or on 

parole. 

Plea bargain

An agreement by a defendant to plead 

guilty to a criminal charge with the expectation of receiving some consideration from 

the prosecution for doing so. Typically the 

consideration is a reduction of the charge. 

The defendant’s goal is a penalty lighter 

than the one warranted by the charged 

offense. 

Positive predictive value 

The proportion of offenders identified by a 

screening or assessment instrument as having substance abuse problems, compared to 

the total number having substance abuse 

problems. 

Preliminary hearing 

A court hearing in which initial information about the case is presented. This hearing usually is used to determine if there is 

sufficient evidence of guilt to continue the 

case, resolve evidentiary issues, or make 

initial case decisions. 

Glossary 297 
Prerelease assessment 

This information on an individual’s situation/condition, as provided by treatment 

professionals, should be available to the 

judge, prosecutor, and other participants 

at the time of a presentence hearing or 

trial/sentencing. If an individual is paroled, 

the information should be conveyed to the 

parole officer for followup and evaluation. 

Recommendations for referral for treatment can be made at this time. 

Presentence hearing 

An event at which the prosecutor, defense 

attorney, and judge meet before a trial to 

establish parameters for that trial. A plea 

bargain is often negotiated at this point. 

Presentence investigation

An investigation into the background and 

character of a defendant that assists the 

court in determining the most appropriate 

sentence in a case. Typically occurs after 

the person has been convicted, but prior to 

sentencing. 

Pretrial hearing 

Appearance in court before a magistrate, 

at which time bond is set or a determination is made to retain a person in jail or 

release him or her. 

Pretrial stage 

Activities in the criminal justice process 

that occur between arrest and trial. 

Prison

A secured institution (Federal or State) in 

which convicted felons are confined after 

sentencing for crimes. Prisons are classified 

as minimum-, medium-, or maximum-security facilities, based on the need for internal institutional fortification. Inmates are 

similarly classified, according to severity of 

offense and/or other behavior and are usually assigned to prisons having a corresponding level of security. 

Probation

A sentence in which the offender is allowed 

to remain in the community in lieu of 

incarceration. The individual is supervised 

and is ordered to comply with specific 

terms and conditions. 

Problem-solving courts

These specialized court settings include 

drug courts, family courts, jail courts, and 

mental health courts. 

Process evaluation

Determination of whether individuals actually received the treatment as it was intended to be delivered; examines implementation and operation of a program in comparison with the stated intent. 

Protocol

Consists of guidelines and procedures for 

dealing with a particular issue or activity. 

Psychopharmacology

The science dealing with the effect of medications in treating psychiatric conditions. 

Recidivism

The commission of crime after an offender 

has been sentenced and/or released. 

Re-entry formulation

The process of providing counseling and 

community-based supports to ex-offenders 

who abused substances and who are 

returning to society. 

Relapse prevention

Strategy to train people with substance use 

disorders to cope more effectively and to 

overcome the stressors/triggers in their 

environments that may lead them back into 

drug use and dependency. 

Reparation

(See Restoration.) 

Residential treatment 

Inpatient treatment, in which the client 

spends 24 hours a day in the treatment 

environment. 

298 Appendix B 
Restoration

Sometimes referred to as reparation, its 

aim is to restore the community to its state 

before a crime was committed. It does this 

in part by preventing the offender from 

reoffending through rehabilitation, incapacitation, or deterrence. 

Restitution

Payment by an offender of the costs of a 

victim’s losses or injuries and/or damages 

to the victim. Payment can be made to a 

general victim compensation fund or to the 

community as a whole (with the payment 

going to the municipal or State treasury). 

Risk/needs assessment 

A comprehensive report that includes a 

client’s social, criminal, and other history. 

The report usually includes a recommendation for sentencing if the client is found 

guilty. 

Sanctions

Legally binding orders of a court or paroling authority that deprive or restrict 

offender liberty or property. An intermediate sanction (see p. 296) is more rigorous 

than traditional probation but less so than 

total incarceration. 

Screening 

Gathering and sorting of information used 

to determine if an individual has a problem 

with substance abuse and, if so, whether a 

detailed clinical assessment is appropriate. 

(See also Assessment.) 

Security classification (in criminal

justice) 

The process of assigning an inmate to a category based on the perceived likelihood of 

an offender’s attempt at escape, propensity 

for violence, or management concerns. 

Sensitivity

The extent to which a screening or assessment instrument accurately identifies those 

with substance use disorders (true positives). 

Sentencing 

The disposition of a case where penalties 

are imposed. 

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. 

Sobering station

A 24-hour facility where individuals can be 

housed and monitored while under the 

influence of mood-altering substances. 

Sobriety maintenance 

The last step in recovery when the client 

has achieved stable sobriety and efforts are 

directed toward maintaining that stability. 

Special-needs probation programs or

caseloads

In these approaches to intermediate sanctions, officers with special training carry a 

restricted caseload. Typically, these 

approaches are used with offenders who 

have committed certain categories of 

domestic violence, sex offenses, and DUI, 

and with offenders who are mentally ill, 

developmentally disabled, or abuse substances. This situation can mean more 

intensive or intrusive supervision than in 

routine caseloads; enhanced social and psychological services; and/or specific training 

or group activities, such as anger management classes. 

Specific populations

These include a wide range of people facing 

a wide range of issues—for example, 

racial/ethnic/sexual minorities and women, 

people with disabilities, older people, and 

those who are underserved or underrepresented in treatment. This term can also 

include violent offenders, sexual offenders, 

victims or perpetrators of domestic abuse, 

psychopaths, and offenders with life sentences. 

Glossary 299 
Specificity

The extent to which a screening or assessment instrument accurately identifies those 

without substance use disorders (true negatives). 

Split sentence 

A sentence involving a short period of 

incarceration followed by probation or 

some other form of community supervision. 

Stakeholders

Those who have a key interest/investment 

in an issue or activity—includes clients, 

treatment and criminal justice personnel, 

and policymakers. 

Test-retest reliability

This quality of a screening or assessment 

instrument, expressed as a coefficient, is 

“obtained by administering the same test a 

second time to the same group after a time 

interval and correlating the two sets of 

scores” (American Educational Research 

Association 1999, p. 183). 

Therapeutic community

Traditionally, this is a long-term (up to 24 

months) rehabilitative model that relies 

mainly on peer staff and on work as education and therapy. Other staff include treatment and mental health professionals and 

vocational and educational counselors. The 

aim here is a global change in a person’s 

lifestyle, focused on developing vocational, 

educational, and social skills. Most residents have been involved with the criminal 

justice system. 

Treatment 

Refers to the broad range of primary and 

supportive services—including identification, brief intervention, assessment, diagnosis, counseling, medical services, psychological services, and followup—provided 

for people with alcohol and illicit drug 

problems. The overall goal of treatment is 

to eliminate the use of alcohol and illicit 

drugs as a contributing factor to physical, 

psychological, and social dysfunction and 

to arrest, retard, or reverse progress of 

associated problems. 

Treatment matching 

Pairing clients with treatments and services 

that reflect their particular traits and 

needs in order to enhance the potential for 

better outcomes. 

Treatment planning 

The process of planning a client’s total 

course of treatment, based on the findings 

of assessment procedures. 

Treatment progress assessment 

A process that determines the value of the 

chosen course of treatment, its suitability 

for the client, and how it should be extended or adjusted if necessary. 

Triage 

A process for sorting injured people into 

groups based on their need for medical 

treatment—in short, immediate attention 

and first-stage treatment for people with 

substance abuse disorders and others. 

Trial

A court hearing at which a prosecutor presents a case against a defendant to show 

that he or she is guilty of a crime. The 

defendant presents information to support 

the plea that he or she is not guilty. The 

judge or jury decides the verdict. 

Unbroken contact 

Early, thorough, and substantial substance 

abuse treatment delivered in an unbroken 

manner throughout the entire criminal 

case-handling process, from arrest through 

the completion of the sentence. The components of the system must transfer not only 

the offender but also the cumulative record 

of what the system has learned and what it 

has done. 

Urinalysis

The testing of a urine sample for the presence of drugs. 

Glossary 301 
Waiver

A court action in which the defendant 

agrees to forgo certain legal rights, such as 

the right to a grand jury hearing or the 

right to a speedy trial. The term is also 

used to indicate the transfer of a juvenile 

offender to the adult criminal justice system when he or she has been accused of 

committing certain serious crimes. 

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. (See also Halfway House.) 

300 Appendix B 
 

Appendix C: 

Screening and

Assessment 

Instruments

Addiction Severity Index (ASI) 

Purpose: The ASI is most useful as a general intake screening tool. It 

effectively assesses a client’s status in several areas, and the composite 

score measures how a client’s need for treatment changes over time. 

Clinical utility: The ASI has been used extensively for treatment planning 

and outcome evaluation. Outcome evaluation packages for individual programs or for treatment systems are available. 

Groups with whom this instrument has been used: Designed for adults 

of both sexes who are not intoxicated (drugs or alcohol) when interviewed. 

Also available in Spanish. 

Norms: The ASI has been used with males and females with drug and 

alcohol disorders in both inpatient and outpatient settings. 

Format: Structured interview. 

Administration time: 50 minutes to 1 hour. 

Scoring time: 5 minutes for severity rating. 

Computer scoring? Yes. 

Administrator training and qualifications: A self-training packet is available as well as onsite training by experienced trainers. 

Fee for use: No cost; minimal charges for photocopying and mailing may 

apply. 

Available from: A. Thomas McLellan, Ph.D. 

Building 7 

PVAMC 

University Avenue 

Philadelphia, PA 19104 

Ph: (800) 238-2433 

303 
The Alcohol Use 

Disorders Identification

Test (AUDIT) 

Purpose: The purpose of the AUDIT is to identify persons whose alcohol consumption has 

become hazardous or harmful to their health. 

Clinical utility: The AUDIT screening procedure is linked to a decision process that 

includes brief intervention with heavy drinkers 

or referral to specialized treatment for patients 

who show evidence of more serious alcohol 

involvement. 

Groups with whom this instrument has been 

used: Adults, particularly primary care, emergency room, surgery, and psychiatric patients; 

DWI offenders, criminals in court, jail, and 

prison; enlisted men in the armed forces; workers in employee assistance programs and industrial settings. 

Norms: Yes, heavy drinkers and people with 

alcohol use disorders. 

Format: A 10-item screening questionnaire 

with 3 questions on the amount and frequency 

of drinking, 3 questions on alcohol dependence, and 4 questions on problems caused by 

alcohol. 

Administration time: 2 minutes. 

Scoring time: 1 minute. 

Computer scoring? No. 

Administrator training and qualifications: The 

AUDIT is administered by a health professional or paraprofessional. Training is required for 

administration. A detailed user’s manual and a 

videotape training module explain proper 

administration, procedures, scoring, interpretation, and clinical management. 

Fee for use: No. 

Available from: Can be downloaded 

from Project Cork 

Web site: 

http://www.projectcork.org 

Beck Depression

Inventory–II (BDI–II) 

Purpose: Used to screen for the presence and 

rate the severity of depression symptoms. 

Clinical utility: Like its predecessor, the 

BDI–II consists of 21 items to assess the intensity of depression. The BDI-II can also be used 

as a screening device to determine the need for 

a referral for further evaluation. Each item is a 

list of four statements arranged in increasing 

severity about a particular symptom of depression. These new items bring the BDI–II into 

alignment with Diagnostic and Statistical 

Manual for Mental Disorders, 4th edition 

(DSM-IV) criteria. 

Items on the new scale replace items that dealt 

with symptoms of weight loss, changes in body 

image, and somatic preoccupation. Another 

item on the BDI that tapped work difficulty 

was revised to examine loss of energy. Also, 

sleep loss and appetite loss items were revised 

to assess both increases and decreases in sleep 

and appetite. The BDI-II shows improved clinical sensitivity and higher reliability than the 

BDI. 

Groups with whom this instrument has been 

used: All clients aged 13 through 80 who can 

read and understand the instructions and 

clients who cannot read (requires reading the 

statements to them). 

Norms: The BDI has been used with people 

with substance use disorders, psychiatric 

patients, medical inpatients, and many other 

populations. 

Format: Paper-and-pencil self-administered 

test. 

Administration time: 5 minutes, either selfadministered or administered verbally by a 

trained administrator. 

Scoring time: N/A. 

Computer scoring? No. Any staff member can 

perform the simple scoring. 

304 Appendix C
Administrator training and qualifications: 

Doctoral-level training or master’s-level training with supervision by a doctoral-level clinician are required to interpret test results. 

Fee for use: $66 for manual and package of 25 

record forms. 

Available from: The Psychological 

Corporation 

19500 Bulderve 

San Antonio, TX 78259 

Ph: (800) 872-1726 

CAGE Questionnaire 

Purpose: The purpose of the CAGE 

Questionnaire is to detect alcoholism. 

Clinical utility: The CAGE Questionnaire is a 

very useful bedside, clinical desk instrument 

and has become the favorite of many family 

practice and general internists—also very popular in nursing. 

Groups with whom this instrument has been 

used: Adults, adolescents (over 16 years). 

Norms: Yes. 

Format: Very brief, relatively nonconfrontational questionnaire for detection of alcoholism, usually beginning “have you ever” but 

which can be phrased to refer to past month or 

current behavior. 

Administration time: Less than 1 minute. 

Scoring time: Instantaneous. 

Computer scoring? No. 

Administrator training and qualifications: No 

training required for administration; it is easy to 

learn, easy to remember, and easy to replicate. 

Fee for use: No. 

Available from: May be downloaded from 

the Project Cork Web site 

http://www.projectcork.org 

Circumstances, 

Motivation, and

Readiness Scales (CMR 

Scales) 

Purpose: The instrument is designed to predict 

retention in treatment and is applicable to both 

residential and outpatient treatment modalities. 

Clinical utility: The instrument consists of four 

derived scales measuring external pressure to 

enter treatment, external pressure to leave 

treatment, motivation to change, and readiness 

for treatment. Items were developed from focus 

groups of recovering staff and clients and 

retain much of the original language. Clients 

entering substance abuse treatment perceive 

the items as relevant to their experience. 

Groups with whom this instrument has been 

used: Adults. 

Norms: Norms are available from a large secondary analysis of more than 10,000 clients in 

referral agencies, methadone maintenance, 

drug-free outpatient and residential treatment. 

Norms are also available for specific populations, such as clients with COD, prison-based 

programs, and women’s programs. 

Format: 18 items at approximately a thirdgrade reading level. Responses to the items 

consist of a 5-point Likert scale on which the 

individual rates each item on a scale from 

Strongly Disagree to Strongly Agree. Versions 

are also available in Spanish and Norwegian. 

Administration time: 5 to 10 minutes. 

Scoring time: Can be easily scored by reversing negatively worded items and summing the 

item values. 

Computer scoring? No. 

Administrator training and qualifications: 

Self-administered; no training required for 

administration. 

Fee for use: N/A. 

Screening and Assessment Instruments 305 
Available from: George De Leon, Ph.D., or 

Gerald Melnick, Ph.D. 

National Development and 

Research Institutes, Inc. 

71 West 23rd Street 

8th Floor 

New York, NY 10010 

Ph: (212) 845-4400 

Fax: (917) 438-0894 

E-mail: 

gerry.melnick@ndri.org 

http://www.ndri.org 

The Drug Abuse 

Screening Test (DAST) 

Purpose: The purpose of the DAST is (1) to 

provide a brief, simple, practical, but valid 

method for identifying individuals who are 

abusing psychoactive drugs; and (2) to yield a 

quantitative index score of the degree of problems related to drug use and misuse. 

Clinical utility: Screening and case finding; 

level of treatment and treatment/goal planning. 

Groups with whom this instrument has been 

used: Individuals with at least a sixth grade 

reading level. 

Norms: Yes. A normative sample consisting of 

501 patients, representative of those applying 

for treatment in Toronto, Canada. 

Format: A 20-item instrument that may be 

given in either a self-report or in a structured 

interview format; a “yes” or “no” response is 

requested from each of 20 questions. 

Administration time: 5 minutes. 

Scoring time: N/A. 

Computer scoring? No. The DAST is planned 

to yield only one total or summary score ranging from 0 to 20, which is computed by summing all items that are endorsed in the direction of increased drug problems. 

Administrator training and qualifications: For 

a qualified drug counselor, only a careful reading and adherence to the instructions in the 

“DAST Guidelines for Administration and 

Scoring,” which is provided, is required. No 

other training is required. 

Fee for use: The DAST form and scoring key 

are available either without cost or at nominal 

cost. 

Available from: Centre for Addiction and 

Mental Health Marketing 

and Sales Services 

33 Russell Street 

Toronto, Ontario, Canada 

M5S 2Sl 

Ph: (800) 661-1111 

(Continental North 

America) 

International and Toronto 

area: (416) 595-6059 

Michigan Alcoholism
 

Screening Test (MAST) 

Purpose: Used to screen for alcoholism with a 

variety of populations. 

Clinical utility: A 25-item questionnaire 

designed to provide a rapid and effective 

screen for lifetime alcohol-related problems 

and alcoholism. 

Groups with whom this instrument has been 

used: Adults. 

Norms: N/A. 

Format: Consists of 25 questions. 

Administration time: 10 minutes. 

Scoring time: 5 minutes. 

Computer scoring? No. 

Administrator training and qualifications: No 

training required. 

Fee for use: Fee for a copy, no fee for use. 

306 Appendix C
 

Available from: Melvin L. Selzer, M.D. 

6967 Paseo Laredo 

La Jolla, CA 92037-6425 

Structured Clinical

Interview for DSM-IV 

Disorders (SCID) 

Purpose: Obtains Axis I and II diagnoses using 

the DSM-IV diagnostic criteria for enabling the 

interviewer to either rule out or to establish a 

diagnosis of “drug abuse” or “drug dependence” and/or “alcohol abuse” or “alcohol 

dependence.” 

Clinical utility: A psychiatric interview. 

Groups with whom this instrument has been 

used: Psychiatric, medical, or communitybased normal adults. 

Norms: No. 

Format: A psychiatric interview form in which 

diagnosis can be made by the examiner asking a 

series of approximately 10 questions of a client. 

Administration time: Administration of Axis I 

and Axis II batteries may require more than 2 

hours each for patients with multiple diagnoses. The Psychoactive Substance Use 

Disorders module may be administered by itself 

in 30 to 60 minutes. 

Scoring time: Approximately 10 minutes. 

Computer scoring? No. 

Administrator training and qualifications: 

Designed for use by a trained clinical evaluator 

at the master’s or doctoral level, although in 

research settings it has been used by bachelor’slevel technicians with extensive training. 

Fee for use: Yes. 

Available from: American Psychiatric 

Publishing, Inc. 

1400 K Street, N.W. 

Washington, DC 20005 

http://www.appi.org/ 

University of Rhode 

Island Change 

Assessment (URICA) 

Purpose: The URICA operationally defines 

four theoretical stages of change—precontemplation, contemplation, action, and maintenance—relevant to change of a “problem” 

determined by the subjects, each assessed by 

eight items. For an alcohol problem population, a 28-item version with 7 items per subscale is available. 

Clinical utility: Assessment of stages of 

change/readiness construct can be used as a 

predictor of treatment and outcome variables. 

Groups with whom this instrument has been 

used: Both inpatient and outpatient adults. 

Norms: Yes, for outpatient alcoholism treatment population. 

Format: The URICA is a 32-item inventory 

designed to assess an individual’s stage of 

change, located along a continuum of change, 

in people who abuse alcohol or drugs. 

Administration time: 5 to 10 minutes to complete. 

Scoring time: 4 to 5 minutes. 

Computer scoring? Yes, computer-scannable 

forms. 

Administrator training and qualifications: N/A 

Fee for use: No; instrument is in the public 

domain. Available from author. 

Available from: Carlo C. DiClemente 

University of Maryland 

Psychology Department 

1000 Hilltop Circle 

Baltimore, MD 21250 

Ph: (410) 455-2415 

Screening and Assessment Instruments 307 
Appendix D: 

Resource Panel

Linell P. Broecker, M.S.W.

Senior Prevention Programs Manager 

Demand Reduction Section 

Drug Enforcement Administration

Washington, DC

Patrick Coleman

Deputy Director

Bureau of Justice Assistance

Washington, DC

Cathi Coridan, M.A. 

Senior Director for Substance Abuse

Programs and Policy

National Mental Health Association

Alexandria, Virginia

Gloria Danzinger

Staff Director

Standing Committee on Substance Abuse

American Bar Association

Washington, DC

Peter J. Delany, D.S.W.

Deputy Director

Division of Epidemiology, Services and

Prevention Research 

National Institute on Drug Abuse

Bethesda, Maryland

309

Note: The information given indicates each participant's affiliation during

the time the panel was convened and may no longer reflect the individual's

current affiliation.
310 Appendix D

Jennifer Kay Edwards, M.A.

Assistant to the Deputy Director

Corrections Program Office

U.S. Department of Justice

Washington, DC

Jerry P. Flanzer, D.S.W., LCSW, CAC

Chief

Services Research Branch

National Institute on Drug Abuse

Bethesda, Maryland

Irene Gainer

Executive Director

Treatment Accountability for Safer 

Communities

Arlington, Virginia 

R.J. Gregrich, M.S.

Chief

Treatment Branch

Office of Demand Reduction

Office of National Drug Control Policy

Washington, DC

Stephen J. Ingley

Executive Director

American Jail Association

Hagerstown, Maryland

Jane E. Kennedy, M.P.A., CDP

Executive Director

Treatment Alternatives to Street Crime

Seattle, Washington

Bruce R. Lorenz, B.S., CADC, 

NCAC II

Director

Thresholds, Inc.

Georgetown, Delaware

Cranston Mitchell

Correctional Program Specialist

Community Corrections Division

National Institute of Corrections

Washington, DC 

Stacia Murphy

President

National Council on Alcoholism and Drug 

Dependence

New York, New York

Madeline Ortiz

Corrections Program Specialist

Prisons Division

National Institute of Corrections

Washington, DC

Marjorie A. Rock, Dr.P.H. 

Associate Professor

Ehrenkranz School of Social Work

New York University

New York, New York 

Erik J. Roskes, M.D. 

Director

Forensic Treatment and Correctional 

Services

School of Medicine

Springfield Hospital Center

Sykesville, Maryland

Susan E. Salasin 

Director

Mental Health and Criminal 

Justice Program

Center for Mental Health Services

Rockville, Maryland

Mary K. Shilton

Executive Director

National Treatment Accountability 

for Safer Communities

Washington, DC

Audrey Wright Spolarich

Health Policy Analysts, Inc.

Washington, DC

Patrick H. Tarr, Ph.D.

Senior Policy Advisor

Office of Policy Development

U.S. Department of Justice

Washington, DC
Resource Panel 311

Jennifer Taussig, M.P.H.

Health Scientist

Centers for Disease Control and 

Prevention

Atlanta, Georgia

Vicky Verdeyen

Psychology Administrator

Bureau of Prisons

Department of Justice

Washington, DC

Beth A. Weinman, M.A.

National Drug Abuse Treatment 

Coordinator

Federal Bureau of Prisons

Department of Justice

Washington, DC

Steve Wing

Senior Advisor for Drug Policy

Office of Policy and Program 

Coordination

Substance Abuse and Mental Health 

Services Administration

Rockville, Maryland
Appendix E: 

Cultural Competency

and Diversity Network

Participants

Elmore T. Briggs, CCDC, NCAC II

Program Manager

Adolescent Recovery Center

Vanguard Services Unlimited

Arlington, Virginia 

African American Workgroup 

Deion Cash

Executive Director

Community Treatment & Correction 

Center, Inc. 

Canton, Ohio 

African American Workgroup 

E. Bernard Anderson, Jr., M.S., M.A., 

NCAC, ICADC, CCS

Regional Administrator

Correctional Treatment

Florida Addictions and Correctional Treatment Services, Inc.

Tallahassee, Florida

LGBT Workgroup

Richard T. Suchinsky, M.D.

Associate Director for Addictive Disorders and Psychiatric

Rehabilitation

Mental Health and Behavioral Sciences Services

Department of Veterans Affairs

Washington, DC

Disabilities Workgroup

313

Note: The information given indicates each participant's affiliation during

the time the panel was convened and may no longer reflect the individual's

current affiliation.
Appendix F:

Special Consultants

Gary Field, Ph.D.

Administrator

Counseling and Treatment Services Correctional Programs

Oregon Department of Corrections

Salem, Oregon

Thomas J. Tobin, Ph.D.

Chief Executive Officer/Co-Founder

The SHARP Program

Orinda, California

315

Note: The information given indicates each participant's affiliation during

the time the panel was convened and may no longer reflect the individual's

current affiliation.
Appendix G:

Field Reviewers

Robert B. Auckerman, M.S.W.

Program Services Consultant

Littleton, Colorado

Joanne Barnett, M.Ed., LPC, LADC, 

CCS, CDP, MAC, CCJS

Addiction Services Coordinator

Community Partners in Action

Hartford, Connecticut

Sonya Brown

State TASC Director

Division of Mental Health

Developmental Disabilities and 

Substance Abuse Services, HHS

Raleigh, North Carolina

Barry S. Brown, Ph.D.

Adjunct Professor

University of North Carolina at Wilmington

Carolina Beach, North Carolina

Eddie Canterbury, LCSW, BCSAC

Social Worker Specialist—LCSW

Rapides Adult Drug Treatment Court

Alexandria, Louisiana

Redonna Chandler, Ph.D.

Health Scientist Administrator

Services Research Branch

National Institute on Drug Abuse

Bethesda, Maryland

317

Note: The information given indicates each participant's affiliation during

the time the panel was convened and may no longer reflect the individual's

current affiliation.
Laura Choate 

Manager 

Office of Drug Court Programs 

California Department of Alcohol 

and Drug Programs 

Sacramento, California 

Richard Craig, Ph.D. 

Director of Research 

Patuxent Institution 

Jessup, Maryland 

George De Leon, Ph.D. 

Director 

Center for Therapeutic Community 

Research 

National Development and Research 

Institutes, Inc. 

New York, New York 

David Farabee 

Research Psychologist 

UCLA Integrated Substance Abuse 

Programs 

Los Angeles, California 

Kathleen J. Farkas, Ph.D., LISW 

Mandel School of Applied 

Social Sciences 

Case Western Reserve University 

Cleveland, Ohio 

Jerry P. Flanzer, D.S.W., LCSW, CAC 

Chief 

Services Research Branch 

National Institute on Drug Abuse 

Bethesda, Maryland 

Richard S. Gebelein 

Judge 

Superior Court of Delaware 

Wilmington, Delaware 

Bobby G. Greer, Ph.D., LPC, CCRC 

Memphis, Tennessee 

Hendree E. Jones, Ph.D. 

Assistant Professor 

CAP Research Director 

Department of Psychiatry and 

Behavioral Sciences 

Johns Hopkins University Center 

Baltimore, Maryland 

Margaret Williams Kherlopian 

Coordinator of Criminal Justice 

Programs 

South Carolina Department of Alcohol 

and Other Drug Abuse Services 

Columbia, South Carolina 

Kevin Knight, Ph.D. 

Research Scientist 

Texas Christian University 

Fort Worth, Texas 

Jeffrey N. Kushner, M.A., M.H.R.A. 

Drug Court Administrator 

Municipal Court of Saint Louis 

Saint Louis, Missouri 

Gerald Melnick, Ph.D. 

Senior Principal Investigator 

National Development and Research 

Institutes, Inc. 

New York, New York 

Ethan Nebelkopf, Ph.D., MFCC 

Clinic Director 

Family and Child Guidance Center 

Native American Health Center 

Oakland, California 

Michael L. Prendergast, Ph.D. 

Director 

Criminal Justice Research Group 

UCLA Integrated Substance Abuse 

Programs 

Los Angeles, California 

JoAnn Y. Sacks, Ph.D. 

Principal Investigator 

National Development and Research 

Institutes 

New York, New York 

318 Appendix G 
Robert Philip Schwartz, M.D. 

Medical Director 

Friends Research Institute 

Baltimore, Maryland 

Elizabeth Simoni, J.P. 

Executive Director 

Maine Pretrial Services, Inc. 

Portland, Maine 

Elizabeth Stanley-Salazar 

Vice President 

Director of Public Policy 

Phoenix Houses of California 

Lake View Terrace, California 

Richard E. Steinberg, M.S. 

President/Chief Executive Officer 

WestCare Foundation, Inc. 

Las Vegas, Nevada 

Pamela D. Stokes, M.S.M. 

Program Analyst 

National Association of State 

Alcohol and Drug Abuse Directors, Inc. 

Washington, DC 

Richard T. Suchinsky, M.D. 

Associate Director for Addictive Disorders 

and Psychiatric Rehabilitation 

Mental Health and Behavioral Sciences 

Services 

Department of Veterans Affairs 

Washington, DC 

Anne Swern 

Counsel to the District Attorney 

of Kings County 

Kings County District Attorney, Charles J. 

Hynes 

Brooklyn, New York 

Faye S. Taxman, Ph.D. 

Director 

Bureau of Governmental Research 

University of Maryland 

College Park, Maryland 

Angel Velez, CASAC 

Addiction Program Specialist-II 

New York State Office of Alcohol and 

Substance Abuse Services 

New York, New York 

Pogos H. Voskanian, M.D. 

Huntingdon Valley, Pennsylvania 

Robert Walker, M.S.W., LCSW 

Assistant Professor 

Center on Drug and Alcohol Research 

University of Kentucky 

Lexington, Kentucky 

Suzanne L. Wenzel, Ph.D. 

Behavioral Scientist 

RAND 

Santa Monica, California 

Karen M. Wheeler 

Program and Policy Development 

Specialist 

Office of Mental Health and Addiction 

Services 

Salem, Oregon 

Dorian L. Wingard, B.A., CCDC 

Education Coordinator 

Chair Education Committee 

Education Resource Center 

Steven’s House Residential Treatment 

Center for Adolescents 

A House of Hope, Inc. Program 

Columbus, Ohio 

Edie Wooldridge, B.A., CADC II 

Program Manager 

InterChange Treatment Program 

Multnomah County Department of 

Community Justice 

Hillsboro, Oregon 

Buck Zeller 

RCE Director, TASC 

Region IV 

Blue Ridge Center 

Asheville, North Carolina 

Field Reviewers 319 
Appendix H— 

Acknowledgments

Numerous people contributed to the development of this TIP, including the TIP Consensus Panel 

(see page xi), the Knowledge Application Program (KAP) Expert Panel and Federal Government 

Participants (see page xiii), the SAMHSA Resource Panel Meeting attendees, (see Appendix D), 

the KAP Cultural Competency and Diversity Network participants (see Appendix E), Special 

Consultants (see Appendix F), and TIP Field Reviewers (see Appendix G). 

This publication was produced under KAP, a Joint Venture of The CDM Group, Inc. (CDM), and 

JBS International, Inc. (JBS), for the Substance Abuse and Mental Health Services 

Administration, Center for Substance Abuse Treatment. 

CDM KAP personnel included Rose M. Urban, M.S.W., J.D., LCSW, LCAS, KAP Executive 

Deputy Project Director; Susan Kimner, Managing Project Co-Director; Elizabeth Marsh, former 

KAP Deputy Project Director; Sheldon Weinberg, KAP Senior research/Applied Psychologist; 

Raquel Witkin, former Deputy Project Manager; Deborah Steinbach, former Editor/Writer ; 

Janet Humphrey, former Editor/Writer; Michelle Myers, former Quality Assurance Editor; 

Elizabeth Plevyak, former Editorial Assistant; and Virgie D. Paul, M.L.S., Librarian. 

320 
Index

 

Because the entire volume is about substance 

abuse treatment for adults in the criminal justice 

system, the use of these terms as entry points has 

been minimized in this index. Commonly known 

acronyms are listed as main headings. Page references for information contained in figures appear 

in italics. 

12-Step programs. See self-help groups 

A

abuse. See also violence 

history of, 27 

physical and sexual, 97–98 

screening and assessment of, 28 

accountability, in criminal justice treatment 

programs, 245 

acculturative stress, 94 

ADAM. See Arrestee Drug Abuse Monitoring 

program 

Addiction Prevention and Recovery Administration 

and Salvation Army, 152 

Addiction Technology Transfer Centers, 246 

Adoption and Safe Families Act of 1997, 99 

Advice to the Counselor boxes 

about, 3 

borderline personality disorder, 63 

boundaries, establishing, 81 

clients in the criminal justice system, 127 

coercion, 80 

community supervision, 221, 225 

co-occurring disorders, screening for, 27 

credibility, counselor, 83 

criminal thinking, 74 

cross-training, 179 

culture and the counselor, 95 

detoxification, screening for, 21 

diversion to treatment, 128 

family involvement, 78 

female offenders, 97 

“good” and “bad” drugs, 111 

homelessness, 73 

immediate needs, client, 144 

infectious diseases, 118 

information management, pretrial, 130 

jailed clients, 165 

mental health issues, 61 

motivation for change, 66 

noncompliance, 209 

parent training, 100 

parole, 229 

pretrial setting, operating in, 143 

prison treatment approaches, 198 

psychopathy, 65 

psychopathy, screening for, 30 

rescreening, 16 

rural clients, 108 

screening and assessment, 13 

specific populations, screening for, 38 

spiritual approaches, 89 

trauma, screening for, 29 

triage and placement, 49 

affective states, 76–77 

aftercare 

in community supervision settings, 227 

in jail settings, 185 

aging populations. See older adults 

agreements. See also behavior contracts; 

memorandum of understanding 

multilevel, 14–16 

ambulatory care. See outpatient treatment 

American Society of Addiction Medicine. See ASAM 

Americans with Disabilities Act, 106 

Amity 

Pima County Substance Abuse Treatment Jail 

Project, 184 

Prison therapeutic community, 202–203, 206 

Project, 231 

anger. See also violence 

and hostility, 76–77 

management, 103, 173, 195 

antisocial personality disorder 

definition, 112 

prevalence data, 113 

traits of, 113 


treatment requirements, 113–114 

anxiety disorders, 116 

arraignment, 128–129 

arrest, 128 

Arrestee Drug Abuse Monitoring program, 1, 

126–127 

ASAM Patient Placement criteria, 56 

Assertive Community Treatment, 112 

assessment 

and accuracy of information, 13–14 

addressing abuse issues, 27 

321 
and continuity of information, 14 

of co-occurring disorders, 23–24, 38–39, 60, 109 

definition, 8 

domains, 18 

as equated with suitability, 8 

guidelines for, 10, 34 

inadequate, as barrier, 47 

instruments, 20, 28, 303–307 

integrated with screening, 39–40 

myths about, 8–9 

protocols, 39–40 

purpose of, 13 

racial and ethnic minorities, 37 

recommendations, 40–42 

of substance use disorder severity, 60 

timing of, 17 

of treatment readiness and stage of change, 66 

B 

barriers 

to effective treatment, 243 

to program coordination, 242 

to treatment in community supervision settings, 

222 

to treatment in jails, 176, 181 

to triage and placement, 47 

basic needs, addressing, 72–73 

in community supervision settings, 218 

for offenders, 72–73 

behavior contracts, 139 

boot camp, 142 

borderline personality disorder, 62–63, 114 


and co-occurring disorders, 114 

and Dialectical Behavior Therapy, 62–63 

treating, 114–115 

boundaries, establishing, 81–82 

boundary spanners, 144, 147, 170 

in community supervision settings, 227 

definition, 137 

Breaking the Cycle (ONDCP), 232 

brief incarceration, 142 

brief interventions, 138 

brief treatment 

and access to community services, 169 

and community resources, 169 

definition, 167 

education, substance abuse, 169 

motivational enhancement, 168 

psychotropic drug education, 170 

transition back to the community, 170 

treatment components, 168 


Brooklyn Drug Treatment Alternative to Prison 

program, 151–152 

Bureau of Justice Assistance, 2 

businesses, as stakeholders, 242 

C

California Drug and Alcohol Treatment Assessment 

study, 2 

Case Management Classification system, 55 

case management services, 112 

in community supervision settings, 219, 227–228 

at the program level, 242 

child custody. See parenting 

Client’s Recovery Plan, 67, 68–69 


Coerced Abstinence Model, 151 

coerced treatment, 22, 79–80, 86–87 

definition, 85 

in prison settings, 207 

cognitive disorders, treatment issues, 116 

collaboration, 230 

in community supervision settings, 229–231 

between substance abuse and criminal justice 

agencies, 236–237 

collateral information, 10, 32, 33, 38, 41, 143 

communication skills, 172–173 

community issues 

organizations as stakeholders, 241–242 

partnerships in jail settings, 180 

service, 141, 169 

community supervision 

barriers to treatment, 222 

comparison of probationers and parolees, 215 


examples of programs, 231–232 

intensive supervision, 214 

intermediate supervision, 214 

population description, 214 

probation before judgment, 130 

and programs for offenders with co-occurring 

disorders, 111, 225 

recommendations, 233 

residential treatment, 215–216 

sample programs, 231–232 

self-help groups, 223, 228, 232 

system collaboration, 229–231 

and therapeutic alliances, 82 

treatment components, 217–218 

treatment issues, 220–226 

treatment issues, parole-specific, 226–228 

treatment issues, probation-specific, 229 

treatment levels, 214–217 

treatment services, 218–220 

community treatment and planning, 69 

confidentiality, 70, 149 

in community supervision settings, 230 

in jail settings, 166, 177 

322 Index 
in presentencing, 131 

in screening and assessment, 14 

in triage and placement, 48 

constitutional issues 

and arrest, 128 

ballot initiatives (diversion to treatment), 136 

continuum of care, in community supervision 

settings, 227 

co-occurring disorders, 22–26 

antisocial personality disorder, 112–114 

anxiety disorders, 116 

assessment, 23–24, 38–39, 60 

attention deficit/hyperactivity disorder, 116 

borderline personality disorder, 62–63, 114–115 

and case management services, 112 

cognitive disorders, 116 

and community supervision settings, 225 

depressive and bipolar disorders, 61, 115 

diversion to treatment, 137 

integrated versus parallel treatment, 137 

intermittent explosive disorder, 62 

in jails, 162 

level of, 52 

and long-term treatment, 175 

medication management, 111 

posttraumatic stress disorder, 61 

prevalence, 22 

prevalence data, 105–106, 162 

and prison settings, 204 

Programs for Assertive Community Treatment, 

226 

and retention in treatment, 87 

schizophrenia and psychotic disorders, 115–116 

screening and assessment of, 23–24, 25–26, 

38–39, 60 

serious mental disorders, 61–62 

treatment issues, 108–109 

treatment programs, 109–111 

cooperation, interagency, 148–149 

cost issues, 251 

crime-related, of drug abuse, 1 

of instruments, 35 

and program development, 251 

counselor issues 

checks and balances, 146 

credibility, 82–83 

in jail environment, 166 

leverage, 146 

negative attitudes, 223 

training, 147–148, 154, 166, 179–180, 209–210, 

230–231, 245–246 

Counselor’s Manual for Relapse Prevention with 


Chemically Dependent Criminal Offenders 


(TAP 19), 88 

Crime and Drugs Solution Work Group (Baltimore), 

147 

crime statistics 

arrests, 126 

community supervision population, 214, 225 

jail population, 159–162 

prison population, 188–190 

women, 95 

Criminal Conduct and Substance Abuse 


Treatment, 74, 195 

criminality, 63–64 

criminal activity and substance abuse, 1 

criminal code, 75 

criminal identity, 77, 192–193 

criminal thinking, 74, 175 

criminogenic personality types, 30 

offender denial of, 79 

and procriminal values and associates, 63–64 

and stigma based on substance abuse treatment, 

75 

thinking errors, 75 


Criminal Justice/Substance Abuse Cross Training: 

Working Together for Change, 246 

criminal justice system 

definition, 5 

interdependence with treatment system, 236 

jail issues, 165 

treatment planning chart, 238–239 


Criminal Justice Treatment Evaluation Meeting 

(1992), 166 

criminal thinking, 74, 75 

cross-training, 82, 170, 209 

in community supervision settings, 223 

in jail settings, 178 

in pretrial and diversion settings, 150 

cultural. See also racial and ethnic minorities 

competence, 37, 83, 148 

identity, 77 

minorities, 93–94 

curfew, 142 

D 

DATOS, 44 

day fines, 141 

day reporting centers, 139–140, 141, 217 

example in Chicago, 140 

example in Salt Lake City, 217 

day treatment, 45 

deficit-based approach to treatment planning, 66 

definitions. See also appendix B, Glossary 

antisocial personality disorder, 112 

arraignment, 128 

arrest, 128 

assessment, 8 

Index 323

 
boundary spanners, 137 

coercion, 85 

cost issues, 251 

criminal justice system, 5 

detainees, 157 

detoxification, 139 

jails, 157, 158 

offender, 5 

personality disorders, 30 

presentencing, 130 

psychopathy, 113 

screening, 7–8 

substance abuse, 4 

substance dependence, 4 

test-retest reliability, 18 

treatment, 4 

trial, 130 

denial, 79 

Denver Women’s Correctional Facility program for 

women and their children, 100 

depression, 61 

treating, 115 

detainees, definition, 157 

detoxification, 20 

as a basic need, 72–73 

definition, 139 

and pretreatment services, 45 

symptoms, 72 

diagnosis, formal, 17 

Dialectical Behavior Therapy, 62–63 

disability, treatment issues, 105–107 

diversion to treatment, 131 

constitutional ballot initiatives, 136 

Driving Under the Influence courts, 137–138 

drug courts, 131–133 

examples of programs, 151–153 

in lieu of detention and prosecution, 129 

memorandum of understanding, 149 

models, 153 

for people with co-occurring disorders, 109–111, 

137 

probation before judgment, 130 

Proposition 36: Substance Abuse and Crime 

Prevention Act (California), 136–137 

sample programs, 151–152 

staff resources, 147 

training resources, 154 

Treatment Accountability for Safer 

Communities, 133–136 

Downward Spiral (board game), 168 

Driving Under the Influence courts, 137–138. See 

also Drug Courts 

Drug Abuse Treatment Outcome Studies, 44 

Drug Court Clearinghouse and Technical Assistance 

Project (American University), 132 

Drug Court Grant Program (Bureau of Justice 

Assistance), 153 

drug courts, 2, 40, 131–133 

components of, 133 

Driving Under the Influence courts, 137–138 

and jails, 181–182 

“mental health court” for people with co-

occurring disorders, 137 

phases of, 133 

substance abuse treatment planning chart, 

134–135 


drug testing, 17–18 

pretrial, 150–151 

DUI/Drug Court Advisory Panel, 138 

E 

early intervention, 44 

education, 150 

about psychotropic drug, 170 

infectious diseases, 118 

in prison settings, 197 

staff, 179 

substance abuse, in brief treatment, 169 

Edward Byrne Memorial State and Local Law 

Enforcement Assistance Program, 153 

eligibility 

for admission to substance abuse treatment, 29 

as equated with screening, 8 

employment. See also vocational training 

in community supervision settings, 224 

counseling in long-term treatment, 174 

job skills training, 100–101 

Empowerment through Literacy Project, 97 

engagement, 84–85 

enhancing motivation for change. See motivational 

readiness 

evaluation 

outcome, 248–250 

process, 248 

reports, 247 

F

family issues, 77–78. See also parenting 

client’s role in the family, 77–78 

in community supervision settings, 218–219 

family counseling, 196 

family mapping in long-term treatment, 174–175 

fathering, 101 

Federal Bureau of Prisons residential treatment 

programs, 204 

Female Offender Treatment and Employment 

Program, 99 

324 Index 
financial concerns 

client fees, 139 

in community supervision settings, 221–222 

means-based fines, 141 

Florida Department of Corrections triage process, 

54–55 

Forever Free from Drugs and Crime, 96 

formal diagnosis, 17 

FRAMES, 138 

Framework for Recovery, 74 

funding issues, in jails, 176–177 

G 

GAINS Center for People with Co-Occurring 

Disorders in the Justice System, 225 

gang subculture, 77, 94 

in jails, 164–165 

gender. See also men’s issues; women’s issues 

gender-specific training, 209 

in prison settings, 193–194 

Greater Baltimore Interfaith Clergy Alliance, 147 

group home, 47 

guilt 

of parents in the criminal justice system, 78 

as a treatment issue, 80 

of women regarding their children, 99 

H 

halfway house, 46–47, 142, 216 

hepatitis, 118, 226 

prevalence data, prison populations, 190 

High Intensity Drug Trafficking Areas Automated 

Tracking System, 15, 179 

history 

of abuse, 27 

substance abuse, 18 

HIV/AIDS 

in community supervision settings, 226 

prevalence data, jail populations, 161 

prevalence data, prison populations, 189 

Project ARRIVE (AIDS prevention training 

model), 117 

homelessness, 73 

house arrest, 142 

housing, in community supervision settings, 218 

I
 

identity issues, 77–79 

implementation evaluation, 247 

incentives, 85 

versus disincentives, 208–209 

to improve retention, 87 

in prison settings, 207–208 

infectious diseases 

medical care, 118 

prevalence data, 116 

prevention and education, 118 

testing for, 117 

treatment issues, 116–118 

information sharing 

as barrier to treatment, 47 

in community supervision settings, 230 

in jail settings, 178–179 

Maricopa County Data Link Project (Arizona), 

244 

between substance abuse and criminal justice 

agencies, 148, 244 

systemwide, 14 

in treatment planning, 67 

informed consent, 14 

initiatives 

Breaking the Cycle (ONDCP), 232 

constitutional ballot, 136 

criminal justice, 2–3 

innocence, presumption of, 145 

inpatient treatment, 45–46 

instruments 

assessment, 20, 303–307 

client’s language of choice, 36 

cost, 35 

effectiveness of, 34 

interview versus self-administered, 35 

level of substance abuse problems, 52 

for literacy, 36 

mental disorders, 53–54 

motivational readiness, 54 

for psychopathy, violence, and recidivism, 

32–33, 51 

readiness for treatment, 23 

screening, 18, 19, 86, 303–307 

for screening and assessing abuse and trauma 

history, 28 

for screening and assessing mental disorders, 

25–26 


screening for psychopathy, 30 

selection and implementation of, 33–34 

sex offenders, 120 

and staff training, 35 

stages of change, 54 

time to administer, 34–35 

Intensive Case Management, 112 

intensive supervision 

parole, 142 

probation, 141 

intensive treatment 

outpatient, 45 

residential, 45–46 

interagency cooperation, 148–149 

Index 325

 
Interim Incarceration Disenrollment Policy 

(Oregon), 145 

intermittent explosive disorder, 62 

J

jails 

barriers to treatment, 176, 181 

and community services, 169–170, 180 

confidentiality, 166, 177 

coordination of treatment services, 175, 177–183 

definition, 157, 158 

examples of programs, 183–184 

funding issues, 176–177 

and gang affiliation, 164–165 

information sharing, 178–179 

justice system issues, 165 

linkages, 181 

negative perception of, 163 

pharmacotherapy in, 170–171, 179, 180 

population description, 159–162 

prioritizing substance abuse treatment, 177, 

178 


recommendations, 185 

relapse prevention, 171–172 

research related to treatment, 184–185 

services that can be provided in, 166–167 

stressors, 165 

suggestions for dedication program space, 164 

and time constraints for treatment, 163–164 

transition back to the community, 170 

treatment components, 168 


treatment environment, 164 

treatment goals, 176 


treatment issues, 173–175 

trends leading to changes in population, 158–159 

job skills training, 100–101 

judges, information and training, 148 

K 

KEY-CREST programs (Delaware), 202, 232 

King County Jail System, North Rehabilitation 

Facility, Stages of Change Program 

(Washington), 183 

L 

language 

“people first”, 17 

and screening and assessment instruments, 36 

leadership, endorsement of, 237 

legislators, as stakeholders, 241 

leverage, counselor, 146 

life skills, 73 

linkages, 170 

aftercare, 185 

community and law enforcement, 153 

with community treatment, 69 

institutional and procedural, 14 

in jail settings, 181 

between substance abuse and criminal justice 

agencies, 128, 131 

long-term treatment 

and co-occurring disorders, 175 

and criminal thinking, 175 

definition, 167 

employment counseling, 174 

family mapping, 174–175 

treatment components, 168 

M 

manipulativeness, client, 75 

Maricopa County Data Link Project (Arizona), 244 

Marshall, Thurgood, 1 

matching offender to treatment. See treatment 

matching 

means-based fines, 141 

media, as stakeholders, 241 

Medicaid, 169 

medically managed intensive inpatient treatment, 46 

medically monitored intensive inpatient treatment, 

46 

medication management, 111 

Megargee and Case Management Classification 

Systems, 55 

memorandum of understanding, 145, 219 

in community supervision settings, 229 

for pretrial and diversion, 149 

Memphis prebooking jail diversion program, 152 

men’s issues 

anger management, 103 

fathering, 101 

in prison settings, 193–194 

relationship building, 102 

mmental disorders. See also co-occurring 

disorders 

instruments for screening and assessing, 25–26 


level of, 52 

prevalence data, prison populations, 189 

screening and assessment of, 38–39 

Mental Health Courts, 109 

methadone treatment, 45 

Montgomery County pre- and post-booking and 

coterminous jail diversion (Pennsylvania), 152 

motivational interviewing, 21, 66, 223 

motivational readiness, 22, 53–54. See also 


readiness for treatment; stages of change 

in community supervision settings, 222–223 

enhancing, 85 

guilt and shame as motivating factors, 80 

instruments for evaluation, 23, 54 

326 Index 
in jails, 168–169 

and treatment planning, 65–67 

multilevel agreements, 14–16 

Multnomah County Sheriff’s Office In-Jail 

Intervention Program (Oregon), 183 

mutual self-help programs. See self-help groups 

N 

National Association of Drug Court Professionals, 

153 

National Drug Control Strategy (ONDCP), 2 

negative predictive value, 34 

nonintensive outpatient treatment, 45 

O 

Oakland Men’s Project (violence prevention 

program), 103 

offender 

definition, 5 

issues, 150–151, 241 

Ohio Violence Prevention Process, 103 

older adults, 107 

in prison settings, 206–207 

Oregon STOP program, 240 

Orientation to Therapeutic Community (training), 

246 

outcome evaluation, 248–250 

outcome information, 250 

outpatient treatment, 45, 141, 216 

Oxford House, 47 

P

parenting. See also family issues 

child custody, 38, 85, 98–99, 165, 226 

fathering, 101–102 

groups, 196 

prevalence data, 98–99 

and women in criminal justice settings, 98–99 

parole. See community supervision 

partial hospitalization. See day treatment 

patient issues, readiness for treatment, 21 

peer support, 88 

“people first” language, 17 

personality disorders, definition, 30 

pharmacotherapy, in jail settings, 179, 180 

Philadelphia Prison System OPTIONS Program 

(Pennsylvania), 183 

plea bargaining, 129–130 

positive predictive value, 34 

posttraumatic stress disorder. See PTSD 

predictors of treatment outcomes, in jail settings, 

185 

presentencing period, 130 

pretreatment 

phase, 22 

services, 44–45 

pretrial settings 

components of, 140 

counselor leverage, 146 

developing treatment services, 146–147 

diversion, 129 

drug testing, 150–151 

existing services, maintaining, 144 

immediate needs, client, 144 

intervention strategies, 138–139 

memorandum of understanding, 149 

offender issues, 150–151 

plea bargaining, 129–130 

population description, 126–127 

presumption of innocence, 145 

recommendations, 154–155 

rights of clients, 145 

sanctions, use of, 140–142 

screening, 143–144 

treatment issues, 125–126, 143 

treatment modalities, 139–140 

treatment services, 127–128, 138, 146–151 

prevalence data 

antisocial personality disorder, 112–113 

community supervision, 214, 225 

co-occurring disorders, 105–106, 108–109 

criminal activity and substance abuse, 1–3 

disability, 105–106 

infectious diseases, 116–117 

rural clients, 107–108 

sex offenders, 119 

substance abuse and violence, 102 

violence, 102 

primary prevention, 44 

prisons 

counseling, 194–197 

and criminal identity, 192–193 

disincentives, 208–209 

educational and vocational training, 197 

further research, 211–212 

and gender, 188, 193–194 

and men’s issues, 193–194 

mental disorders in, 204 

older inmates, 206 

and people with co-occurring disorders, 204 

population description, 187–190 

race and ethnicity, 188 

recommendations, 210–211 

sample therapeutic communities, 201–204, 205 

sanctions in, 207–208 

and self-help groups, 196–197 

sex offenders, 204–206 

and substance abuse, 188–189 

systems issues, 207–210 

Index 327 
therapeutic communities, 199–201 

therapeutic techniques in, 198–199 

training, 209–210 

and trauma, 191 

treatment components, 194–199 

treatment issues, 191–193 

treatment services, 190, 191 

women’s issues, 194 

probation. See community supervision 

probation before judgment, 130 

Probationers in Recovery (California), 232 

process evaluation, 248 

procriminal values and associates, 63–64 

program components, 84 

incentives and sanctions, 85 

phasing, 88 

program development 

cost issues, 251 

evaluation, 248–251 

information flow, 244 

program coordination, 242–250 

systems issues, 235–242 

training, 246–247 

Programs for Assertive Community Treatment, 226 

Project ARRIVE (AIDS prevention training model), 

117 

Project for Homemakers in Arizona Seeking 

Employment, 101 

Project KEEP, 179, 181 

Project MATCH, 168 

Project RECOVERY, 2 

Project REFORM, 2 

Proposition 36: Substance Abuse and Crime 

Prevention Act (California), 16, 85, 136–137, 252 

prosocial activity, 88 

Provider’s Introduction to Substance Abuse 


Treatment for Lesbian, Gay, Bisexual, and 


Transgender Individuals, A, 105 

psychopathy, 29, 63–65 

definition, 113 

instruments for, 32–33 

risk factors for, 30 

treatment requirements, 113–114 

psychosocial residential care, 46 

PTSD, 61 

assessment of, 28 

and borderline personality disorder, 115 

prevalence, 27, 96 

in prison settings, 191 

symptoms of, 191 

treatment of, 116 

public safety, and public health, 235–236 

R 

racial and ethnic minorities 

in criminal justice populations, 93–94 

in jails and prisons, 77 

prison populations, 188 

screening and assessment of, 37 

readiness for treatment, 22, 53–54. See also 


motivational readiness; stages of change 

client, 21 

instruments for evaluation, 23 

and treatment placement, 53–54 

and treatment planning, 65–67 

recidivism, 150 

in community supervision settings, 228 

instruments for, 32–33, 51 

risk factors for, 29, 31, 51 

and substance abuse treatment, 2 

treatment interventions, 51 

records, sealed, 81 

referral, 28 

Regional Drug Initiative (Oregon), 240 

relapse prevention 

in community supervision settings, 220, 224 

plans, 67 

and self-management skills, 88–89 

and sex offenders, 120–122 

in short-term treatment, 171 

relationship between substance abuse and criminal 

behavior, 1 

relationship building, 102 

rescreening, 16. See also screening 

research and evaluation, 247–250 

residential care, 45–46, 141 

Residential Substance Abuse Treatment for State 

Prisoners Formula Grant Program, 2 

Residential Substance Abuse Treatment, South 

Idaho Correctional Institution, 199 

residential treatment, 215–216 

resistance, 79–80 

restitution, 141 

retention in treatment, 85–86 

incentives and sanctions, 87 

rights, due process, 145 

risk factors for recidivism, 29, 31, 51 

role playing, in prison settings, 198 

rural clients, 107–108 

S 

safety, of women in the criminal justice system, 96 

Salvation Army and Addiction Prevention and 

Recovery Administration, 152 

SAMHSA, key goals, 252 

sanctions, 85, 140–141 

328 Index 
examples used in diversion, 141 

how to use, 142 

to improve retention, 87 

in pretrial settings, 140–143 

in prison settings, 207–208 

and relapse prevention, 220 

victim impact meetings, 141 

without treatment, 151 

written, 150 

schizophrenia and psychotic disorders, 115–116 

screening 

and accuracy of information, 13–14 

addressing abuse issues, 27 

computerization, 36 

and continuity of information, 14 

for co-occurring disorders, 23–24, 38–39 

definition, 7–8 

and detoxification, 20 

domains, 11–12, 18 

drug testing as screening device, 17–18 

as equated with eligibility, 8 

guidelines for, 9–10, 11, 12 


importance of in pretrial, 143–144 

inadequate, as barrier, 47 

instruments, 18, 19, 28, 86, 303–307 

integrated with assessment, 39–40 

language of instruments, 36 

for literacy, 36 

for medical conditions, 21 

myths about, 8–9 

in pretrial settings, 143–144 

protocols, 39–40 

for psychopathy, 30 

purpose of, 7, 10 

racial and ethnic minorities, 37 

recommendations, 40–42 

rescreening, 16 

selection of tools for, 10 

timing of, 17 

of women, 37–38 

sealed records, 81 

Second-Felony Offender Law (New York), 151 

self-destructive behavior, and borderline 

personality disorder, 115 

self-esteem 

in community supervision settings, 221 

and women, 98 

self-help groups, 90 

in community supervision settings, 223, 228, 232 

in jail settings, 161, 172, 185 

in prison settings, 196–197, 196–197, 200 

and short-term treatment, 172 

self-management skills, and relapse prevention, 89 

sensitivity, 34 

sentencing, 131 

Serious and Violent Offender Reentry Initiative, 

2–3, 228 

serious mental disorders, 61–62 

sex offenders, 119–122 

prevalence data, 119 

in prison settings, 193, 204 

and relapse prevention, 120–122 

SHARPER FUTURE, 121 

treatment issues, 120 

sexual orientation, 104–105. See also gender 

while incarcerated, 104–105 

shame, 80. See also guilt; stigma 

SHARPER FUTURE, 121 

shock incarceration, 142 

short-term treatment 

anger management, 173 

cognitive skills training, 172 

communication skills, 172–173 

definition, 167 

nonhospital intensive residential, 46 

problemsolving, 173 

and relapse prevention, 171 

self-help groups, 172 

social skills training, 173 

strengths building, 172 

treatment components, 168 


sobering stations, 139 

social skills training, in short-term treatment, 173 

Special Offender Services program (Pennsylvania), 

232 

specialty courts. See drug courts 

specificity, 34 

spiritual approaches, 89–90 

staff issues 

behavior modeling, 88 

counselor credibility, 82–83 

creating therapeutic alliances, 82 

education, 179 

resources in pretrial, 147 

training, 147–148, 179, 205, 209, 230–231, 

245–246 

training for screening, 35 

training resources, 246 

stages of change, 53–54 

instruments, 54 

strategies for working with offenders, 84 

and treatment planning, 83 

stakeholders, identification of, 237–242 

status, role as a person of, 79 

Stay’n Out (New York), 201, 202 

stigma, 17, 64, 209 

in community supervision settings, 221 

and co-occurring disorders, 109 

Index 329

 
and homelessness, 73 

and sex offenders, 204–205 

as a treatment issue, 80–81 

strengths-based approach, to treatment planning, 

66–67 

strengths building, 172 

stressors 

environmental, 31, 67 

in jails, 165 

and older adults, 107 

psychosocial, 115 

substance abuse 

counseling, in prison settings, 194–197 

and criminal activity, 1 

and criminal justice system, 236 

definition, 4 

level of problems, 52 

offender denial of, 79 

prevalence data, jail populations, 161 

prevalence data, prison populations, 188–189 

prioritizing treatment in jail settings, 177, 178 

and relationship with violence, 102 

signs and symptoms of, 20 

treatment in prison settings, 190, 191 


Substance Abuse and Crime Prevention Act 

(Proposition 36, California), 136–137 

Substance Abuse and Mental Health Services 

Administration. See SAMHSA 

substance abuse history, 18 

Substance Abuse Treatment for Women 


Offenders: Guide to Promising Practices (TAP 

23), 38, 97 

Substance Abuse Treatment Trust Fund 

(California), 136 

substance dependence, definition, 4 

substance use disorders, assessing severity of, 60 

suitability, as equated with assessment, 8 

support services, maintaining, 144 

T

testing, for infectious diseases, 117–118 

test-retest reliability, definition, 18 

Texas Kyle New Vision program, 203 

therapeutic alliances, 82 

and anxiety disorders, 116 

therapeutic communities, 46 

in community supervision settings, 215 

elements of, 199–201 

examples of programs, 201–204 

goals of, 199 

and offenders with mental illness, 205 

in prison settings, 199 

therapeutic community. See also specific programs 

in jail settings, 184 

Therapeutic Community Experiential Training, 246 

thinking errors, 75 


Thinking for a Change, 74, 76, 195 

“three strikes and you’re out” legislation, 2, 206 

TIPs cited 

Brief Interventions and Brief Therapies for 


Substance Abuse (TIP 34), 138 

Combining Substance Abuse Treatment With 


Intermediate Sanctions for Adults in the 


Criminal Justice System (TIP 12), 3, 207 

Comprehensive Case Management for 


Substance Abuse Treatment (TIP 27), 220 

Continuity of Offender Treatment for 


Substance Use Disorders From Institution to 


Community (TIP 30), 70, 170, 227 

Detoxification and Substance Abuse Treatment 


(in development), 21, 45, 73, 139, 217 

Detoxification From Alcohol and Other Drugs 


(TIP 19), 139 

Enhancing Motivation for Change in Substance 


Abuse Treatment (TIP 35), 21, 22, 23, 54, 

66, 80, 168, 223 

Improving Cultural Competence in Substance 


Abuse Treatment (in development), 37, 83, 

94, 95, 148 

Integrating Substance Abuse Treatment and 


Vocational Services (TIP 38), 20, 101, 219, 

242 

Medication-Assisted Treatment for Opioid 


Addiction in Opioid Treatment Programs 


(TIP 43), 45 

Planning for Alcohol and Other Drug Abuse 


Treatment for Adults in the Criminal Justice 


System (TIP 17), 3 

Screening and Assessing Adolescents for 


Substance Use Disorders (TIP 31), 18 

Screening and Assessment for Alcohol and 


Other Drug Abuse Among Adults in the 


Criminal Justice System (TIP 7), 3, 18, 19, 

20 

Simple Screening Instruments for Outreach for 


Alcohol and Other Drug Abuse and 


Infectious Diseases (TIP 11), 18, 19 

Substance Abuse: Administrative Issues in 


Intensive Outpatient Treatment (in 

development), 45, 216 

Substance Abuse Among Older Adults (TIP 26), 

107 

Substance Abuse and Trauma (in 

development), 98, 116, 192 

Substance Abuse: Clinical Issues in Intensive 


Outpatient Treatment (in development), 45, 

216 

330 Index 
Substance Abuse Treatment: Addressing the 

Specific Needs of Women (in development), 

38, 96, 97, 193, 210 

Substance Abuse Treatment and Domestic 

Violence (TIP 25), 29, 98 

Substance Abuse Treatment and Family 

Therapy (TIP 39), 196 

Substance Abuse Treatment and Men’s Issues 

(in development), 101, 193, 210 

Substance Abuse Treatment and Trauma (in 

development), 29 

Substance Abuse Treatment for Persons With 

Child Abuse and Neglect Issues (TIP 36), 29, 

98 

Substance Abuse Treatment for Persons With 

Co-Occurring Disorders (TIP 42), 18, 19, 

25, 26, 39, 61, 109, 114, 192 

Substance Abuse Treatment for Persons With 

HIV/AIDS (TIP 37), 117 

Substance Abuse Treatment: Group Therapy 

(TIP 41), 98 

Substance Use Disorder Treatment for People 

With Physical and Cognitive Disabilities 

(TIP 29), 107, 116 

Treatment Drug Courts: Integrating Substance 

Abuse Treatment With Legal Case 

Processing (TIP 23), 132 

training 

of counselors in community supervision settings, 

224, 230–231 

of counselors in jails, 166 

gender-specific, 209 

of judges, 148 

staff, 35, 147–148, 179, 205, 209–210, 230–231, 

245–246 

Web sites, 154 

Training for Professionals Working with MICA 

Offenders (training module), 246 

transition back to the community, 170 

trauma, 26–27 

abuse, 97–98 

and borderline personality disorder, 115 

prevalence, 27 

in prison settings, 191 

sample questions for assessment, 29 

screening and assessment of, 28 


treatment 

for cultural minorities, 93–95 

definition, 4 

retention in, 85–86 

Treatment Accountability for Safer Communities, 

40, 133–136 

treatment components. See program components 

treatment issues 

anger and hostility, 76–77 

anxiety disorders, 116 

basic needs, addressing, 72 

cognitive disorders, 116 

co-occurring disorders, 108–109 

criminal code, 75 

criminal identity, 77 

criminal thinking, 74–75 

cultural identity, 77 

depressive and bipolar disorders, 115 

detoxification, 72–73 

and disability, 105–107 

family issues, 77–79 

goals in the jail setting, 176 

homelessness, 73 

infectious diseases, 116–118 

life skills, 73–74 

manipulativeness, 75 

older adults, 107 

pretrial, 125–126 

rural clients, 107–108 

schizophrenia and psychotic disorders, 

115–116 

sex offenders, 119–122 

sexual orientation, 104–105 

status, role as a person of, 79 

timing of treatment, 148 

for violent offenders, 102–104 

for women, 95–100 

treatment levels 

effectiveness of, 44 

inpatient and residential care, 45–46 

outpatient, 45 

pretreatment services, 44–45 

treatment matching, 43, 55, 56, 59 

treatment planning 

assessing substance use disorder severity, 60 

client motivation, 65–67 

and co-occurring disorders, 60–63 

for criminality and psychopathy, 63–65 

and linkages with community treatment, 69 

and offender involvement, 67 

planning chart, 134–135, 238–239 

recommendations, 70, 90–91 

and stages of change, 83 

strengths-based approach, 66–67 

treatment programs, sample, 109 

Amity/Pima County Substance Abuse Treatment 

Jail Project, 184 

Amity Prison therapeutic community, 202–203 

Amity Project, 231 

Breaking the Cycle (ONDCP), 232 

Index 331 
 

Brooklyn Drug Treatment Alternative to Prison V

 

program, 151–152 

Denver Women’s Correctional Facility program 

for women and their children, 100 

Federal Bureau of Prisons residential treatment 

programs, 204 

Female Offender Treatment and Employment 

Program, 99 

Forever Free from Drugs and Crime, 96 

KEY-CREST programs (Delaware), 202, 232 

King County Jail System, North Rehabilitation 

Facility, Stages of Change Program 

(Washington), 183 

Memphis prebooking jail diversion program, 152 

Multnomah County Sheriff’s Office In-Jail 

Intervention Program (Oregon), 183 

Oakland Men’s Project (violence prevention 

program), 103 

Oregon STOP program, 240 

Philadelphia Prison System OPTIONS Program 

(Pennsylvania), 183 

Probationers in Recovery (California), 232 

Programs for Assertive Community Treatment, 

226 

Project MATCH, 168 

Residential Substance Abuse Treatment, South 

Idaho Correctional Institution, 199 

SHARPER FUTURE, 121 

Special Offender Services program 

(Pennsylvania), 232 

Stay’n Out (New York), 201, 202 


Texas Kyle New Vision program, 203 

Walden House, 67, 99 

Walden House and the San Francisco Sheriff’s 

Office SISTER Project, 184 

Willamette Family Treatment Services, 139 

treatment services 

and arrest, 128 

coordination, in jails, 175 

developing, in pretrial, 146–147 

triage and placement 

barriers to, 47 

creating, 47–49 

examples of approaches, 54–56 

information needed for, 51, 52, 53, 54 

key activities, 48 

recommendations, 56–57 

strategies for, 48–49, 50 


using screening information in decisionmaking, 

49–50 

trial, definition, 130 

tuberculosis, prevalence data, prison populations, 

190 

victims, 241 

victim impact meetings, 141 

video feedback, 198 

violence, 29, 94, 193. See also abuse; anger 

and borderline personality disorder, 115 

domestic, 173 

instruments for, 32–33 


managing and preventing, 103 

and relationship with substance abuse, 102 

risk factors for, 31 

violent crime, 102 

working with violent offenders, 102–104 

Violence Interruption Process, Illinois TASC, 103 

Violent Crime Control and Law Enforcement Act of 

1994, 204 

vocational training, 242 

in community supervision settings, 219 

in prison settings, 197 

W 

Walden House, 67, 99 

and the San Francisco Sheriff’s Office SISTER 

Project (California), 184 

Wayne County Jail Target Cities Jail-Based 

Substance Abuse Treatment Program (Michigan), 

184 

Web sites cited 

Addiction Technology Transfer Centers, 246 

Association for the Treatment of Sexual Abusers, 

121 

Baltimore’s approach to improving drug 

treatment, 147 

borderline personality disorder, treatment 

guideline, 115 

Bureau of Justice Assistance, 153 

Federal Bureau of Prisons Clinical Practice 


Guidelines: Detoxification of Chemically 

Dependent Inmates, 21 

Forever Free from Drugs and Crime, 96 

Framework for Recovery, 74 

GAINS Center for People with Co-Occurring 

Disorders in the Justice System, 225 

Health Insurance Portability and 

Accountability Act, 14, 48, 70, 131, 149, 

166, 230 

High Intensity Drug Trafficking Areas 

Automated Tracking System, 15 

Mid-America Addiction Technology Transfer 

Center, 46 

National Addiction Technology Transfer 

Center, 148 

332 Index 
National Association of Drug Court 

Professionals, 153 

parenting programs for male offenders, 78 

Partnership Against Violence Network (Pavnet), 

103 

Project for Homemakers in Arizona Seeking 

Employment, 101 

Regional Drug Initiative (Oregon), 240 

Serious and Violent Offender Reentry Initiative, 

3, 228 

SHARPER FUTURE, 121 

Slosson Oral Reading Test - Revised, 36 

Substance Abuse and Mental Health Services 

Administration, 153, 252 

TCU Drug Screen, 19 

TCU Treatment Motivation Scales, 23 

therapeutic community standards, 199 

Thinking for a Change, 76, 195 

training resources, 154, 246 

Willamette Family Treatment Services, 139 

withdrawal, 20, 139 

women’s issues 

abuse, 97–98 

in community supervision settings, 226 

criminal justice population, 95–96 

guilt, 99 

HIV educational programs, 117 

job skills training, 100–101 

parenting, 98–99 

physical and sexual abuse of, 97–98 

in prison settings, 194 

safety, 96 

screening and assessment of, 37–38 

self-esteem, 98 

and strengths-based approach to treatment, 67 

treatment issues, 95–97 

women-specific treatment programs, 96 

Working with Criminal Justice Clients (curriculum), 

246 

work release center, 142 

Index 333 
335

SAMHSA TIPs and Publications Based on TIPs

What Is a TIP?

Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that brings together clinicians,

researchers, program managers, policymakers, and other Federal and non-Federal experts to reach consensus on state-of-the-art

treatment practices. TIPs are developed under the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s)

KnowledgeApplication Program (KAP) to improve the treatment capabilities of the Nation’s alcohol and drug abuse treatment service system.

What Is a Quick Guide?

A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket-sized booklet. Each Quick Guide is

divided into sections to help readers quickly locate relevant material. Some contain glossaries of terms or lists of resources. Page 

numbers from the original TIP are referenced so providers can refer back to the source document for more information.

What Are KAP Keys?

Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening in-struments, checklists, and

summaries of treatment phases. Printed on coated paper, each KAP Keys set is fastened together with a key ring and can be kept

within a treatment provider’s reach and consulted fre-quently. The Keys allow you, the busy clinician or program administrator, to

locate information easily and to use this information to enhance treatment services.

Ordering Information

Publications may be ordered or downloaded for free at http://store.samhsa.gov. To order over the phone, please call 

1-877-SAMHSA-7 (1-877-726-4727) (English and Español).

TIP 1 State Methadone Treatment Guidelines—Replaced by

TIP 43

TIP 2 Pregnant, Substance-Using Women—Replaced by

TIP 51

TIP 3 Screening and Assessment of Alcohol- and Other

Drug-Abusing Adolescents—Replaced by TIP 31

TIP 4 Guidelines for the Treatment of Alcohol- and Other

Drug-Abusing Adolescents—Replaced by TIP 32

TIP 5 Improving Treatment for Drug-Exposed Infants

TIP 6 Screening for Infectious Diseases Among Substance

Abusers—Archived

TIP 7 Screening and Assessment for Alcohol and Other

Drug Abuse Among Adults in the Criminal Justice

System—Replaced by TIP 44

TIP 8 Intensive Outpatient Treatment for Alcohol and

Other Drug Abuse—Replaced by TIPs 46 and 47

TIP 9 Assessment and Treatment of Patients With

Coexisting Mental Illness and Alcohol and Other

Drug Abuse—Replaced by TIP 42

TIP 10 Assessment and Treatment of Cocaine- Abusing

Methadone-Maintained Patients—Replaced by TIP 43

TIP 11 Simple Screening Instruments for Outreach for

Alcohol and Other Drug Abuse and Infectious

Diseases—Replaced by TIP 53

TIP 12 Combining Substance Abuse Treatment With

Intermediate Sanctions for Adults in the Criminal

Justice System—Replaced by TIP 44

TIP 13 Role and Current Status of Patient Placement

Criteria in the Treatment of Substance Use

Disorders

 Quick Guide for Clinicians 

 Quick Guide for Administrators 

 KAP Keys for Clinicians

TIP 14 Developing State Outcomes Monitoring Systems for

Alcohol and Other Drug Abuse Treatment

TIP 15 Treatment for HIV-Infected Alcohol and Other Drug

Abusers—Replaced by TIP 37

TIP 16 Alcohol and Other Drug Screening of Hospitalized

Trauma Patients 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians

TIP 17 Planning for Alcohol and Other Drug Abuse

Treatment for Adults in the Criminal Justice

System—Replaced by TIP 44

TIP 18 The Tuberculosis Epidemic: Legal and Ethical Issues

for Alcohol and Other Drug Abuse Treatment

Providers—Archived

TIP 19 Detoxification From Alcohol and Other Drugs—

Replaced by TIP 45

TIP 20 Matching Treatment to Patient Needs in Opioid

Substitution Therapy—Replaced by TIP 43

TIP 21 Combining Alcohol and Other Drug Abuse

Treatment With Diversion for Juveniles in the

Justice System 

 Quick Guide for Clinicians and Administrators 
336

TIP 22 LAAM in the Treatment of Opiate Addiction—

Replaced by TIP 43

TIP 23 Treatment Drug Courts: Integrating Substance Abuse

Treatment With Legal Case Processing 

 Quick Guide for Administrators 

TIP 24 A Guide to Substance Abuse Services for Primary

Care Clinicians 

 Concise Desk Reference Guide 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 25 Substance Abuse Treatment and Domestic Violence 

 Linking Substance Abuse Treatment and Domestic

Violence Services: A Guide for Treatment Providers 

 Linking Substance Abuse Treatment and Domestic

Violence Services: A Guide for Administrators 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 26 Substance Abuse Among Older Adults 

 Substance Abuse Among Older Adults: A Guide for

Treatment Providers 

 Substance Abuse Among Older Adults: A Guide for

Social Service Providers 

 Substance Abuse Among Older Adults: Physician’s

Guide 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians

TIP 27 Comprehensive Case Management for Substance

Abuse Treatment

 Case Management for Substance Abuse Treatment: A

Guide for Treatment Providers 

 Case Management for Substance Abuse Treatment: A

Guide for Administrators 

 Quick Guide for Clinicians 

 Quick Guide for Administrators

TIP 28 Naltrexone and Alcoholism Treatment—Replaced by

TIP 49

TIP 29 Substance Use Disorder Treatment for People With

Physical and Cognitive Disabilities

 Quick Guide for Clinicians

 Quick Guide for Administrators 

 KAP Keys for Clinicians 

TIP 30 Continuity of Offender Treatment for Substance Use

Disorders From Institution to Community 

 Quick Guide for Clinicians

 KAP Keys for Clinicians

TIP 31 Screening and Assessing Adolescents for Substance

Use Disorders

 See companion products for TIP 32.

TIP 32 Treatment of Adolescents With Substance Use

Disorders 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 33 Treatment for Stimulant Use Disorders

 Quick Guide for Clinicians

 KAP Keys for Clinicians

TIP 34 Brief Interventions and Brief Therapies for Substance

Abuse 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 35 Enhancing Motivation for Change in Substance Abuse

Treatment

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 36 Substance Abuse Treatment for Persons With Child

Abuse and Neglect Issues

 Quick Guide for Clinicians 

 KAP Keys for Clinicians

 Helping Yourself Heal: A Recovering Woman’s Guide to

Coping With Childhood Abuse Issues 

 Also available in Spanish

 Helping Yourself Heal: A Recovering Man’s Guide to

Coping With the Effects of Childhood Abuse 

 Also available in Spanish

TIP 37 Substance Abuse Treatment for Persons With

HIV/AIDS

 Quick Guide for Clinicians

 KAP Keys for Clinicians 

 Drugs, Alcohol, and HIV/AIDS: A Consumer Guide 

 Also available in Spanish

 Drugs, Alcohol, and HIV/AIDS: A Consumer Guide for

African Americans

TIP 38 Integrating Substance Abuse Treatment and

Vocational Services

 Quick Guide for Clinicians 

 Quick Guide for Administrators 

 KAP Keys for Clinicians 

TIP 39 Substance Abuse Treatment and Family Therapy

 Quick Guide for Clinicians

 Quick Guide for Administrators

 Family Therapy Can Help: For People in Recovery

From Mental Illness or Addiction
337

TIP 40 Clinical Guidelines for the Use of Buprenorphine in

the Treatment of Opioid Addiction

 Quick Guide for Physicians 

 KAP Keys for Physicians 

TIP 41 Substance Abuse Treatment: Group Therapy

 Quick Guide for Clinicians 

TIP 42 Substance Abuse Treatment for Persons With CoOccurring Disorders

 Quick Guide for Clinicians 

 Quick Guide for Administrators 

 KAP Keys for Clinicians 

TIP 43 Medication-Assisted Treatment for Opioid Addiction

in Opioid Treatment Programs

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 44 Substance Abuse Treatment for Adults in the

Criminal Justice System

 Quick Guide for Clinicians

 KAP Keys for Clinicians 

TIP 45 Detoxification and Substance Abuse Treatment

 Quick Guide for Clinicians

 Quick Guide for Administrators

 KAP Keys for Clinicians 

TIP 46 Substance Abuse: Administrative Issues in

Outpatient Treatment

 Quick Guide for Administrators

TIP 47 Substance Abuse: Clinical Issues in Outpatient

Treatment

 Quick Guide for Clinicians 

 KAP Keys for Clinicians

TIP 48 Managing Depressive Symptoms in Substance Abuse

Clients During Early Recovery

TIP 49 Incorporating Alcohol Pharmacotherapies Into

Medical Practice

 Quick Guide for Counselors 

 Quick Guide for Physicians 

 KAP Keys for Clinicians 

TIP 50 Addressing Suicidal Thoughts and Behaviors in

Substance Abuse Treatment

 Quick Guide for Clinicians 

 Quick Guide for Administrators

TIP 51 Substance Abuse Treatment: Addressing the Specific

Needs of Women

 Quick Guide for Clinicians

 Quick Guide for Administrators

TIP 52 Clinical Supervision and Professional Development

of the Substance Abuse Counselor

 Quick Guide for Clinical Supervisors

 Quick Guide for Administrators

TIP 53 Addressing Viral Hepatitis in People With Substance

Use Disorders

 Quick Guide for Clinicians and Administrators

 KAP Keys for Clinicians 

TIP 54 Managing Chronic Pain in Adults With or in

Recovery From Substance Use Disorders

 Quick Guide for Clinicians 

 KAP Keys for Clinicians

 You Can Manage Your Chronic Pain To Live a Good

Life: A Guide for People in Recovery From Mental

Illness or Addiction

TIP 55 Behavioral Health Services for People Who Are

Homeless

TIP 56 Addressing the Specific Behavioral Health Needs of

Men 

TIP 57 Trauma-Informed Care in Behavioral Health

Services 

TIP 58 Addressing Fetal Alcohol Spectrum Disorders

(FASD)

TIP 59 Improving Cultural Competence
Substance Abuse Treatment 

For Adults in the

Criminal Justice System

This TIP, Substance Abuse Treatment for Adults in the Criminal

Justice System, revises and supersedes TIP 7, Screening and

Assessment for Alcohol and Other Drug Abuse Among Adults in

the Criminal Justice System, TIP 12, Combining Substance Abuse

Treatment With Intermediate Sanctions for Adults in the

Criminal Justice System, and TIP 17, Planning for Alcohol and

Other Drug Abuse Treatment for Adults in the Criminal Justice

System. The revised TIP provides the current clinical evidencebased guidelines, tools, and resources necessary to help substance abuse counselors treat clients involved with the criminal

justice system.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

HHS Publication No. (SMA) 13-4056

First Printed 2005

Revised 2009, 2011, 2013, and 2014

Collateral Products

Based on TIP 44

Quick Guide for Clinicians

KAP Keys for Clinicians