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Chapter 14 of TAP 11: Treatment for Alcohol and Other Drug Abuse

Chapter 14–State Courts Coordinating With the State Treatment Field

The impact of substance abuse on the criminal and juvenile justice systems throughout the country is profound. The United States now incarcerates more persons on a per capita basis than any other country in the world, and the caseloads for community corrections agencies have soared. Often, income-generating crimes and violent offenses are directly associated with substance abuse. Many alcohol- and drug-related law violations have been criminalized, and mandatory sentences have been prescribed. Thus, courts have become backlogged, and jails and prisons often are filled beyond capacity. McGarry (1993) of the National Intermediate Sanctions Project States:

. . . the intervention of the criminal justice system seems to have little or no effect on re-offending: the same offenders reappear time after time. Judges in particular feel that their hands are tied in these cases. In some jurisdictions, the sentencing laws require a mandatory minimum term of incarceration, while, in others, judges must sentence offenders to a term of meaningless (in their eyes) supervision through probation. Neither response seems to affect behavior. At the same time, the costs of prison, jail, and probation are draining the coffers of State and local governments at a growing rate.

An American health care crisis also looms in the wake of the AIDS epidemic. The number of persons infected with HIV is increasing most rapidly among those who inject illicit drugs. Other infectious diseases, such as Hepatitis B and tuberculosis, also can be fatal and are increasingly prevalent among substance abusers. In addition, babies born to substance abusing mothers present significant medical challenges and are requiring more extensive and expensive medical treatment. Many criminal offenders, whether incarcerated or on community supervision, need both substance abuse treatment and advanced medical care because of the infectious diseases so common among chemically dependent persons.

Courts are faced with difficult decisions at both the individual offender level and at the community and State levels. Appropriate sentencing and sanctioning choices, family court and child placement issues, the availability of substance abuse treatment and appropriate medical care, and economic considerations are among the concerns courts must consider. This chapter explores issues and challenges facing State courts and proposes critical areas around which coordination with the treatment field is vital.

The Impact of Substance Abuse on the Courts

Approximately 1.2 million persons are incarcerated in the United States. The majority of these inmates are male. However, the number of women in prison tripled over the past decade, while the overall prison population doubled. Ethnic minority persons are over represented in the criminal justice system. African Americans, who comprise 12 percent of the U.S. population, make up 47 percent of the prison and jail populations. Hispanic persons constitute 9.6 percent of the prison population and 14 percent of those in jails, while they represent only seven percent of the total U.S. population (American College of Physicians, National Commission on Correctional Health Care & American Correctional Health Services Association, 1992).

Much of the increase in correctional facility populations is directly associated with substance abuse and related crimes. While overall arrest rates rose 72.7 percent between 1981 and 1990, arrests for drug-related violations rose 125.9 percent. In addition to increased arrests, mandatory and fixed term sentences for certain drug-related crimes in some States also has contributed to the growing criminal justice system. By 1989, one third of women and twenty percent of men in local jails were being held on drug charges. Fifty-four percent of federal prisoners in 1990 were drug offenders (American College of Physicians et al., 1992).

The juvenile justice system is no exception to these alarming statistics. A study conducted by the National Center for Juvenile Justice reviewed nearly 300,000 court records of drug and alcohol cases. These were drawn from 841 juvenile courts in 17 States between 1985 and 1988. During that four year period, in the courts studied, juvenile drug case rates (cases per 1,000 youth at risk) increased nearly 12 percent. The alcohol case rate increased by eight percent. The study also found disparities in the case rates for alcohol and drug use by ethnicity. While the drug case rate for white youth decreased 15 percent, the drug case rate for nonwhite youth increased 88 percent from 1985 through 1988. However, the alcohol case rate for white youth was nearly four times the nonwhite rate (Sickmund, 1991).

Challenges Facing State Courts

Under present policies, the challenges facing State courts may become even more troublesome. Some of the most prevalent concerns related to substance abuse that are confronting State courts include:

• increasing numbers of cases;
• bottlenecks and delays in processing cases through courts;
• limited court resources for meeting greater demands;
• high costs to the courts and the entire criminal justice system for providing needed services and facilities;
• civil and family/domestic cases; and
• the need to collaborate with the treatment field to expand the use of treatment resources for alcohol and drug-involved persons.

Courts and criminal justice systems are handling larger caseloads because of current concerns about the effects of alcohol and other drugs on individuals and society. In many instances, more forceful laws related to drug and alcohol offenses have been passed, and they are being vigorously enforced. For example, the onset of the crack epidemic in 1985 resulted in a 150 percent increase in felony drug arrests in New York State by 1991 (Wachtler, 1991).

The expanding case rates have caused overloads in many courts resulting in bottlenecks for the timely processing of cases by the judiciary. These delays, in conjunction with limited jail and prison space, interfere with individuals' rights to a speedy trial. They also undermine the deterrent effects of the criminal justice system and result in feelings of frustration and disrespect for the law (Supreme Court, State of New Jersey, Task Force on Drugs and the Courts).

While increasing numbers of offenders with substance abuse-related problems are well-documented, of equal importance are the corresponding constraints on resources at the disposal of the judiciary. Court resources have not kept up with the rise in caseloads. Court cases have doubled and even tripled in some jurisdictions, but increases in judicial personnel and other resources have been modest to nonexistent.

Almost one-third of all criminal justice expenses in 1985 were related to alcohol, drug abuse, and mental health problems (Rice, Kelman, Miller & Dunmeyer, 1990). An average annual increase of 13 percent per year in State prison populations is expected to result in an overall growth of more than 68 percent in incarcerated individuals by 1994. It costs an average of $25,000 per year to incarcerate each inmate in a State prison. Coupled with building new prisons required to relieve crowded conditions, this means States are facing unprecedented expenditures in the future (American College of Physicians et al., 1992). Resources to deal with growing populations and spiraling costs are finite. Members of State systems will be forced to set priorities and make the best use of limited funds. In many situations, effective, coordinated use of substance abuse treatment can result in savings for incarceration and other criminal justice costs.

Another consequence of increased drug caseloads is the pressure placed on civil dockets and family/domestic relations court dockets. Judges, courtrooms, court staff, and other resources sometimes are directed to handle criminal cases to the detriment of the other business of the courts (American Judicature Society [AJS], 1990).

In addition to this displacement, substance abuse has had a direct impact on civil and family or domestic courts. Substance abuse compounds family violence and interferes with the capacity of parents to provide adequate care for their children. The consequences often include neglect, abuse and abandonment of children. These children may suffer both physical and emotional trauma that requires lengthy and expensive treatment. Courts face difficult decisions about removing children from their homes, visitations, reuniting families, termination of parental rights, and adoptions.

Adult domestic partners also may experience physical or financial neglect, abuse, and abandonment at the hands of alcohol- or drug-involved partners. It is often difficult for women in abusive relationships to obtain protection until they are seriously battered or press charges against their partners. If they are financially or emotionally dependent on their partners, deciding to do the latter can be both difficult and precarious.

Substance abuse compounds pregnancy for women and places a greater risk on the unborn child. Combining substance abuse and pregnancy increases the potential for medical complications for a woman. For example, with cocaine use, potential consequences during pregnancy include maternal hypertension, spontaneous abortion, hemorrhage from the placenta, premature rupture of membranes, and premature onset of labor, among others (Bandstra, 1990). In addition, pregnant women with substance abuse disorders also encounter barriers to receiving treatment, including the following (U. S. General Accounting Office, 1991):

• lack of available treatment for pregnant women and mothers with young children, including free or publicly funded drug treatment;
• lack of programs that are appropriate for the unique needs of drug-abusing pregnant women and mothers, including child care services and prenatal care;
• lack of accessible public transportation to reach treatment programs;
• negative attitudes and behaviors of health care providers toward pregnant women who abuse substances;
• personal barriers to treatment, including the wish to deny the pregnancy and inadequate knowledge of drugs and their effects;
• the threat of prosecution for child abuse that may result in incarceration and losing custody of their children; and
• limited outreach and referral services to help women locate and use appropriate existing services.

Treating infants for drug withdrawal is painful for the newborn and often requires expensive procedures and intensive care. Effects of alcohol or drug exposure may accompany these children throughout life, decreasing their potential for a happy, productive life. Low birthweight, premature delivery, deformities, retardation, and behavioral problems are examples of some of the consequences of prenatal exposure. Such infants may be difficult to care for, and as they become older they may have problems concentrating and bonding with adults appropriately. Hyperactivity, emotional lability, impulsivity, and lack of physical coordination are problems for many of these children. Learning problems, lower I.Q.s, and poor verbal skills often are noted as well (Larsen & Horowitz, 1992).

In addition, children born to mothers infected with HIV are at risk of contracting the virus. If this occurs, they will require medical care and other assistance that is often beyond the means of family members to provide. As parents become very ill or die from AIDS complications, courts sometimes must decide about the care and placement of affected children.

The Importance of Systems Coordination

State courts are a part of larger systems at two levels. At minimum, State substance abuse agency directors, health care system representatives, judicial system delegates, and legislative leaders (and perhaps others) must work in concert, at a macro level, to achieve effective policy decisions. At the community or individual (micro) level, the same systems must interact effectively to provide appropriate interventions for alcohol- and drug-involved persons. See Figure 14-A for a graphic depiction of these two systems levels. Discrete systems include substance abuse treatment, health care, judicial and criminal justice, State legislative and enforcement agencies, and other systems, such as social welfare and its service delivery agencies. Each of these systems has unique characteristics, funding mechanisms, and responsibilities. However, at the policy-making and intervention levels they are very interdependent. What affects one system impacts each of the others. Concurrently, the individual needing treatment usually requires services from a variety of systems. Coordination of these efforts can minimize duplication of efforts or gaps in needed services (Downes & Shaening, 1993; Hafemeister, 1991; McGarry, 1993).

Members of each of the discrete systems have various perspectives on needs and desired outcomes. When these systems join at the micro or macro level, there may be conflicts and tensions about expectations and goals. However, coordination within these interdependent systems allows the key players to achieve a fresh understanding of how their respective roles and systems impact, and are affected by, the larger systems. When common purposes and specific functions are identified and integrated, more can be accomplished than through any individual effort (Downes & Shaening, 1993).

Communication among systems is also vital to understand the philosophies of each. The major goal of treatment providers is to help individuals make changes needed to achieve abstinence. While the criminal and juvenile justice systems share this purpose, they also have a public protection duty. Although these differences are inherent in the respective systems, frequent communication and collaboration can facilitate a better understanding of each party and respect for, if not total agreement with, each point of view.

Developing partnerships among key players in the treatment and justice systems, on behalf of drug-involved persons, is vital. Several important elements of such an alliance include the following (Downes & Shaening, 1993; McGarry, 1993):

• interagency policies clarifying responsibilities for designing and delivering treatment;
• the development of realistic treatment and performance outcomes for persons who are under the supervision of both the treatment and criminal justice systems;
• feedback mechanisms to the judiciary about the progress of individuals;
• feedback to all involved parties about the general performance of the system;
• collaborative efforts to address the health-related needs of persons in the justice system;
• opportunities for sharing about mutual expectations and interdependencies among personnel from discrete systems who are interacting in interdependent systems; and
• development of effective strategies for case management coordination among various agencies with responsibilities for interventions.

With evidence heavily weighted toward the effectiveness of treatment for alcohol and other drug abuse problems, State court officials are increasingly aware of the need to refer individuals for treatment. Both the financial and human economies resulting from treatment are well worth the investment in treatment services. These include decreased substance abuse, lower rates of criminal behavior, potential savings in health care and justice system costs, and increased productivity.

In addition to the State substance abuse agency that provides State-level planning, coordination, program monitoring, and allocation of financial resources, the treatment community includes diverse treatment programs that can be accessed for persons needing intervention, (Hafemeister, 1991). Both substance abuse treatment and medical care often are needed in tandem by persons who come to the attention of State courts. Health care professionals, as well as substance abuse treatment professionals from other disciplines (e.g., psychology, social work), have state-of-the-art information and expertise about assessment and treatment of substance abuse problems. Through collaborative efforts, their knowledge and skills can be shared to increase the effectiveness of interventions for persons in the justice system.

This important role of treatment requires coordination and collaboration between the judicial (both criminal and juvenile justice) system and the treatment field. Effective communication, planning, and sharing of expertise is vital for realistic treatment matching and case management of individuals involved in both the treatment and justice systems. Without active coordination efforts, the possibility of untoward results spirals. Such ramifications may include (but are not limited to):

• wasting valuable treatment resources through inappropriate referrals or ineffective treatment programs;
• losing patients (both figuratively and literally) from treatment when accountability and case management procedures are not coordinated;
• higher relapse and recidivism rates if comprehensive services are not provided or if neither system consistently follows clients during and after the treatment experience;
• both fragmentation and duplication of services; and
• continuing need for interventions because treatment goals are not achieved.

Because treatment resources are limited, the treatment field and the courts must work closely to identify treatment resources and make the best use of expertise that is available. Once identified, coordination for the effective use of limited resources is a vital task for both treatment and the courts.

Integration between treatment and judicial structures is necessary for accountability of both individuals and organizations. Relapse prevention is a vital shared role between the treatment field and the criminal/juvenile justice system. Monitoring, through case management and aftercare, is similarly a responsibility that must be carefully considered and coordinated between the two systems.

The Changing Role of the Courts

The fundamental task of the courts is to make decisions about the culpability of persons involved in a particular case based on the information provided. Also within the purview of the courts is the determination of consequences, including various sanctions and other requirements imposed for criminal activities. Similarly, decisions in civil and domestic court cases may define and limit the roles, responsibilities, and freedom of persons not necessarily charged with a criminal offense. Such individuals may be at risk of harming themselves or others or of being harmed by someone because judgment is clouded by chemical dependency.

The array of options for sentencing has expanded greatly as innovative programs have developed within the spectrum of the criminal and juvenile justice systems. In some cases, discretion has been taken away from judges by legislation that requires mandatory sentences. Concomitantly, as treatment has become more sophisticated and complex, judges and court staff increasingly must seek expertise from those who specialize in this field. The expert knowledge and skills of treatment professionals can be invaluable in developing individualized treatment recommendations, creating an effective continuum of care, and providing comprehensive services to meet individual needs.

These changes require much greater coordination and collaboration with substance abuse treatment agencies than was necessary in the past. Areas in which collaboration may be particularly valuable include (but are not limited to):

• identification and assessment of individuals with alcohol and other drug abuse problems;
• selection of the most appropriate treatment approaches and programs to which referrals may be made, and consideration of other sanctioning options that can be effective complements to treatment;
• arrangements for a comprehensive array of services to meet the entire spectrum of the needs manifested by a substance abuser;
• consideration of relapse prevention interventions that may be provided by both treatment and criminal/juvenile justice personnel;
• coordination of efforts to hold substance abusers accountable for their own recovery, including attendance at treatment, cooperation with treatment tasks, and remaining drug free (as indicated by random urinalysis); and
• provision of appropriate rewards or consequences for behaviors.

Referral to treatment programs and sentencing sanctions can be integrated for alcohol- or drug-involved offenders by all justice agencies. A thorough case management process can monitor the compliance and progress of individuals through treatment and various other services needed. Contingencies can be used to encourage participation. However, such endeavors require frequent communication, coordination, and collaboration between court and treatment personnel.

An important part of coordination between the judicial and treatment systems is sharing information. One area in which this should occur includes individual client/patient information (keeping in mind confidentiality considerations) which is vital to both systems. If a person is to be helped to the greatest extent possible, a team effort among involved parties will be the most productive approach. State-of-the-art management information systems (MIS) can significantly enhance efforts to coordinate services and share information. When data are combined in a single MIS, those needing access to current information can obtain it more readily. For example, if a judge needs updated assessment information and recommendations before imposing sentencing and sanctions, it is much more efficient and cost effective to obtain all available data through one system, rather than spending time collecting individual reports from several sources.

Information about the abilities and constraints of both the courts and treatment field also need to be shared. Where possible, increasing referrals for treatment, as an alternative to adjudication or incarceration, is likely to be the most productive and cost-effective response. For example, it is estimated that the cost of successfully treating alcohol problems would be approximately one-tenth of what the disease currently costs society. Other reports indicate that the median total yearly cost per patient for drug abuse treatment was $4,600. This can be contrasted with an annual cost of $25,000 per inmate in New York State prisons in 1990 (Singer, 1992).

Coordination Between the Courts and Treatment Around Five Critical Elements

At every stage of the criminal and juvenile justice systems, identifying persons with alcohol or other drug problems is essential. Drug testing, drug recognition techniques, and brief screening instruments (discussed in Chapter 4) may be helpful in identifying those in need of further assessment for substance abuse treatment. The Criminal Justice Treatment Planning Chart (Center for Substance Abuse Treatment [CSAT], 1993a) and the Juvenile Justice Treatment Planning Chart (CSAT, 1993b) show the various junctures within each system at which drug testing and other screenings are appropriate. For the criminal justice system, the major points of intervention are:

• Pre-trial hearings, including supervision of persons on release or in jail;
• pre-sentence investigations and hearings, including provisions for release, jail, or diversion programs;
• trial/sentencing resulting in probation or incarceration; and
• parole.

Similarly, the juvenile justice system affords opportunity for identification of alcohol- and drug- involved youth at the following points:

• intake/arrest leading to either an informal adjustment or filing of a petition;
• the social investigation, fact-finding hearing, and adjudication;
• case disposition, which may include community supervision or commitment to a residential program; and
• aftercare.

It is vital for the courts and criminal justice system to be vigilant concerning indicators of substance abuse. Institutionalizing screening procedures will ensure that fewer problems are overlooked. Having data available on a system-wide MIS increases the efficiency and effectiveness with which information is accessed to assist in identifying those who potentially need treatment.

Assessment

Assessment is the first critical area of substance abuse intervention. Thorough assessments, as discussed in Chapter 4, are used to determine the nature and complexity of the individual's problems. Comprehensive assessments evaluate the severity of substance abuse problems, identify cofactors, and develop treatment recommendations. Without a comprehensive assessment, referrals for treatment may be inappropriate and treatment resources may be misused.

Trained substance abuse and health professionals should conduct and interpret the findings of assessments. Such findings and recommendations should be communicated in a way that is understandable to non-treatment professionals. The court has an essential role in directing persons to the assessment process and using the resulting information and recommendations to decide about sentencing, sanctions, and referral for treatment.

Before members of the judiciary make dispositions, complete assessment information and recommendations are required. This assists in the appraisal of:

• risk for release;
• decisions concerning diversion;
• various levels of community supervision or incarceration required;
• community reintegration following incarceration; and
• the need for health care related to infectious diseases.

Recommendations for treatment, with supporting data from assessments, should be used in case disposition, including treatment referrals, sentencing, and conditions of supervision and release. Although thorough assessments may be time-consuming and require additional expenditures, they are ultimately cost-effective.

Assessment and treatment referral recommendations should be viewed as an ongoing, or several-stage process. For example, if an individual is referred by the court for intensive treatment services in lieu of incarceration, the court will need to obtain information about his or her progress and status upon completion of the program. At that time, a new (or revised) assessment report may be needed to identify continuing problems and outline ongoing or changing treatment needs. For example, case management and continuing care are essential following inpatient treatment. In addition, referral to self help groups such as Alcoholics and Narcotics Anonymous (AA and NA) and various other services may be needed. Assessment should be viewed as a process rather than a time-limited event.

Mechanisms, such as state-of-the-art management information systems, can ensure that assessment results follow individuals through the various components of the system. This helps eliminate redundancy and control costs for conducting assessments.

Coordination and collaboration between the judiciary and treatment may include such considerations as which instruments and processes used in an assessment are considered valid and acceptable by scientific and legal standards. Negotiating the most efficient and cost-effective procedures for referring persons for assessment, sharing needed information, monitoring cases, and returning recommendations in a timely manner are other considerations for communication and coordination between courts and treatment agencies. Joint decisions may include concurring on the nature and purpose for assessments, designating persons to be responsible for various tasks, developing mutually agreed upon policies and procedures, and defining desired outcomes. Each entity can look to the other for expertise and for consistent application when such decisions have been made in tandem.

Patient-Treatment Matching

The importance of patient-treatment matching was discussed in Chapter 5. Effective matching increases the likelihood that individuals will receive the treatment services that are most appropriate for their needs. Thus, the chances of responding positively, remaining in treatment longer, and beginning recovery are enhanced. Effective treatment matching offers a greater chance of treatment success.

Matching is also important for fiscal management. As treatment resources are scarce, it is imperative that their use be maximized by making the most appropriate referrals. Funds may be misused and other persons may be denied treatment if individuals are inappropriately placed in treatment programs. Generally, it is most prudent to begin with the least restrictive treatment setting that is likely to meet the individual's needs. Outpatient treatment is less expensive than inpatient programs and can be very effective for many individuals. Thus, beginning with less costly and less restrictive programs is advisable; if necessary, the treatment plan can be modified to provide more intensive programs if the initial approach is not effective.

Coordination between the courts and treatment is important in accomplishing the following tasks.

• The range of treatment resources available in the community should be identified.
• The characteristics of programs and the persons and problems with whom they are most successful should be delineated.
• The information to be shared between agencies and how this can be done without breaching confidentiality can be outlined.
• The mechanisms of the referral process should be specified with appropriate time frames and communication requirements for each system.
• Case management responsibilities for each entity should be spelled out to avoid duplication of efforts or lapses in monitoring substance abusers.
• Appropriate funding mechanisms and responsibilities should be identified.

Busy court and treatment personnel may need to find efficient ways to communicate and collaborate on these and other issues. The absence of cooperative efforts often are even more time consuming and costly than the initial investment of resources required for effective coordination.

Comprehensive Services

Most persons with substance abuse problems face a variety of additional challenges and need an array of services. A continuum of treatment programs might include, but not be limited to, the following. These were reviewed in Chapter 3:

• Detoxification (and readiness for treatment);
• Assessment;
• Pharmacotherapeutic Interventions;
• Outpatient Drug Free Programs;
• Inpatient Treatment;
• Therapeutic Communities;
• Self-Help Support Programs; and
• Relapse Prevention.

Figure 14-B shows this continuum in a circle, indicating that movement can occur at the connecting points between any of the services.

Within these programs, various services might be included, such as group, individual and family counseling, behavior modification, acupuncture, and many others. Particular individuals will need different combinations of treatment programs and services to achieve and maintain recovery. For example, one individual might begin treatment with detoxification, followed by pharmacotherapeutic interventions providing group and individual counseling, followed by a self-help group. Another person might begin the treatment experience with outpatient treatment, find that a period of inpatient treatment is needed, and then continue with a follow-up outpatient program and a self-help group. The possible combinations are limitless and depend upon the assessed needs of individual patients. There is no particular order in which they must occur; rather the most appropriate combination of services needs to be identified and selected.

In addition to primary treatment for substance abuse, most patients will need ancillary services to address health and psychosocial problems. These services may include, but are not limited to, the following:

• Health Education;
• Preventive Health Care;
• Assessment and Testing for Infectious Diseases;
• Medical Treatment;
• Vocational Training and Counseling;
• Educational Services;
• Referral for Legal Aid and Immigration Services;
• Social and Athletic Activities;
• Housing Services;
• Income Maintenance;
• Counseling for Personal and Relationship Problems; and
• Peer/Support Groups.

Again, each person's needs must be assessed and a constellation of services appropriate for his or her needs should be provided. These needs may change over time; as some problems are addressed and resolved, other issues may become more important.

Further, within the criminal and juvenile justice systems there also are continuums of care. These are reflected in the Criminal Justice Treatment Planning Chart (CSAT, 1993a) and the Juvenile Justice Treatment Planning Chart (CSAT, 1993b). Each reflects the general movement of offenders or youth through the system. Possible options for both criminal/juvenile justice interventions and substance abuse treatment responses are indicated at each point for which courts provide supervision.

Meeting the comprehensive needs of persons involved in the criminal or juvenile justice systems requires extensive coordination between these systems and treatment. All persons involved must remain focused on the goal of providing comprehensive, quality interventions. This will require interactive planning and closely coordinated delivery of both treatment and sanctions. Without adequate communication and collaboration, there is a greater risk that a person's needs will not be thoroughly addressed and treatment will not be effective. Such coordination also promotes both patient and organizational accountability.

Relapse Prevention

Relapse prevention is another of the five critical elements of substance abuse treatment. In Chapter 1 the process of addiction was reviewed. As it is a chronic, relapsing disorder, many persons require multiple episodes of treatment in pursuit of recovery. A key element of effective treatment is relapse prevention: methods of helping patients anticipate and cope with situations that result in relapse. Information on relapse and relapse prevention was provided in Chapter 9.

Relapse prevention programming in both treatment services and criminal and juvenile justice agencies is important because it helps chemically dependent persons achieve and sustain abstinence. Relapse prevention, much like health promotion for other chronic diseases, emphasizes and reinforces long-term behavioral changes. As patients experience increased levels of success in coping with addiction, they are more likely to manage subsequent cravings and social pressures without relapsing to substance use. Relapse prevention is yet another way of promoting accountability of alcohol- and drug-involved individuals because they are taught specific ways of handling situations that, for them, trigger relapse.

Relapse prevention efforts increase periods of abstinence or decrease the duration of episodes of substance use after treatment and save treatment dollars by decreasing the need for additional treatment services. Thus, more persons ultimately can access scarce treatment resources.

Court and treatment personnel may need to receive joint training in relapse prevention techniques and collaborate on policies that determine whether or not participation in relapse prevention programs is to be mandatory. Relapse prevention must be a part of the continuum of treatment services and sanctions provided through both the treatment and the criminal/juvenile justice systems. To do this effectively, coordination is imperative.

Accountability

Accountability is the last of the five critical elements of treatment. Accountability applies to both individuals and organizations. Court and treatment personnel are concerned about providing cost-effective, quality treatment services that ultimately impact the problem of substance abuse. Only through evaluating treatment services and using the information generated to modify programs, where needed, can quality be maintained and improved. Effective evaluation begins early in program development; it is not a procedure tacked on at the end of service provision. As plans for services and coordination activities are developed, an overriding question should be the way in which they will be evaluated to determine their effectiveness.

Both the courts and the treatment community have a vested interest in knowing that treatment services are effective. Evaluation of services is also useful in identifying gaps in services, within both the treatment system and the criminal and juvenile justice systems. Recurring problems often can be directly attributed to the lack of specific programs and services. Such information, provided to decision makers, may be used to obtain additional resources and implement new programs.

Successful evaluation efforts require considerable coordination among systems. Lack of communication and collaboration can result in inadequate accountability, because insufficient information is available. This is an area in which management information systems tailored to the needs of the justice and treatment systems can be invaluable. Such systems are cost effective because they readily supply data on program services.

Similarly, coordination is required at the individual patient level, as well as the systems level, to insure accountability. As with program and systems evaluations, planning for evaluation of patient progress and compliance must begin early. Collaborative efforts are needed to develop treatment plans and sanctioning strategies based on assessment information. Specific measures for holding patients accountable for attending and participating in treatment and remaining drug-free (as indicated by random urinalysis) should be included in the treatment and sanctioning plans. Accountability requires regular communication among treatment and criminal/juvenile justice staff to monitor compliance with the various aspects of the plan.

Conclusion

Both the treatment and judicial systems are concerned for and have a responsibility to see that alcohol- and drug-involved persons receive appropriate treatment. Treatment is successful and cost effective, and it has been shown to decrease criminal activity, while increasing productivity.

Coordination of services is essential, especially in the five critical areas of treatment: assessment, patient-matched referrals, comprehensive service delivery, relapse prevention, and accountability. Leukefeld (1991) suggests the following roles of the treatment and criminal/juvenile justice systems for working collaboratively and improving treatment.

• The criminal justice system provides an environment for identifying potential substance abusers.
• Probation and parole (as well as other court-ordered sanctions) can enhance behavioral contingencies to keep substance abusers in treatment and reduce drug use.
• Treatment can be enhanced by establishing working relationships between substance abuse treatment programs and criminal/ juvenile justice agencies.
• Treatment with legal coercion, combined with compulsory community follow up to monitor against relapse, can produce somewhat better outcomes.
• Court referral to substance abuse treatment generally increases the length of time persons remain in treatment.
• Linking substance abuse treatment and the criminal/ juvenile justice system can help disrupt the addiction life cycle and decrease alcohol and other drug abuse.

The communication and collaboration needed to achieve coordinated service delivery is required at several levels. At the State level, various systems must consider policies and funding alternatives needed to meet the demand for treatment services. At local levels, agencies need to identify gaps and develop practices for cooperative working arrangements. Finally, at the agency level, mechanisms should be in place for coordination between the courts and treatment to identify persons needing substance abuse treatment and to ensure that the five critical elements of treatment are adequately provided.

References

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American Judicature Society (AJS) (1990, April-May). The drugging of the courts: How sick is the patient and what is the treatment? (Edited transcript of a panel presentation at the midyear meeting of AJS). Judicature, The Journal of the American Judicature Society, 73(6), 314-321.

Bandstra, E.S. (1990). Medical issues for mothers and infants arising from perinatal use of cocaine. Washington, DC: American Bar Association Center on Children and the Law.

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Sickmund, M. (1991, December). Juvenile court drug and alcohol cases: 1985-1988. OJJDP Update on Statistics, Juvenile Justice Bulletin. Washington, DC: Office of Juvenile Justice and Delinquency Prevention.

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Last Updated 11-7-02