Lessons Learned in Offender Treatment

With more than 2 million individuals in federal and state prisons at the end of 2006,1 the nation's correctional systems clearly have been operating under tremendous strain. Concern about the system's “revolving door” has been prominent for years,2 with evidence suggesting that more than 60% of released inmates will be rearrested within three years.3 And with studies indicating that more than two-thirds of jail inmates might have a substance use disorder requiring treatment,4 it is clear that any attempt to have an impact on the burgeoning correctional census must incorporate innovative programmatic and clinical strategies for treating the substance-affected offender.

The Davidson County Drug Court program in Nashville, Tennessee, founded in 1997, is a rehabilitation-focused effort that has become a national prototype for innovation in addressing the offender. The first court-operated residential treatment facility in the country (most drug court programs operate mainly on an outpatient model, few having been able to follow Davidson County's lead), the program serves approximately 200 adult nonviolent offenders with substance use disorders each year.

The program incorporates three distinct phases. In the first phase, the client receives a comprehensive assessment and a treatment plan is developed. In Phase Two, the client works on core issues in individual and small group therapy, attends 12-Step meetings, and participates in community service. In the final phase, the client continues attending group therapy and 12-Step meetings, but also is expected to work 40 hours a week outside of the facility.

The client continues to return for drug screening and weekly group meetings for up to a year post-discharge. The program utilizes a modified therapeutic community (TC) model, in which the client is assigned a “big brother/sister” to guide him/her throughout the time in the program.

Davidson County's program has shown strong evidence of efficacy. The present recidivism rates are a 31% rearrest rate and an 18% conviction rate one year after graduation. The program has not compared those rates with recidivism rates for other area treatment programs targeting offenders, because the other programs generally offer outpatient treatment as opposed to residential services. But it is not uncommon to see recidivism rates of 60 to 70% in the type of population served by the Davidson County Drug Court.

Judge Seth Norman, founder of the Davidson County Drug Court program and its presiding judge, notes that the effort also is cost-effective. “It's cheaper to put people in one of my facilities than it is to lock them up in the penitentiary,” he explains. “We're saving about $15 per day per individual.”

Clinical challenges and tools

Clinically, the issues encountered by the Davidson County program's staff echo the concerns identified by researchers and other clinicians working with incarcerated populations.2,5 These challenges can include establishing trust, working within the parameters of a client's long criminal history, and addressing trauma and co-occurring mental illness.

David Patzer, MD, the drug court program's staff psychiatrist, believes establishing trust constitutes a primary concern for Davidson County clinicians. “[The clients] have lived lives where they tend not to have a lot of trust in authority,” Patzer explains. He says that the program's modified TC effectively generates client trust because messages are delivered by peers instead of authority figures.

“New people come in and they can see changes in the people that have already been here,” Patzer says. “A lot of times they'll see someone they knew from the outside, whom they knew on the street. They see big changes in them, and that is pretty powerful.”

Therapeutic communities have been a popular setting in which to place offender populations since the 1960s, and have demonstrated significant success across many correctional communities.6 Research has further demonstrated that Davidson County's model, where the client receives support from the TC both in treatment and post-release, is more efficacious than an approach in which the offender receives support only while in prison or on work release.6

Because treatment in incarcerated populations often is mandated, issues of confidentiality commonly surface. Patzer says that because clients know he is technically “working for the law,” there is an initial hesitancy in sharing information. But he suggests that while mandated treatment can exacerbate trust issues, it also can be advantageous, providing the client with initial motivation. “If they run away from the program they know their sentences could be enhanced,” he says.

Patzer explains that once clients have been in treatment for a while, he works to shift their motivation. “I tend to go from using the fear of the legal system as motivation to using what can come from recovery—the new freedom, and the ability to accomplish things they never thought they would accomplish,” he says.

In addition to trust issues, a client's lifetime of criminal involvement often can intensify the treatment challenge. “We tend to see a lot of people who are second, third, fourth generation involved in crime and drugs … for some of them, that's all they know,” Patzer observes. He believes that a strength of the Davidson County program lies in its time commitment. “[Clients] tend to stay here for about a year. So people are separated from their neighborhoods and from the drug-using friends that they had,” Patzer says. “We have them focusing on recovery 24 hours a day, 7 days a week. We keep monitoring them for at least two years, and that length of time is really important.”

He adds that vocational training also is critical for breaking the cycle of crime and addiction. In Davidson County's program, clients are given the opportunity to learn to read, complete their GED, and learn a new trade.

The offenders in the Davidson County program do not have their criminal charge removed from their record upon program completion, as is the case in some drug court programs around the country, because the treatment option in Davidson County is offered post-plea. The “carrot” for their participation in the program is that offenders who successfully complete the program can serve the balance of a sentence on probation instead of behind bars.

Combating a client's history of trauma poses another challenge for Davidson County clinicians. Patzer states that trauma histories are particularly common among female clients. Research has shown that rates of post-traumatic stress disorder (PTSD) among women in the criminal justice system exceed 30%.7 Further, research has demonstrated that providing treatment for these clients may be particularly challenging because individuals with comorbid PTSD and substance dependence generally experience more psychological distress and psychosocial difficulties post discharge.8

Patzer explains that the Davidson County program combats clients' history of trauma by first working to create a safe place. “We always try to be aware of things that might appear threatening,” he says. “The residents are expected to police themselves and write each other up. If someone even appears threatening, they can go to jail. It's something we take very seriously.”

In addition, Patzer states the importance of connecting with local community resources, including rape crisis centers, where “even when [clients] leave the program, they can get ongoing therapy for post-traumatic stress disorder, and history of abuse and rape.”

Other co-occurring mental illnesses are similarly common among incarcerated populations.9 Patzer estimates that 50 to 60% of Davidson County clients have a dual diagnosis, and he stresses the importance of treating comorbid mental illness effectively and immediately. He says part of the program's success stems from its ability to provide medication management services to dually diagnosed clients.

But Patzer cautions that clinicians providing medication services must be equipped to deal with potential client resistance. Although his clients will “trust using drugs from the street,” it is more challenging “to get them to trust medication, just because there seems to be such a stigma against mental illness where they come from,” Patzer says.

Programmatic challenges, solutions

Although the Davidson County program has been successfully operating for the past 13 years, Judge Norman says that when the program started, “There wasn't any handbook. We've tried more things and discarded more things. It's just trial and error.” For example, the founding group had underestimated the prevalence of co-occurring medical illness. “We did not realize how many other medical difficulties these people had that had been anesthetized for years by drug use,” Norman said. “When we started getting them off the drugs, these other problems began to crop up.” He emphasizes the importance of partnering with community agencies and local hospitals to address this issue.

Norman and Patzer agree that program success is contingent on receiving adequate funding and community support. In the case of the Davidson County court, funding is pieced together from a variety of sources, including state money, proceeds from drug fines and other offender fees that by statute can support treatment efforts, and even the residential program participants themselves. When residents begin working outside the facility, they begin paying some rent as part of their program participation.

“There's always that business about convincing the public that these aren't ‘bad people,’” says Patzer. “There's always getting beyond that moral view of addiction and trying to convince the legislature and the public that addiction is a disease.”

Norman suggests that community support might best be garnered through public service. “Last year we did something like 40,000 hours of public service work,” the judge says. “That, to me, is the best PR work we can do.”

Norman says the program's next steps involve working to enhance dual diagnosis services. “I have a judge here who runs a small mental health court and we're trying to work together … to see if we can get a co-occurring facility started,” he says. Program leaders also would like to beef up vocational and educational training, possibly through partnerships with local community colleges.

Norman would like to see Davidson County's program replicated across Tennessee, and the nation for that matter. However, he is concerned that such an effort would require a major paradigm shift for many legislators, who would need to understand that the program is not “treatment in lieu of punishment”, but “treatment in conjunction with punishment.”

The judge adds, “I don't see the sense in sending the nonviolent drug offender to prison when you can treat him and have more success that way.”

References

1. Sabol WJ, Couture H, Harrison PM.Bureau of Justice Statistics Bulletin: Prisoners in 2006 (Publication No. NCJ 219416). December 2007.Retrieved fromhttps://www.ojp.usdoj.gov/bjs/pub/pdf/p06.pdf.
2. Harrison LD. The revolving prison door for drug-involved offenders: challenges and opportunities. Crime Delinq 2001; 47:462–85.
3. Langan PA, Levin DJ.Bureau of Justice Statistics Special Report: Recidivism of Prisoners Released in 1994 (Publication No. NCJ 193427). June 2002.Retrieved fromhttps://www.ojp.usdoj.gov/bjs/pub/pdf/rpr94.pdf.
4. Karberg JC, James DJ.Bureau of Justice Statistics Special Report: Substance Dependence, Abuse, and Treatment of Jail Inmates, 2002 (Publication No. NCJ 209588). July 2005.Retrieved fromhttps://www.ojp.usdoj.gov/bjs/pub/pdf/sdatji02.pdf.
5. Henderson DJ. Drug abuse and incarcerated women: a research review. J Subst Abuse Treat 1998; 15:579–87.
6. Martin SS, Butzin CA, Suam CA, et al. Three-year outcomes of therapeutic community treatment for drug-involved offenders in Delaware: from prison to work release to aftercare. Prison J 1999; 79:294–320.
7. Teplin LA, Abram KM, McClelland GM. Prevalence of psychiatric disorders among incarcerated women, I: Pretrial jail detainees. Arch Gen Psychiatry 1996; 53:505–12.
8. Ouimette PC, Ahrens C, Moos RH, et al. Posttraumatic stress disorder in substance abuse patients: relationship to one-year posttreatment outcomes. Psychol Addictive Behav 1997; 11:34–47.
9. National GAINS Center for People with Co-Occurring Disorders in the Justice System.The Prevalence of Co-Occurring Mental Illness and Substance Use Disorders in Jails. Spring 2002.Retrieved from https://gainscenter.samhsa.gov/pdfs/jail_diversion/gainsjailprev.pdf.