COERCED TREATMENT FOR SUBSTANCE OFFENDERS

The logic for coerced treatment is that substance abusers have limited internal motivation and consequently need to be externally motivated to enter treatment in order to change their behaviors. Expected change includes reduced arrests, reduced crime, and no drug use. It is important to keep in mind that, from a criminal justice point of view, no drug use is expected, which is different from a public health harm reduction approach. Consequently, substance offenders who have limited internal motivation to change their behaviors are externally motivated to enter treatment using the authority of the criminal justice system. This authority includes probation, parole, diversion, and drug courts, which can include incentives for substance offenders like reduced sentences or decreased time under criminal justice supervision.

Coerced substance-abuse treatment has a traditional relationship with community treatment. The history of drug-abuse treatment in the United States can be traced to two U.S. Public Health Service farms at Lexington, Kentucky and Fort Worth, Texas, which were opened in the late 1930s. These facilities were established largely through the effort of James V. Bennett, former Director of the Federal Bureau of Prisons, when he recognized the need for treating drug abusers. Drug-abuse treatment at these farms, which were renamed hospitals, was designed primarily for federal prisoners, but volunteers without coercion could also receive treatment. However, after withdrawal from drugs, most volunteers did not stay, and with no community follow-up, there was a high relapse rate.

With these high relapse rates and using the California and New York civil commitment coerced treatment programs as models, the Narcotic Addict Rehabilitation Act (NARA PL 89-793) was passed by Congress in 1966 as a federal civil commitment program to reduce drug use. For NARA Titles I (treatment in lieu of prosecution) and III (treatment with no formal charges) court-ordered treatment was initially provided at the Lexington and Fort Worth hospitals after an evaluation period. Later, NARA in-patient treatment facilities were opened in several cities. These facilities served as the foundation for community-based drug abuse treatment. When NARA was phased out, the U.S. Public Health Service facilities were transferred to the Federal Bureau of Prisons in the mid-1970s (Leukefeld & Tims, 1988).

Another milestone in coerced substance abuse treatment was establishment of the Treatment Alternatives to Street Crime (TASC) program, which is now called Treatment Accountability for Safer Communities. The Special Action Office created TASC in 1972 for Drug Abuse Prevention, an office with responsibilities similar to those of the current White House Office of National Drug Control Policy. TASC can be described as a diversion program and as case management that helps bridge community corrections and the drug-abuse treatment system. TASC provides identification, assessment, referral, case management and monitoring services for drug/alcohol dependent offenders accused or convicted of nonviolent crimes. TASC defuses some of the friction between community corrections and drug treatment services and is now operating in over 125 communities nationwide. Overall, TASC's effectiveness has been established in reducing drug abuse and keeping drug abusers in treatment for a longer period of time.

THE DRUG-CRIME RELATIONSHIP

Coerced treatment is considered within the context of the relationship between drugs and crime that has been well documented. For example, since the mid-1970s, both the National Institute on Drug Abuse and the National Institute of Justice have supported projects to understand the drug-crime connection, with findings that suggest that drug use enhances criminal careers. In fact, a survey of inmates in state and federal correctional facilities indicates that 83 percent of state prisoners reported previous drug use and 57 percent reported using a drug in the month before their offense (BJS, 1998). The Drug Use Forecasting (DUF) system, renamed ADAM (Arrestee Drug Abuse Monitoring Program) has consistently reported that 51 to 83 percent of male arrestees in major urban cities test positive for drugs (ADAM Annual Report, 1998). In fact, two-thirds of prisoners are drug abusers whereas over 60 percent of persons who come into contact with jails and lock-ups use a drug other than alcohol at the time of arrest (ONDCP, 1995).

CONTROL VERSUS TREATMENT

The relationship between treatment and control can cloud the overall perception of coerced treatment. Most community treatment providers perceive treatment and control as opposites with treatment on one side, as "the good guys," and control from the criminal justice system on the other side. In fact, many community treatment providers point to criminal justice authority as disruptive to the therapeutic relationship. However, this is largely refuted by the literature that indicates drug offenders under criminal justice authority generally remain in treatment longer and consequently have better treatment outcomes. In fact, criminal justice involved offenders remain in community treatment at least as long as others in treatment who are not criminal justice involved. There are other ways of thinking about treatment and control if the assumption is that interventions incorporate both treatment and control. For example, a therapeutic community/residential treatment facility is very high in treatment and control, whereas outpatient treatment is low in both treatment exposure and control unless a participant is involved in criminal justice supervision. Nevertheless, treatment and control are usually discussed as opposite processes, with this depending on ideology, perceived public interest, and political needs.

CONTROVERSIES

Coerced treatment and the use of court authority within the criminal justice system have not been without controversy, particularly since many community drug treatment providers believe that substance abusers should enter treatment voluntarily. As one early example of this controversy, Robert L. DuPont as Director of the National Institute on Drug Abuse, when addressing the Federal Bar Association in 1977, proposed setting up a trip wire, in the form of urine testing, that would identify heroin users who were on probation and parole. If an addicted probationer or parolee did not stop daily drug use, he or she would be referred for compulsory drug abuse treatment. And if treatment was refused or daily heroin use continued, the individual would be reincarcerated. Although the trip wire proposal was modified by other proponents, it never got underway because of the ensuing controversy. Controversy focused on three areas:

1. the image problem created when a health agency proposed a mechanism for behavioral control using the criminal justice system,
2. the violation of probationers' civil rights when tested, and
3. the inadequacy of the urine testing technology.

In spite of the controversy, practitioners interested in the relationship between drugs and crime supported the concept because of the large number of crimes committed by substance abusers (Leukefeld, 1985).

COMMUNITY SUBSTANCE-ABUSE TREATMENT

Drug abusers in community treatment are involved with community corrections. They are frequently on diversion, probation, parole, or mandatory release. Early data from the Client Oriented Data Acquisition Process (CODAP) indicates that 17 percent of clients who entered drug-abuse treatment were on probation, parole, or mandatory release. By 1982, CODAP reported an increase in community corrections involvement for 27 percent of the males and 15 percent of the females. During the 1980s, Hubbard et al. (1989) found that over 30 percent of clients in residential and outpatient treatment were referred to treatment by the criminal justice system; this finding remains valid in the year 2000.

COERCED TREATMENT OUTCOMES

Drug treatment provided through the criminal justice system has had successes. As a result, coerced drug treatment, for example, has been separated into categories, including Civil Commitment (supervision of parolees with urine testing), Criminal Justice Authority (community corrections), urine testing, offender community treatment services (community drug abuse treatment) and treatment in prisons and jails. The research on drug treatment for drug offenders has grown. The interest in examining interventions comes from

1. the decreased anti-rehabilitation atmosphere in the criminal justice system (Martinson, 1974);
2. data which have shown promise including the Stay'n Out Program in New York (Wexler et al., 1992), the Cornerstone Program in Oregon (Field, 1985), and Key and Crest Programs in Delaware (Martin et al., 1999);
3. the large number of chronic drug abusers who are incarcerated; and
4. the need to understand interventions and retention for drug offenders and their related costs.

DRUG COURTS

The current interest in drug courts developed in response to the overlap between substance abuse and crime in order to provide treatment for defendants. The interest in drug courts increased recently with the expanded number of courts that grew to 275 jurisdictions in 1998 from the first drug court in Dade County, Florida, in 1989 (Belenko, 1998). The benefits of drug courts have been documented: reduced recidivism, decreased drug use, increased birth rates of drug-free babies, high program retention, increased relapse prevention, and cost efficient treatment. The drug court is a court-managed drug intervention and treatment program designed to provide a cost-effective alternative to traditional criminal case processing. Drug courts are treatment-oriented and target clients whose major problems stem from substance abuse. However, although there are standards that are required for each drug court program, each drug court program is different.

CHRONIC AND RELAPSING NATURE OF SUBSTANCE ABUSE

It is easy to forget that drug abuse can be chronic and relapsing. Without proper follow-up and treatment, substance abusers often return to drug use. It is no secret that recovery is a difficult process that is not completely understood, with or without coerced treatment. Intervention and treatment efforts need to focus on those factors that keep individuals drug free. These options can range from urine testing to methadone treatment. Nevertheless, many people believe that substance-abuse treatment does not work. They cite professional and/or personal experiences about individuals who immediately return to drug use during treatment and/or supervision. However, after discussion it becomes clear that the proper blend of treatment combined with follow-up supervision, relapse prevention, and self-help groups like Alcoholics Anonymous was not used, and/or attendance was minimal.

Finally, there are no instant cures for substance abuse. Recovery for many can take a lifetime. Decreasing substance use during the course of an addict's life can combine the interventions of coerced treatment, community treatment, and possibly incarceration with twelve step groups. More emphasis needs to be placed on matching substance abusers with appropriate services as well as looking at ways to mix and match interventions. In addition, both external motivation—coerced treatment—and internal motivation that substance abusers bring to treatment at varying levels need to be better understood. Clearly, coercion can bring a substance offender to treatment, but it cannot be used to force a substance offender to participate in treatment.

BIBLIOGRAPHY

Arrestee Drug Abuse Monitoring Program Annual Report. (1998). Washington, D.C.: U.S. Government Printing Office.

Belenko, S. (1998). Research on Drug Courts: A Critical Review. National Court Institute Review, 1: (1), 1-30.

Bureau of Justice Statistics. (1998). Washington, D.C.: U.S. Government Printing Office.

Drug Abuse Treatment in Prisons and Jails (NIDA Monograph no. 118), pp. 156-75.

Field, G. (1985). The Cornerstone Program: A Client Outcome Study. Federal Probation 49, 50-55.

Hubbard, R. L., et al. (1989). Drug Abuse Treatment: A National Study of Effectiveness. Chapel Hill, NC: University of North Carolina Press.

Leukefeld, C. G. (1985). The Clinical Connection: Drugs and Crime. The International Journal of the Addictions 25 (6), 621-640.

Leukefeld, C. G., & Tims, F. M. (eds.). (1988). Compulsory Treatment for Drug Abuse: Research and Clinical Practice (NIDA Research Monograph No.86). Rockville, MD: U.S. Government Printing Office.

Martin, S. S., Butzin, C. A., Saum, C. A., & Inciardi, J. A. (1999). Three-year Outcomes of Therapeutic Community Treatment for Drug-Involved Offenders in Delaware: From Prison to Work Release to Aftercare. The Prison Journal 79 (3), 294-320.

Martinson, R. (1974). What Works? Questions and Answers about Prison Reform. The Public Interest 35, 22-54.

Office of National Drug Control Policy. (1995). National Drug Control Strategy. Washington, D.C.:U.S. Government Printing Office.

Wexler, H. K., Falkin, G. P., Lipton, D. S., & Rosenblum, A. B. (1992). Outcome Evaluation of a Prison Therapeutic Community for Substance Abuse Treatment, in Leukefeld, C. G., and Tims, F. M. (eds.).

Marie Ragghianti

Revised by Carl Leukefeld