Chapter 7—Critical Issues in Implementing Programs

Every substance abuse treatment program—no matter in what setting— faces operational challenges. Such challenges range from the need to maintain community support and funding, to how to locate and recruit skilled staff, to setting up ways to attract appropriate clients. Programs in criminal justice settings share some particular and unique challenges. Critical issues include the need to:

• Engage in a systematic planning process that covers not only the program itself, but the relationship between the in-custody treatment program, the correctional system, and treatment in the community
• Select an appropriate treatment approach and good programming principles
• Gain and/or maintain the support and understanding of the prison or jail administration and the on-line security staff
• Select and train both the security and treatment staffs
• Set up good working relationships with the institution’s medical/psychiatric staff
• Establish a plan for providing continuous quality improvement and evaluation.

This chapter highlights what the CSAT women’s program grantees suggest about how to handle these issues. Other program planners may find it helpful to know what kinds of difficulties the grantees have encountered in implementing their women’s programs, as well as the strategies and methods they are using to resolve these issues successfully.

Engaging in a Systematic Planning Process

Those interested in developing a drug treatment program for women in a correctional facility need to go through a systematic planning process. With the help of a number of practitioners and experts in the field, the Center for Substance Abuse Treatment (CSAT) has compiled a manual titled Critical Elements in Developing Effective Jail-Based Drug Treatment Programming (CSAT 1996a). This manual, available as publication number PHD 729 from the National Clearinghouse for Alcohol and Drug Information (NCADI), provides chronological guidelines on the following critical elements perti
nent to both women’s and men’s treatment programs:

Stage I: Pre-Planning Assessment
1. Identify resources
2. Identify costs and benefits
3. Study legislation and regulations
4. Identify possible barriers

Stage II: Planning and Program Development
1. Determine jail or prison population profile
2. Write a mission statement
3. Develop a support base
4. Select a treatment approach
5. Develop a strategy for continuity of care
6. Develop a screening and referral system
7. Design an information tracking system
8. Develop policies and procedures
9. Plan and conduct training
10. Foster interagency partnerships
11. Establish an ongoing continuous quality improvement and evaluation program

Selecting an Effective Approach

Choosing an effective approach is the most critical basic task in designing treatment for addicted women. Good treatment is designed to address women-specific issues, and good programming addresses issues directly related to the women’s substance abuse behavior. Chapters 2, 4, and 5 in this Guide provide a framework for making choices about program design.

What does experience suggest works best in programming for women offenders? The experience of the CSAT women’s prison demonstration programs is consistent with earlier findings concerning what works in treating women offenders. In a nationwide study of innovative strategies and community programs for female offenders, Austin et al. (1992) concluded that the most promising strategies often used the “empowerment” model of skill building to enhance the women’s coping and decision-making skills and enable them to achieve independence.

The study found that effective therapeutic approaches are multidimensional and deal specifically with women’s issues, such as alcoholism/addiction, parenting, relationships, gender bias, domestic violence, and sexual abuse. The following characteristics appeared to influence successful program outcomes:

• A design that provides for a continuum of care
• Program expectations, rules, and sanctions that are clearly stated and uniformly enforced
• Consistent supervision
• Diverse and representative staffing
• Coordination of community resources
• Access to ongoing social and emotional support
• Multidimensional approaches that deal with women’s issues specifically

This Guide focuses on issues that are specific to treating women offenders. However, there are many established principles for effective AOD treatment programs that apply regardless of whether men or women are being treated. Table 14 summarizes these generic principles, based on a broad review of the experience of a number of jail and prison treatment programs (Peters 1993, pp. 17-19).

Gaining Support From the Prison Administration

Introducing intensive substance abuse treatment into a corrections setting requires meshing two different systems that often have differing goals and philosophies. The overall environment in a prison or jail can be supportive for treatment or it can be nonresponsive, setting up a series of structural, physical, and emotional barriers for a treatment program and its clients. Those setting up new programs for women will obviously need to work within the basic climate of the particular institution.

It is important to be aware that, in the past, some custodial officers have distrusted TC staff and operations and have deliberately sabotaged treatment programs (Camp and Camp 1990; Inciardi and Scarpitti 1992). One potential source of resistance can come from correctional staff who have alcohol problems themselves. Because alcohol problems occur among people in all segments of U.S. society, such resistance is commonly encountered by alcohol prevention and intervention programs across all American institutions, be they school systems, workplaces, or prisons and jails.

The literature makes clear how important it is to gain administrative support for correctional treatment programs (Peters 1993, p. 17). For CSAT women program grantees, experience has been mixed but positive. Some grantees received enthusiastic support for their programs and an understanding of treatment needs from the beginning. Others have had to work hard to educate the administrators and to advocate for the needs of their women clients. These grantees report that it took about 2 years to overcome institutional barriers and to make fundamental changes needed by the programs. Two of the grantees had to struggle against sabotage efforts by various levels of correctional staff.

Table 14. Principles of effective treatment with offenders
Table 14. Principles of effective treatment with offenders (continued)

Support is important at two levels: from administrators at the top and from the overall institution, particularly on-line security staff. Situations are so varied it is hard to generalize, but it appears that women’s treatment programs are likely to face the greatest obstacles when they are in traditional male-oriented correctional settings where the institution’s philosophy focuses on punishment and control. For jail programs, the Sheriff’s department philosophy and orientation in the hiring and training of deputies will affect how supportive and accepting the correctional staff is toward a treatment program.

In some correctional institutions, understanding and support for substance abuse treatment can be very strong. Two CSAT grantees, the Forever Free and Choices programs, report particularly positive support from their institutions. In both cases, the institution is headed by a female warden who is committed to rehabilitation goals for the women offenders. In addition, Choices—a new community pun ishment facility in Arkansas where residents can move about freely on the grounds—is designed to be a rehabilitation facility; the security guards are called “residential supervisors” and wear nontraditional uniforms (khaki pants and blue oxford shirts). The officers wear regular uniforms at times when they oversee residents who are performing community service.

Also, the way correctional treatment programs are structured can produce close and reinforcing ties across systems, with all entities perceiving success of the treatment program as a shared mission. The Forever Free program at the California Institute for Women in Frontera, California, is one example. The women’s treatment program is coordinated by two agencies— the Office of Substance Abuse Programs in the California Department of Corrections (CDC) and the State Department of Alcohol and Drug Programs (the CSAT grantee).

In this coordinated structure, the CDC Office of Substance Abuse Programs provides: (1) the overall grant project director and evaluator; (2) a correctional counselor who provides project oversight, is responsible for screening and selection of program participants, and is the liaison with institutional management staff and parole services; (3) a correctional counselor who handles case management, classification, and disciplinary issues; and (4) a parole agent who serves as the continuity of care coordinator. This parole agent is responsible for assuring that program participants make a smooth transition from custody into the community and that the women stay in treatment for as long as possible while they are on parole. The subcontractor—Mental Health Systems, Inc.—operates the in-custody treatment program and provides the project manager and counselor staff. The State Department of Alcohol and Drug Programs provides funding for the women’s post-release community treatment.

For treatment programs, it is important to build communication, understanding, and support not just with the top administrators but throughout the entire institutional setting. These efforts need to be ongoing. Two key areas that need continuing attention include:

• Differences that arise from the differing responsibilities and roles of treatment and correctional staff. At the North Rehabilitation Facility, for example, the correctional staff has been involved with treatment for 15 years in integrated treatment/security situations, yet staff says there are still differences to be worked out. Even the vocabularies may be different, with the women being “offenders” to one system and “clients” to the other.
• Lack of understanding about principles of treatment, especially treatment in therapeutic communities (TCs). Corrections staff may perceive treatment as “coddling” the inmates. Some corrections staff may have difficulty adapting to the client autonomy and control inherent in the TC models. According to Pan et al. (1993), TCs implement techniques and strategies that challenge the routines of highly organized prisons.

Natural bureaucratic resistance can arise either from suspicious or willful individuals, from sheer organizational rigidity, or both. These authors suggest that this type of resistance is very difficult to overcome unless the TC modality is supported by high-level staff.

For a clear discussion of the underpinnings and differences in perceptions between the corrections and treatment systems, see CSAT TIP 17: Planning for Alcohol and Other Drug Abuse Treatment for Adults in the Criminal Justice System (CSAT 1995a).

Program Planning Phase

Creating a supportive relationship between the institution and the treatment staff needs to start at the very beginning—when initial plans are made for a program. Usually a correctional facility provides treatment services by contracting with an outside agency. In some cases, the correctional facility has designed the treatment program before the person who will run that program becomes involved. The expected project director needs to be included early in the program planning, so that person can work cooperatively with the decision-makers at the correctional facility and with any other agencies to be involved.

As was discussed earlier, there are a number of treatment models. Once a given model has been decided on, it can be very difficult if not impossible to make fundamental changes in how the program will operate. For this reason, correctional institutions need to be careful not to make all the key decisions about the model until after the project director comes on board. Institution policies and constraints may limit some desired treatment options, such as the ability to make 8 hours every day available for treatment. All parties need to be working together to find the best compromise.
In the planning stage, treatment staff need to look very carefully at the institution’s history, especially at the correctional staff who will gain or lose power and position when the new treatment program starts. One grantee stressed that, to avoid possible undercutting and sabotage, it is important to know about and address any existing turf issues in a frank manner and at the beginning.

The Stepping Out project points out how important it is to get input about program plans from all affected personnel, particularly custody staff. Pivotal custody staff positions, such as sergeants and work assignment deputies, need to work closely with program designers and operators from startup through the life of the project. Without the cooperation and buy-in of key custody staff, a treatment program will not operate successfully.

Sufficient startup time for a new program is important. Several of the CSAT-funded programs were expected to be up and running within brief periods, such as 1 month after their contract was awarded. This does not allow enough time for the treatment staff to work with administrators in selecting and training security officers for the program. Neither is the time adequate to develop or update needed curriculum materials or to recruit and train the treatment staff.

Ongoing Relations With the Institution

Two of the CSAT grantees commented that it takes a lot of work to build and maintain their relationship with correctional staff, but that this relationship continues to improve over time. Some of the grantees’ suggestions for building this acceptance for the program include the following:

• Consistently try to involve the administration in the program process at every opportunity. Promote the TC or other model as a highly attractive form of rehabilitation.
• Meet with the administration on a regular, ongoing basis and confront any issues immediately. Don’t let problems or conflicts linger unresolved.
• Be persistent and determined about the needs of your program. As one project director said, “They know I won’t be deterred and I’ll keep calling.”
• Look for opportunities to integrate treatment staff into the institution as a resource. As an example, the WCI Village program now has a senior counselor assigned to the institution’s classification board. This assures that appropriate, eligible women are being sent to the program, but it is also providing a substance abuse specialist as a resource for the institution.
• Take advantage of any chance to orient and train the entire agency about the program. This is a new direction that offers promise. Such institution-wide orientation would help with the situation reported by one grantee, where the staff felt fortunate to have two positive, supportive security deputies assigned to their program. However, these two supportive deputies did not represent overall staff attitudes about the program; these deputies experienced trouble with their peers when the time came for them to assimilate back into the institution’s overall deputy staff.

One of the grantees stressed how essential it is to establish clear lines of communication within the institution. For example, program changes that affect deputy duties must be communicated through the chain of command, not in a memo from the program director to deputies. It is important to hold regularly scheduled meetings between custody staff, program operators, and other concerned parties as often as is practical and necessary. The treatment program also needs to have a designated staff person on site at all times, or available by telephone, who can respond to any institutional concerns.

Selection and Role Of Corrections Security Staff

Security officers are significant players in a woman’s treatment unit, particularly in TCs or other residential programs that operate in a therapeutic milieu. Security staff can be a positive force in helping women heal. If they are negative about the program or the women in it, they can also damage the treatment process. One grantee reports their program experienced “sabotage and undercutting.” According to this grantee, “It was necessary to facilitate transfers of key custody people on the female unit in order to implement services and to penetrate the existing regime and their antifemale inmate attitudes and behavior.” The CSAT women’s programs, nearly all TCs or intensive residential programs, share a set of consistent recommendations about selecting security staff. They suggest that:

• Many officers or deputies will not be appropriate for the treatment program. If at all possible, the treatment staff should be allowed to reject those persons who are not suitable.
• Training for security officers will be necessary and should be ongoing. Alternate or substitute staff must also receive training.
• Security staff for the program should be a regular assignment. Rotating security personnel is not desirable.

The CSAT grantees believe that either women or men deputies can be equally successful. A supportive male deputy can be a fine role model for the women clients, many of whom have primarily experienced abusive males in their personal lives. As a result of their very low self-esteem, these women are sensitive to feelings of being devalued. Deputies who are not highly supportive of the treatment process can sabotage it. One grantee pointed out that negative, nonsupportive attitudes from any deputy can undermine the women’s vulnerable sense of self-esteem and their progress, but if that deputy is a woman, the effects are especially bad. Women clients really feed into the negativism coming from another woman. In addition, a negative deputy can have a divisive influence, splitting the treatment group.

Functions of the Security Officers on Treatment Units

Some officer functions will be determined by the particular institution. At some facilities, for example, the officers may accompany the women for security reasons to all their education, vocational, or other sessions outside the treatment unit. In the CSAT women’s programs—both TCs and others— the officers are trained and available to support the women participants during evening and night hours, when treatment staff are not onsite.

The daytime functions assumed by security officers in the WCI Village program are fairly typical of TCs. The officers can perform their share of tasks, have a non-clinical role as part of the group, and support the process. They participate in the ongoing life of the group but do not take part in treatment sessions. In other words, for confidentiality and other reasons, the officers do not sit in on groups where the women are dealing with their issues.

Qualities of Corrections Staff

The North Rehabilitation Facility finds that security officers who are successful have an accepting attitude toward addicted women offenders as fellow human beings; they are able to perceive of the inmates as people, not objects. In a pragmatic sense, their officers want to help the women become better neighbors and citizens as a benefit to the total community. Other desirable qualities for custody officers to possess include:

• Having a nurturing personality
• Being empathic and emotionally healthy as individuals
• Feeling comfortable with inmate/client decision-making
• Having participated in a TC themselves (an advantage in TC programs)

The assigned security officers will need to have cross-training, which is described later in this section. But in addition to that, the treatment staff needs to provide clear guidelines and expectations for officers in TC settings. The officers will need ongoing guidance and individual interventions. For example, a new officer in one of the short-term TC programs was not allowing the women to give each other friendly hugs after treatment hours.

The security officers’ behavior needs to be consistent with treatment goals. Officers need to understand and appreciate the TC treatment process, so they can be “on board” with treatment staff in supporting and reinforcing the TC milieu. Officers need to understand all the rules thoroughly, to enforce them consistently, and be careful not to bend the rules. They need help in setting boundaries. Some officers may simply not be oriented to substance abuse treatment and may need help in understanding what a difficult process the women are experiencing.

The CSAT-supported treatment programs have had some limited experience with security officers who are themselves recovering from substance abuse. Such officers understand what the women participants are going through, but they also need training and other guidance.

Program staffs say that officers who are recovering from substance abuse themselves can be highly supportive of treatment goals, contributing significantly to a positive environment for clients. On the other hand, such officers can be unduly biased in favor of their own recovery philosophy or may tend to monopolize the group’s attention with their own personal recovery issues.

The essential point here is that security officers can be an integral, positive part of the TC community and treatment process. However, all security officers— even those in personal recovery with a positive attitude toward treatment—will need guidance.

Selection and Training of Substance Abuse Treatment Staff

For corrections treatment programs, there can be debate about which staffing model will be more appropriate: the “professional” model or the “recovering addict” model. The “professional” model calls for selecting staff who are educated, trained, and experienced in counseling, psychology, or social work. The “recovering addict” model promotes the use of ex-addicts and/or ex-offenders in key leadership and clinical positions (Inciardi 1995). Counselors who have professional academic degrees earn higher salaries and so cost more, but they generally have trained clinical skills and a detachment that may not be found in the recovering addict counselor. However, recovering addict counselors are excellent role models. They have developed coping skills, in terms of living in the community while abstaining from drug use, that can be helpful for drug-dependent offenders. Recovering counselors provide offenders with a credible role model to which they can relate (Bureau of Justice Assistance 1991, p. 47).

The CSAT women’s grantees are using two different staffing patterns, depending on the type and length of the program. For the short-term intensive programs that focus on motivating and referring women to appropriate treatment, it can be an advantage to have staff with professional degrees who are clinically trained. All the other programs—whether intensive outpatient or TCs—use and recommend a staff/supervisor mix of trained professionals and certified substance abuse counselors who are either recovering or ex-offenders.

Staff for Short-Term Programs

The 2-week, intensive program in the Baltimore Detention Center uses a “professional” model, with all clinical staff having at least a master’s degree. This program is a motivational model, designed to provide intense, targeted help to women and move them into appropriate community treatment programs and other services.

The short-term program at North Rehabilitation Facility combines addictions counselors with professional clinical staff. The project director points out that, when a program has only 13 or 14 days to assess and motivate the women, staff must be clinically astute. Among the skills they need will be:

• A sound understanding of the therapeutic models of developmental change for women
• The ability to assess where the individual woman is on the continuum of developmental change and motivation
• An awareness of the wide array of therapeutic tools available and a knowledge of how to match those tools with the needs of a great diversity of individual clients

Staff for Mid- and Long-Term Residential Programs

The intensive, longer term women’s programs depend on certified substance abuse counselors, both recovering individuals and recovering ex-offenders, as the backbone of their treatment staffs. Clinically trained professionals—both staff and supervisory personnel—help support the treatment process.

The clinical staff are selected for expertise in the areas most targeted by the particular program. Programs commonly have staff with special clinical expertise in screening and assessment, mental health (particularly cooccurring disorders), and family therapy. One program director mentioned that it had been of tremendous benefit for her to have a clinical background, as her program blended a medical model of substance abuse with a TC model.

In hiring certified counselors who are recovering, programs set certain criteria. The Forever Free program, for example, requires that counselors have been in “sober and clean” recovery for a minimum of 3 years, and they may not be on parole, probation, or under any other court-ordered supervision. Some correctional institutions have a policy that forbids ex-offenders to be employed on staff. This problem can often be overcome by having the treatment contractor hire the ex-offenders. However, the contract staff will still have to pass securi ty clearance checks. Corrections will always do background checks on anyone working in their prison. Consequently, obtaining the administration’s buy-in with the program will be essential if they will be asked to waive restrictions on ex-offenders working in the institution.

Special TC Needs

TC models have special staffing needs. It is imperative that TC programs have some counselor staff who have themselves experienced a TC program. Finding and recruiting staff with this experience can be difficult, particularly in parts of the country where few TC programs exist. CSAT, through its technical assistance initiatives, may be able to provide some suggestions. Therapeutic Communities of America may be another resource. Time needs to be allotted for this recruitment process, because it may require a regional, if not national, search. Some strategies for expanding the available base of individuals with TC experience are mentioned below.

Attaining a Racial/Ethnic and Gender Staff Mix

It is very important that treatment staff be ethnically and culturally diverse, approximating the same mix as the women clients. Just having a representative staff mix will not be sufficient, however. Programs need to have a theme of cultural diversity within the program, and staff training will need to deal with understanding the women’s cultural differences and sensitivities. Several of the women’s correctional programs offer separate group sessions by cultural grouping (such as Caucasian, African-American, Hispanic, Asian American, and Pacific Islander groups) and by sexual preference (such as groups for lesbian, bisexual, and transsexual women).

The issue of whether to include men as staff counselors in women’s treatment programs is less clear-cut. The women’s programs discussed in this report have predominantly all-female counseling staffs and point to this as an advantage of their programs. There are valid reasons for using male counselors, however. Among these are:

• The shortage of available women counselors who have experienced a TC and are recovering and/or have come out of the correctional system themselves
• The value for the women clients of working and interacting with a positive, supportive male role model, who can exemplify relationships in which men do not assume dominant, aggressive, and abusive roles

Male counselors, if used, need to be selected carefully. One program director said that she looked for a male counselor who would not be too aggressive and harshly confrontational. The male counselor selected had the desired low-key demeanor, but he was unable to confront the women with their issues. Instead, he felt sorry for the women, took on a role as their caretaker, and pushed to do such activities as taking the women to the gym. The women’s response was to act out in relation to this man, becoming very needy and dependent (for example, by urgently requesting immediate individual sessions).

Women are able to set responsible standards and to demand— in a positive, nurturing way— that other women meet these expectations. Male staff must also have this quality.

The grantees point out that, unquestionably, women clients need to experience a positive and supportive male role model at some point in their recovery. The real issue is: what is the best time for this—during in-custody treatment, in the post-release community treatment phase, or in the continuing care phase?

In Delaware, where women now receive a continuum of care at all these levels, the first tentative answer seems to be “after the community treatment phase.”

Their experience is that women in the coeducational TC work release program are still vulnerable to their pre-prison patterns of relationships with abusive men. Work on developing positive male-female relationships may need to come after the woman has set up a stable recovery process and has resolved her issues of employment and self-sufficiency.

Qualities of Treatment Staff

Staff at the North Rehabilitation Facility state the most important quality is “the counselor must be perceived as caring.” Other grantees point to the staff’s attitude and their energy, commitment, integrity, and compassion as being paramount to the healing process.

Recruiting Staff

As one project director expressed it, what is emerging is a new type of professional—counselors who know both the custody environment and substance abuse treatment. This director suggests that it is highly desirable to find counselors who have come out of the correctional system. It is even better if this person comes with education or training about the developmental theories regarding women and treatment, how to handle paperwork, to do assessments, and to match clients with appropriate treatment strategies. At this point, few counselor candidates will have all these qualifications. The CSAT demonstration programs are using a variety of strategies to expand the number of qualified counselors available for their programs. These include:

• Agree in advance, at the time a counselor is hired, on a plan for further outside training, such as through seminars, bachelor’s degree programs, and workshops.
• Conduct intensive in-house training. At the In Focus program, staff receive 40 hours a year of trainings on such topics as women-specific issues, parenting, co-occurring disorders, relapse, and criminality.
• Offer internships and part-time placements for students. The OPTIONS TC program, for example, is a popular student placement choice, and both graduate and undergraduate students have participated in the program. The students receive free training, and the project may possibly gain a staff member later.
• Provide part-time work for correctional officers who are starting a new career. Two projects have been able to employ corrections officers who were studying for a social work degree—an ideal combination.
• Employ returning program graduates within the program. The Forever Free program has graduates in stable recovery who are both on their staff and volunteer to come back to lead groups. WCI Village also uses graduates in a volunteer capacity; the graduates volunteer to lead groups and support the program. These volunteer activities help WCI graduates obtain the training and hours needed to become a certified substance abuse counselor.

Training and Staff Supervision

In-house training and ongoing supervision of staff are very important in a jail or prison environment. This is a difficult population, with multiple needs, and staff may need help to avoid becoming overinvolved emotionally and burned out. Staff who are recovering themselves have to be vigilant that the daily work is not their own treatment. TCs have been moving toward inclusion of more clinically trained staff members, not just supervisors, in combination with experienced certified counselors. This includes professionals who are oriented toward traditional mental health models of treatment (Carroll and Sobel 1986). The balance in staff backgrounds is helpful in both TC and other models. Types of training may need to cover such issues as:

• Understanding the TC milieu for women. Clinical staff who have not experienced a TC themselves need to understand how to work in this environment, which is so dependent on mutual self-help and peer responsibility. Counselors who have experienced a male TC themselves can have great difficulty in adjusting to the less confrontational tone of a woman’s program. In one of the CSAT demonstration programs, two counselors could not make this adjustment and had to be replaced.
• Adopting an open, clinical mind set. Counselors who are recovering themselves may have a tendency to overuse the techniques that helped them (the “comfortable and familiar” syndrome). The treatment models used by the CSAT grantees take advantage of a wide array of therapeutic tools, matched to the needs of the particular woman. Training can encourage counselors to understand the women as individuals, with different needs, and to broaden their repertoire of responses and techniques.
• Understanding the program’s theory and process of change model and how to use it in assessing and planning each woman’s treatment. Counselors need both the curiosity and the professional mind set to ask, “What is this woman ready for developmentally? For her, what is the attraction of the addiction? How does it make her feel? What does she get out of it?” Women hold on to addiction and its lifestyle just as many abused women stay with the abuser. In both cases, the person must understand and come to terms with the pull— the attachment—before it can be given up.

Cross-Training for Treatment and Corrections Staff

Cross-training for program staff is considered to be critical for the success of a drug treatment program (Bureau of Justice Assistance 1991, p. 49). This training educates treatment staff about corrections issues, such as security, and educates corrections staff about treatment issues. The training serves a number of vital functions, such as promoting teamwork and helping the treatment and corrections staffs to understand their roles and any existing stereotypes.

Cross-training needs to be scheduled before the program gets underway, and then be followed up by regularly scheduled in-service training sessions. Such training may be complex in the beginning, and professional training assistance can sometimes be helpful.

Topics for Cross-Training

Table 15 lists general cross-training topics (not specific to women’s programs) for treatment and corrections staff in prison and jail settings.

The CSAT women’s program grantees suggest that, in addition to these generic topics, cross-training for the assigned program security staff and their substitutes needs to encompass the following:

• Training regarding AOD treatment, including such issues as confidentiality of program information
• Need for sensitivity to the emotions and potential distress that can be evoked during counseling
• Importance of maintaining a positive, nonpunitive environment within the treatment program
• The critical role of support and encouragement that correctional staff can play after treatment hours

Grantee Lessons on Cross-Training

The Stepping Out program staff recommends that cross-training begin early in the startup process. One lesson they learned was that custody staff need succinct and unambiguous information about the program. Giving the custody staff volumes of material is not useful to them; what they need are program summaries and focused information on how their duties interact with the program.

For the treatment staff during cross-training, women’s program grantees suggest the following topics:

• Special issues regarding treatment within a corrections setting
• Security issues and potential breaches
• Importance of not “triangulating” patients, treatment staff, and correctional officers

Table 15. Cross-training topics

One available resource is the cross-training curriculum for probation/parole officers and drug treatment personnel developed jointly by the National Association of State Alcohol and Drug Abuse Directors (NASADAD) and the American Parole and Probation Association (APPA). Call 202-293-0090 or e-mail: dcoffice@nasadad.org. CSAT also has a cross-discipline training course for corrections and drug treatment personnel (see Criminal Justice-Substance Abuse Cross-Training under Staff Training in the Resource List, this volume).

Relationships With the Medical and Psychiatric Staffs

Much has been written about the inadequate medical services that jails provide to women (Gray et al. 1995). Lawsuits filed by or on
behalf of women in jails predominantly deal with medical services. Only about half of U.S. jails offer gynecological and obstetrical services, about 70 percent offer psychiatric services, and 90 percent do intake screening and health appraisals. Among State prisons, about 95 percent do intake screening and health appraisals and 80 percent provide obstetrical, gynecological, and psychiatric services (ACA 1990).

The CSAT demonstration grantees stressed how important it is to have a good relationship with the facility’s medical and psychiatric staffs. Based on their experience, the women’s treatment staffs in jails pointed out the following issues:

• Screening for sexually transmitted diseases (STDs). Women offenders with drug problems have a high rate of STDs, often untreated. Programs need to be aware that the medical screening available for women offenders may be so limited that STDs are neither diagnosed nor treated. One jail program supported by CSAT reported that none of their women clients were being diagnosed with STDs during the standard medical exams. When an STD specialist joined the program and began screening the women, 70 percent were found to have one or more STDs.
• Need for medication. A number of women being admitted to jails and detention centers are in need of medication for major mental disorders. Women leaving mental institutions may find themselves alone and become homeless; they stop taking prescribed medications and self-medicate with street drugs that are easily accessible (Lord 1995). The problem is self-perpetuating. While actively using drugs, the woman becomes noncompliant with her psychiatric treatment and medications. Women with a dual diagnosis (a major mental disorder combined with substance abuse) need to be stabilized when they enter custody. With medication, a number of these women will be able to participate in a short-term, intensive pre-release program.

In prison settings, the staffs commented on the following issues:

• Need for gynecological care. One program director commented on the high level of gynecological problems among the women and their previous lack of medical care. Some women in this program have HIV and STDs. Other women are already starting menopause in their late 30s and early 40s. These are issues related to relapse in women.
• Need for supportive prenatal and postpartum care. At WCI Village, the program provides a nurturing, supportive climate for a woman throughout her pregnancy and after birth of the baby. All the program participants provide this support. The woman delivers her baby at the hospital, and the infant is immediately removed either to foster care or to a relative. When the mother returns to the prison infirmary after the delivery, the whole Village group comes to visit and support her as she grapples with her feelings about the separation from her infant.
• Overprescription of medications. In the prison setting, program directors felt that, for some individuals, psychiatric medications are being overprescribed and prolonging their addictions.

Treatment staff needs to have good ongoing communication with the facility’s psychiatrists and mental health care providers. As was discussed in chapter 4, most of the programs attempt to admit women who have serious mental health diagnoses, as long as they are stabilized on medication and can benefit from—and not disrupt—the program. These women will need a mental health consultation before entering the treatment program, and some may need to be transferred temporarily to the psychiatric unit while in treatment. Issues that have come up in this collaboration include:

• A need for information. One program finds it difficult to get adequate information about individuals from the mental health unit. For example, staff want to know more about the expected effects of the drugs that each client is taking, particularly the potential side effects.
• Need for orientation on the program. The mental health staff needs to understand the criteria governing which women can be accommodated by the treatment program. One program found that, because programming is so scarce for women offenders with severe mental illness, the mental health unit kept trying to send women who were not appropriate for their program.

Evaluating the Program

Evaluation of programs has become increasingly important during the 1990s, as both the Federsl and State governments have demanded more accountability for government funds. State AOD agencies generally require that programs have continuous quality improvement (CQI) or quality assurance (QA) programs. Because policymakers will want to know about results, it is important to design an evaluation while a treatment program is being developed. Even if there is no formal budget for evaluation, it is still possible to design simple but useful measures for evaluating process and outcomes. This information needs to be collected consistently from the time the program starts.

Research on outcomes of treatment, especially for women, is badly needed. The CSAT-supported demonstration programs described in this Guide have all developed process and/or out
comes evaluation plans, so that findings will be available on these models. But every project should be doing some evaluation, and the plans need to be made in tandem with the initial implementation planning. Baseline data may need to be collected before the program starts. Some of the important reasons for carrying out some type of evaluation include:

• Obtaining financial support. This is a time of uncertain and changing funding streams. Gathering feedback that shows the success of the program, and the program’s ability to demonstrate concrete results in reducing recidivism and saving public money, can be a significant asset in helping to generate continued funding and administrative support for the program.
• Insight for staff about what works. Specific feedback from participants is invaluable in showing what is working, or not working, in a program.
• Knowledge for matching clients to community programs. Feedback about follow-up outcomes can be particularly useful for in-custody treatment programs, since it will help determine which community continuing care facilities and resources are of most benefit to which types of clients. This information will improve treatment matching.

Potential types of evaluationcan demonstrate:

• Advantageous effects on the institution. Evaluation can show that a treatment program provides concrete advantages for the prison or jail. For example, data can show the program’s effects in reducing disorderly behavior and rules violations among the participant population.
• Process information. Data can show whether the program is being implemented according to plan, the number of clients being retained and for how long, the number of clients successfully completing the program, the range and type of community resources introduced to the clients, the level of client satisfaction with the program, and the clients’ self-evaluation of change.
• Treatment outcomes. Post-release client outcome measures can show the percentage of program participants who enter post-release treatment, the types of treatment received, and the period of time they remain in treatment. At 3-month follow-up after release, outcome measures can be used to assess client drug use (self-report and urinalysis, combined with psychosocial measures), and client attendance at mutual-help support groups.
• Recidivism outcomes. The recidivism of clients can be measured by: rate of recidivism for program graduates at 6 months and 12 months; rearrest status at 1 year follow-up; and the cause of the recidivism (for example, new arrests vs. technical probation/parole violations).
• Other indicators of improvement. Other measures can look at the clients’ improved social and economic functioning, such as employment or schooling, gaining custody of children, and living in independent and drug-free situations. Cost data are particularly important in the current funding environment. How much government money is being saved when a substance-abusing offender, after treatment, is able to work and become economically self-sufficient, to resume care of her children, and to cease criminal activities? Such cost-offset data are critical for convincing State policymakers about the cost benefits of treatment programs.

For a brief discussion of process evaluation and its challenges in correctional settings, see “Process Evaluation Techniques for Corrections-based Drug Treatment Programs” (Scarpitti et al. 1993). Other brief resources on program evaluation will be found in Establishing Substance Abuse Treatment Programs in Prisons: A Practitioner’s Handbook (CSAT 1993a, pp. 60-65) and in TIP 17, Planning for Alcohol and Other Drug Abuse Treatment for Adults in the Criminal Justice System (CSAT 1995a, pp. 91-95). For a full description of the evaluation process and the many variables that should be addressed in well-designed studies, see TIP 14, Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment (CSAT 1995c).

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