Primary Recommendations
These recommendations propose steps that we think the agency would find timely, practical, and efficacious. They are each meant to build upon program features that have served the program well to this point. If a few agency practices are somewhat antiquated (e.g., wearing signs as a “learning experience”), we encountered nothing that appeared inappropriate or in need of corrective action.
Other than assigning them either
primary or secondary status, we do not rank the recommendations by importance or by a sequence for implementation. Nor do we offer particular strategies for implementing the recommendations; that would go beyond the scope of our consultation. And the agency community can probably decide how best to proceed without much help. For tools that can help with several recommendations, however, we cite two institutional sources: Texas Christian University’s institute for Behavioral Research (
www.ibr.tcu.edu/) and NiaTx (
www.niatx.net). The former offers relatively simple and validated instruments for capturing crucial client data; the latter focuses on means and methods for fostering treatment programming change.
We only note that oftentimes big and important progress requires a conservative step-wise approach. Especially when, as with the agency, the current structure is sound and there is no urgent need for change. Paradoxically, perhaps, when conditions are stable can be a good time to move ahead, because stability allows for gradual adaptation. “Fixes” on the other hand, are often undertaken with more urgency and less deliberation. Seeing no need for big fixes, our sense is that the agency is in good shape to not only consider upgrades and enhancements, but also to start making them real. These, then, are our recommendations.
Streamline intake and assessment. Legal, mental health and medical eligibility is well documented and clear, but there appears to be a great deal of data duplication in intake, psychosocial, and case management. While getting the story more than once can turn up inconsistencies or get a more fine-grained profile, it is unclear whether and how that impacts subsequent treatment. And separate clinical and case management files may be a barrier to integrating information. We recommend unifying and consolidating the process with fewer tools. We especially recommend using one tool that can be staged and also used for reassessment: the ASI for example or the TCU Intake instrument. To screen for substance abuse as part of eligibility process the TCU Drug Screen II might be a good choice. (It is free and normed on the CJS population.)
Consider recruiting “higher risk” offenders. Currently the agency screens the offender pool for highly motivated clients with relatively good family support and recovery prospects. Once admitted, these clients experience a high intensity program. Dominant voices in the treatment research and public policy arena these days cite evidence that more-highly motivated and supported the prospective client, the less they may need intensive treatment. And, that needless long intense programs for those clients can lead to poorer outcomes for some, premature departures for others, and in other cases success that was likely without intensive treatment. Also, greater public savings from crime-reduction result from partial success with more challenging/higher-risk offenders than greater success with low risk offenders. It might be prudent to partner with the Drug Court and bring in the Reentry Council to review other CJS treatment interventions, ones that might be implemented or adapted to work towards the best match between the client profile and the treatment particulars.
In any case the agency would only strengthen its impact with clear parameters for defining its target population, having specific admission criteria that are sensitive to the realities of that population, and interventions that are appropriate to that population. This might seem obvious enough, but it is neither simple nor easy in practice. Note: it is not necessary to stick to one narrowly defined target population; a community with a range of personalities and risk ratings has potential advantages. But continuing attention need be paid to how two or more “streams” of clients affect the program, and quick adjustments may be called for.
Condition phase advancements on individual achievement. The current system of cohort advancement inevitably reduces client incentives to do one’s best and degrades, at least a little, staff focus on individual achievement. Enabling a client to join a more advanced peer group, the approach favored in TCs generally, can create a positive culture of achievement. Reducing the necessary minimum LOS also frees up resources. Current best-practice wisdom suggests that 6 months can be an acceptable minimum time in intensive residential treatment. THE AGENCY could establish, for example, 2 months as the minimum time per phase, anticipating that 2 to 4 months per phase would be the norm. (Clients could not only be held back pending progress, but set back should their behaviors warrant). Any move to reduce program duration implies consultation with the criminal justice system. An agreed plan is likely as long as appropriate treatment objectives per phase are clearly defined and clearly achieved, and that where necessary the client has a prolonged final phase of supervision in transitioning to life in the mainstream community.
Establish clear recovery-based treatment objectives for each phase. The agency offers clients an array of useful written materials and exercises and related group discussion sessions: e.g. Change Company publications, Purpose Driven Life materials, relapse prevention activities. Client attention to the materials and group participation is tracked, but measurable learning and appropriate practice and use of the content is not. Nor is the learning consistently reinforced throughout the program environment. These are vital conditions for durable treatment gains. But they require that the core elements of a “recovery curriculum” be made clear to everyone; that the particular concepts, practices, and skills at issue be carefully defined; that the respective means to teaching and instilling them be identified and targeted; and that their achievement be made as measurable as practical.
Towards this end, we urge extended consultation among agency staff, knowledgeable associates, the local community of maturely recovering drug-abusers, and if possible professionals who have researched developmental recovery among substance abusing offenders. Out of this work agency staff would determine specific sets of knowledge, skills, and so on that would be appropriate to each client phase. While selections may need revisiting now and then, focusing hard on a sound set of unambiguous learning objectives will grow staff competence and even mastery in teaching them ever more effectively.
These core achievements—e.g., understand key scientific facts about addiction and important things known about recovery, participate regularly in a social activity that strengthens recovery and that you can continue after release, master at least 3 skills that can help keep you out of trouble and that you can do easily wherever you are—should be distributed across the treatment phases with some developmental logic. Consistent with current best practice standards, cognitive or cognitive behavioral skills—which are themselves of central importance for relapse prevention—need to be taught with robust modeling, rehearsal, and practice application. All staff and interns should be fully familiar with all the core requirements and how they are taught and the purposes they serve. Discussion about, comments upon, and lots of good, bad, and indifferent enactments or core practices and precepts should become prominent features of the agency as a learning community.
Strengthen and enhance staff, intern, and volunteer training. This also involves several components. For one, we urge developing a unified set of standard operating procedures that can be relied upon by all staff, interns, and volunteers. Most procedures are already well defined. What’s needed is to consolidate and organize them for ready reference. We also see benefits from enhancing the “onboarding” process—i.e., building strong, capable, and concerted teams using standard procedures for staff orientation. We recommend creating protocols to observe staff and interns to ensure they are competent in their various functions—run groups, work with individuals, perform documentation, etc.—so they can be “signed--off” as competent to do them independently.
Crucial to any such training is attention to issues related to working with a criminal justice population and the boundaries that may apply to interactions with clients. We also heard requests for more attention to the challenge of being an agent of both therapy and institutional authority, which implies greater focus on the operational definition of “rational authority.”
We urge sharpening policies and practices around providing ongoing clinical supervision: when it happens, by whom, what’s expected, etc. While some of this in place—intern group clinical supervision, for example—more is needed. The ideal is to build and maintain a culture of clinical supervision and a regime of well--defined standards.
Secondary Recommendations & Suggestions
Deepen staff insight into the client experience. The need starts with client Orientation, which as we observed it, was over-loaded with a premature run-down of the program’s many (necessary) rules and sanctions. Focusing more on client testimony, Q and A, and various experiential engagement activities on Day One, Session One could help make Orientation more welcoming. We also suggest exploring NiaTx’s approaches to simulating the client experience for staff by putting select staff through client processes to determine what is and what is not likely to have a desired impact. We suggest that the first process to focus on be intake and orientation.
Once more TCU offers a useful tool. The Client Evaluation of Self in Treatment (CEST) tracks engagement, motivation, psychological functioning, social functioning and criminal thinking. It could be used in conjunction with mid-term evaluations to track progress and provide additional information for phase progression. Some sections combined into their Inmate Pre-Release Assessment (IPASS) can be used to determine risk of relapse and recidivism prior to release into the community and then can inform aftercare plan. The Engagement scale also tracks effectiveness of counselors for supportive, not punitive, purposes. Not least we suggest if at all possible interviewing Interview clients that leave the program to help improve retention.
On the walls, less is more. The client-produced sayings and aphorisms that cover most of the visible wall space seems overwhelming at first, but rather quickly fades to wallpaper. Rather like the whole being less than the sum of its parts. We suggest limiting signs and posters to key themes, identified core learning, and only the most outstanding inspirational or instructive sayings. To get continued value from the existing collection of sayings, perhaps they could all be catalogued as a menu of themes; have clients choose several for a seminar and/or add something new to the catalogue, which would always be available for client perusal.
Consider having more NA in lieu of AA meetings. NA is an important context for enabling clients to identify with the culture of abstinence and recovery. Alcoholism recovery of course is real recovery and the necessary focus of many clients. But for many criminal justice system (CJS) substance abusers, groups dominated by older mainstream or middle-class participants can be problematic. For most CJS folks, at least at first, NA fits better with its ready reference to poly--drug use and the criminal street life and most of all a more familiar set of personalities.
Ensure ready reference skills. Only professional researchers and scholars need to stay highly current in the field of substance abuse treatment. And given the time and possible expense it used to take, few practitioners could do more than make occasional efforts to catch up a little. No more, of course. Not only can Google Scholar, for example, turn up thousands of relevant web pages (and many full articles as well as abstracts), many leading on-line science publications have addiction or substance-abuse subsections, and there are dozens of professionally respected addiction and offender-specific journals, magazines, and newsletters. Although few if any important issues in our field might be fully “settled,” keeping an eye on the literature helps one stay humble, remain sensitive to important treatment factors, improve existing skills and practices, and learn more about what one is already doing and its impact. At least one staff person should be a capable and frequent investigator of findings about the science and art of substance abuse treatment and recovery.
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