Response: A Sensible Division of Labor

Sally J. Stevens: The article (Heaps et al., 2009) calls attention to the overwhelming need for a systems approach to substance abuse among criminal offenders. Although individual research projects and treatment programs can address particular types of problems, only a systems approach can effectively address the larger picture.

Douglas McDonald: There are three basic ways that criminal justice agencies and drug treatment programs can interact: (1) justice agency employees conduct screening and assessment and refer patients to independent organizations for treatment; (2) a justice agency contracts with a treatment organization to screen, assess, place, and treat patients; and (3) a justice agency engages an intermediary like Treatment Alternatives for Safe Communities (TASC) of Illinois to screen and assess offenders and to refer them to independent treatment programs. The problem with the first model is that assessing drug treatment needs is not the strength of the criminal justice system. The problem with the second is that there are very few programs with the resources to provide the complete range of services across a continuum of care. The third option, using an intermediary agency, strikes me as the best.

The advantages and disadvantages of such choices in “make or buy” decisions have been much studied in the business literature on contracting, privatization, and outsourcing. The issue is whether the costs and benefits of making a product or delivering a service directly are more advantageous than purchasing the product or contracting the service out to another firm. In general, it makes sense to contract with another provider to deliver services that are ancillary to your organization’s primary mission. For example, schools often hire an outside business to operate their cafeterias, because food service is peripheral to their core mission of education. Rather than having school principals become experts in food service, it is more efficient to hand the task to an organization that focuses its resources and attention on that service. The core business of the criminal justice system is enforcing laws, processing defendants and offenders, and delivering justice. Drug and alcohol treatment services for offenders who abuse substances may be important and effective in reducing recidivism, but these services are of secondary importance to criminal justice agencies’ missions. This makes them good candidates for outsourcing.

Stevens: Using an intermediary agency for screening and referral has some clear advantages. That way, each agency and treatment program in the three-part system specializes in a single aspect of client management— criminal justice processing and sanctions, or screening and assessment and placement, or providing a particular evidence-based treatment model—and can learn to do it really well. As things stand, many treatment programs offer too many services. Some claim to provide multiple evidence-based models, but the fact is that training requirements coupled with high counselor turnover rates make it difficult to implement and provide even one evidence-based model effectively. Ideally, the intermediary should also provide oversight, as Illinois TASC does, to ensure that programs are actually providing what they’ve promised and to evaluate their effectiveness, at least in terms of treatment retention and immediate outcomes.

Shiela Strauss: A tripartite system consisting of criminal justice, screening and referral, and treatment services provides a sensible division of labor. Since none of the branches needs to be able to perform every task, training and work responsibilities can be divided. If all the branches function effectively, each branch realizes that together they can achieve the overarching objective. This sense of “collective efficacy” will likely foster a good deal of cooperation.

Stevens: An intermediary screening and referral agency well-versed in treatment can also ensure consistency in appropriate treatment placement. We have had experience with referral agencies sending juvenile and adult offenders to different treatment programs somewhat haphazardly, without solid clinical justifications based on addiction intensity or American Society of Addiction Medicine (ASAM) criteria. Thereafter, when justice-involved clients get to the treatment facility, little is done to check on the fidelity of treatment implementation and the appropriateness of the approach. That is where fidelity monitoring comes in.

McDonald: Avoiding conflicts of interest is another advantage to having an intermediary agency perform screening, assessment, and referral. For instance, suppose a treatment provider that is also responsible for screening and placement happens to have a surplus of inpatient beds with few outpatient slots. There’s a good chance that the agency, in that situation, will refer more people to inpatient treatment, which could well be an expensive and inefficient use of treatment resources. In contrast, an independent screening and referral agency is less likely to be swayed by such considerations. If it is not in the business of delivering the treatment service itself, it is better positioned to disinterestedly refer each client to the most clinically appropriate treatment services.

Stevens: Our institute provides treatment services in rural areas where we have to make extra effort to provide clients with access to care, especially specialized treatments. For example, we’ve implemented a mobile outreach program to bring specialized evidence-based services from metropolitan areas to rural treatment centers that otherwise could not provide them. The rural agency and trained treatment providers each make concessions; for instance, the providers undertake long commutes and modify their evidence-based protocols to dovetail with what is already in place at the rural agency. As we’ve been talking, I’ve been wondering how the Illinois TASC model would work in our setting. Of course, it would face the same difficulties of sparse provider resources, but it might be better suited to handle some of the logistical issues. I think, too, that the tripod approach with a central screening agency mediating between justice and treatment would avoid some of the resource misallocation that occurs. For instance, I’m aware of several cases in Tucson and nearby rural counties in which African-American adolescent males were referred to drug treatment after offenses such as vandalism, shoplifting, and theft, even though they had never used drugs or had done so only very rarely. That would not happen if expert personnel were making the referral decisions with ASAM criteria.

McDonald: I am struck that 35 years have passed since the Federal Government initiated the nationwide TASC program to provide case management for offenders reentering communities. And yet we’re still talking about the need to integrate substance abuse treatment and the criminal justice system. We still experience some of the same problems and struggle with some of the same issues around treating offenders. Yes, there have been some promising innovations, like drug courts, which have taken off and made a dent. Yes, the authors’ brief for their Illinois TASC approach is well-reasoned, and their progress to date is estimable—but overall, the lack of progress in the field is discouraging.

Stevens: We have recommended that Arizona contract with one agency for screening and assessment to be conducted in various locations throughout the State. This would promote appropriate placement and facilitate consistent collection of outcomes data. The challenge is daunting and even more so because this system would serve not only people involved in the criminal justice system, but also anyone with substance abuse problems. The questions include: How do you set up a centralized screening and assessment facility? How does it fit in with the existing treatment system? How do clients access the service? How do you place clients in treatment programs around the State? How are training and fidelity checks performed? From our position, at the beginning of this road, we can appreciate the distance Illinois TASC has traveled.