The United States has the largest population of incarcerated people on the planet, and drug policy reform advocates say that more than one-quarter of the individuals filling our state prisons are there for drug offenses. And that number doesn't even reflect the presence in the system of people who have committed other crimes at least in part because of an underlying problem with substances.
Mental health community leaders are often fond of referring to the Los Angeles County Jail as the largest psychiatric center in the country. Prison and jail facilities are no less an addiction holding facility than a psychiatric center, with still too few of the residents receiving innovative treatment services to help them deal with the problems that will plague their life on the outside.
Of course, court-ordered substance abuse treatment programs have gained significant ground in recent years, with much of this occurring under an explosive growth in local and regional drug court programs across the country. With many in the field working hard to convince policy makers and the public that a treatment-focused approach makes the most sense for the addicted offender— and ultimately for society— this article examines the perspectives of four professionals who are among the many trying to make a difference.
For the nationally renowned David Smith, MD, a 40-year professional in the addiction field, the progression from tough talk to treatment in the justice system has been a welcome sight. Smith, medical director of the California Department of Alcohol and Drug Programs and perhaps best known as founder of the Haight-Ashbury Free Clinics, saw the 2000 adoption of Proposition 36 by state voters and its implementation at the county level as an affirmation of a treatment-focused approach to managing nonviolent drug offenders, an extension of gains drug courts were able to make since the 1990s.
“Mandated intervention, the earlier the better, just makes sense,” Smith says. “This isn't criminalization, it's medicalization.”
For years, the paradigm of assistance in the treatment field generally followed the 12-Step model, where entry is based upon the concept that “people will eventually find their way” into a program, Smith says. But by the time the average person with a substance abuse problem “sees the light,” Smith says, a job loss, family alienation, or substance abuse-related criminal offense might already have occurred. He believes that “in many cases, you have to have mandated treatment, and that's what drug court does, and in California, the concept is further enhanced.” (See related article on mandated treatment on page 17.)
Smith adds, “In California we have had these specialty courts— mental health court, drug court— and the judges do their job as judges, but they act like therapists in their encounters with each individual.”
Smith says his hometown of San Francisco, with its longstanding effort to make publicly funded addiction treatment services available “on demand” to all who need them, maintains a progressive attitude toward treatment for criminal offenders with abuse or addiction problems. He believes it is important for communities to begin addressing addiction as their all-encompassing and most prominent social problem.
In San Francisco there is a “huge drug problem on the street,” he says, with needle abscesses placing great pressure on medical costs at San Francisco General Hospital. “We have a needle exchange program, but the reality is, we have a lot of people who just stay out there, shoot up, and get overdosed, and they use up huge quantities of healthcare resources,” Smith says.
He believes that in some cases, arresting a person— even on a minor charge simply to launch a criminal justice system intervention— accrues to his/her benefit, with access to treatment services in his state now enhanced through initiatives such as Proposition 36 and drug court programs.
A dose of responsibility
Robert Darby, a licensed chemical dependency counselor in Cleveland, works mostly with military veterans with a history of addiction and criminal behavior. Generally these individuals pursue services voluntarily and find Darby either in his solo practice or in an agency with which he is affiliated. He tends to think that a client's true readiness for change remains an important consideration in this population.
“I don't care how good your program, the courts, the probation officer, or any of it is. None of it will make a difference unless the individual involved is willing to participate, and make a commitment to change behavior,” Darby says.
He sees a multidisciplinary effort at assessing each individual to determine the correct treatment approach as important; this may encompass medical experts and vocational counselors as well as therapists. “I am in support of early interventions, whether it be through the courts, family counseling, employers, clergy, whomever,” Darby says. “This is a progressive disease, and the earlier it is managed appropriately, the better the individual's chances.”
Darby says he invests a tremendous amount of personal energy in addressing each client on an individual basis and in involving each in the appropriate steps of a program. “I can help them take that first real step toward recovery, but my first question to each and every one of them is, ‘What are you willing to do to help?’
“I tell them I am willing to go the extra mile for them, but they have to be truthful and honest with me,” he adds. “I'll know if they are not able to give a commitment, and without personally investing in recovery they're just going through the motions.”