With more than 2 million individuals in federal and state prisons at the end of 2006,1 the nation's correctional systems clearly have been operating under tremendous strain. Concern about the system's “revolving door” has been prominent for years,2 with evidence suggesting that more than 60% of released inmates will be rearrested within three years.3 And with studies indicating that more than two-thirds of jail inmates might have a substance use disorder requiring treatment,4 it is clear that any attempt to have an impact on the burgeoning correctional census must incorporate innovative programmatic and clinical strategies for treating the substance-affected offender.
The Davidson County Drug Court program in Nashville, Tennessee, founded in 1997, is a rehabilitation-focused effort that has become a national prototype for innovation in addressing the offender. The first court-operated residential treatment facility in the country (most drug court programs operate mainly on an outpatient model, few having been able to follow Davidson County's lead), the program serves approximately 200 adult nonviolent offenders with substance use disorders each year.
The program incorporates three distinct phases. In the first phase, the client receives a comprehensive assessment and a treatment plan is developed. In Phase Two, the client works on core issues in individual and small group therapy, attends 12-Step meetings, and participates in community service. In the final phase, the client continues attending group therapy and 12-Step meetings, but also is expected to work 40 hours a week outside of the facility.
The client continues to return for drug screening and weekly group meetings for up to a year post-discharge. The program utilizes a modified therapeutic community (TC) model, in which the client is assigned a “big brother/sister” to guide him/her throughout the time in the program.
Davidson County's program has shown strong evidence of efficacy. The present recidivism rates are a 31% rearrest rate and an 18% conviction rate one year after graduation. The program has not compared those rates with recidivism rates for other area treatment programs targeting offenders, because the other programs generally offer outpatient treatment as opposed to residential services. But it is not uncommon to see recidivism rates of 60 to 70% in the type of population served by the Davidson County Drug Court.
Judge Seth Norman, founder of the Davidson County Drug Court program and its presiding judge, notes that the effort also is cost-effective. “It's cheaper to put people in one of my facilities than it is to lock them up in the penitentiary,” he explains. “We're saving about $15 per day per individual.”
Clinical challenges and tools
Clinically, the issues encountered by the Davidson County program's staff echo the concerns identified by researchers and other clinicians working with incarcerated populations.2,5 These challenges can include establishing trust, working within the parameters of a client's long criminal history, and addressing trauma and co-occurring mental illness.
David Patzer, MD, the drug court program's staff psychiatrist, believes establishing trust constitutes a primary concern for Davidson County clinicians. “[The clients] have lived lives where they tend not to have a lot of trust in authority,” Patzer explains. He says that the program's modified TC effectively generates client trust because messages are delivered by peers instead of authority figures.
“New people come in and they can see changes in the people that have already been here,” Patzer says. “A lot of times they'll see someone they knew from the outside, whom they knew on the street. They see big changes in them, and that is pretty powerful.”
Therapeutic communities have been a popular setting in which to place offender populations since the 1960s, and have demonstrated significant success across many correctional communities.6 Research has further demonstrated that Davidson County's model, where the client receives support from the TC both in treatment and post-release, is more efficacious than an approach in which the offender receives support only while in prison or on work release.6
Because treatment in incarcerated populations often is mandated, issues of confidentiality commonly surface. Patzer says that because clients know he is technically “working for the law,” there is an initial hesitancy in sharing information. But he suggests that while mandated treatment can exacerbate trust issues, it also can be advantageous, providing the client with initial motivation. “If they run away from the program they know their sentences could be enhanced,” he says.
Patzer explains that once clients have been in treatment for a while, he works to shift their motivation. “I tend to go from using the fear of the legal system as motivation to using what can come from recovery—the new freedom, and the ability to accomplish things they never thought they would accomplish,” he says.