Durham County Adult Drug Treatment Court (DCADTC)

Durham County Adult Drug Treatment Court (DCADTC) Submitted by Dr. Valerie Anderson Robin Stephenson Jessica Wilson Dr. Janis Kupersmidt innovation Research & Training Process Evaluation Results July 13, 2005 (919) 493-7700 www.irtinc.us

Presentation Overview • Overview of Drug Court Participants and Program II. Program Structure & Components • Program Eligibility, Referral, and Admissions • Phase System • Sanctions • Incentives • Treatment • Ancillary Services III. Program Facilitation • Team Members • Team Functioning • Case Management & Judicial Supervision IV. Consumer Satisfaction • Consumer Satisfaction Survey • Summary of Challenges Reported by Participants • Life Improvements Attributed to the Program V. Summary • Strengths • Areas for Improvement • Testimonials

I. Overview of Drug Court Participants

I. Overview of Drug Court Participants, continued

The average age of participants at the time of enrollment was 35; ages ranged from 18 to 63 years. The court has served slightly more females than males. Two-thirds of the participants the court has served were African American (66%); the remaining participants were Caucasian/White. The majority of participants were Single or Never Married (59%). On average, participants had 1 dependent, although this number ranged from 0 to 7. The majority of participants held a high school diploma or lower levels of education. Only one had completed college or graduate school. Almost half of the participants entered the court unemployed, while 28% were employed full-time and 11% were employed part time. The most common primary drug of choice was crack (35%), followed by heroin and alcohol (18% each), marijuana (14%) and cocaine (11%). One-third of the participants had previously received mental health treatment before program admission, and two-thirds had previously received substance abuse treatment. Summary of Participant Characteristics

Program Graduation and Retention Rates

Graduation and Retention Rates by Primary Drug of Choice

Drug Court Status by Race and Gender

Program AdmissionsAverage Length of Time for Program Referral, Screening, and Admission

Program EnrollmentAverage Length of Program Enrollment for Discharged Participants

Program AdmissionsReferrals, Eligibility & Enrollment Procedures

Program AdmissionsEligibility Criteria

Strengths Eligibility criteria listed in the Procedures Manual are clear, describe the court’s target population, and are generally consistent with state and federal guidelines. The DCADTC appears to be reaching its target population in terms of chemical dependency as determined by the SASSI. Team members use consensus-based decision-making to determine whether to admit potential clients with a history of assault or other violent crimes. Team members reported that, in general, they adhere strictly to the written eligibility criteria. In general, team members agreed that time limits or other parameters should be placed on violent crimes (e.g., if they occurred as a result of self-defense, or if they occurred many years ago). The team interviews former participants who wish to re-enroll in the program prior to making an admission decision. Barriers The eligibility criteria do not reflect the State’s criteria regarding eligibility for community or intermediate punishment for all pending offenses. The definition of, and process of determining, whether potential clients have “substantial mental health problems that prohibit their productive participation” is unclear. No clear definition in eligibility criteria of how the court determines whether a candidate who has previously participated in a DTC program is eligible for re-enrollment. Team members expressed varying views regarding the suitability of the program for former participants. Data recorded in the MIS make it difficult to determine whether a significant proportion of participants have a history of violent crimes. Program AdmissionsEligibility Criteria

Program AdmissionsEligibility CriteriaRecommendations: • Consider revising eligibility criteria to more explicitly state the requirement of eligibility for intermediate or community punishment. • Document the process for determining whether a candidate has substantial mental health problems that prohibit their productive participation. • Consider developing a formalized interview and/or decision-making protocol for use in determining the suitability of the program for repeat participants. • Review MIS database to examine whether there are barriers to accessing information on violent crimes for participants whose history of violent crimes is recorded as “unknown.” • Review the range of “other” reasons for ineligibility recorded in the MIS to determine whether common themes are present. If so, the State may wish to add descriptive response fields that reflect these other reasons.

Program AdmissionsReferral, Admission, and Intake

Strengths Team members’ reports regarding the primary source of referrals for the program, and the appropriateness of those referrals, were in agreement with quantitative data on primary referral source. There is a strong relationship between the DTC and Probation, which facilitates appropriate and timely referrals. Team members make regular monthly presentations to Durham County Jail residents, insuring that they are aware of their potential eligibility for the program. The Case Manager conducts a pre-screening before passing cases to the ADA, who also conducts a screening, and the team comes to a consensus on all drug court admissions. Barriers The eligibility screening process occasionally gets “backed up” and slowed down due to the heavy caseload of the ADA. This barrier has been addressed to some extent by providing assistance to the ADA. Team members perceived that many referring parties were not knowledgeable about eligibility criteria, resulting in valuable time spent screening many ineligible cases. Team members’ descriptions of the referral and admission process differed significantly from the documented process described in the program’s written materials. Program AdmissionsReferral, Admission, and Intake

Program AdmissionsReferral, Admission, and IntakeRecommendations: • Continue to monitor the time required to receive the results of eligibility screenings conducted by the D.A.’s office; if necessary, request additional support. • Establish a regular schedule for providing ongoing education about the DTC eligibility criteria for referring parties, especially those who refer large numbers of candidates (such as judges and offenders). • Revise and update written court materials (e.g., Handbook and Procedure Manual) to reflect the court’s actual referral and eligibility screening practices.

Phase SystemProgram phases, graduation, and termination Strengths • The treatment phase system that is in place for participants receiving treatment through the Criminal Justice Resource Center (CJRC) is generally well-defined, and largely serves as the court’s phase system. • Program completion is an important component of the program that is commemorated in an elaborate graduation ceremony. • Participants are maintained in the program for as long as possible in order to maximize the possibility of recovery and program completion. • The use of the sanctions grid facilitates decision-making in termination decisions. • Team members and participants agreed that the termination policy is fair, and allows ample opportunity for participants to succeed in the program. • DCADTC has involved and interested alumni, and is working toward establishing a formal alumni program. Barriers • There is no unified phase system in place that outlines and documents the requirements for progression through the program. • According to two team members, the decision to keep non-compliant participants enrolled in the program occasionally reflects a desire to maintain program capacity. • Clinical perspectives sometimes clash with judicial perspectives when making termination decisions. • Team members disagreed about the suitability of the program for former participants, and occasionally, recollections of the former participant’s personality or behavior drives admission decisions. • The criteria for determining eligibility for graduation are not documented in program materials, and include both objective and subjective parameters. • The requirement regarding the completion of a GED is not enforced.

Phase SystemRecommendations: • Develop a written protocol that outlines the overall phase system in terms of the number and frequency of court sessions, frequency of meetings with the Case Manager and Probation Officer, the length of and requirements for progressing through each phase, and other distinctive features of the program. • Monitor instances in which decisions to keep non-compliant participants enrolled in the program are driven by a desire to maintain program capacity rather than by clinical or judicial motives. • Consider developing a protocol for making admission decisions for former participants. This protocol could include a standardized interview and/or standardized methods for evaluating the candidacy of former participants. • Enhance cross-training so that all team members will be trained to thoroughly consider both judicial and clinical perspectives when making termination decisions. This would also address Key Component 9 (ongoing interdisciplinary education promotes effective drug court planning, implementation, and operations). • Develop policies for tracking whether former participants go on to complete their GED once released from the program, or discuss current barriers to ensuring that participants who begin working toward their GED are able to complete the GED prior to graduation.

Strengths The sanctions used by the court are reasonable, have a clear progression of severity, and are documented in the form of a Sanctions Grid. Sanctions are strictly imposed based on the Sanctions Grid, without according flexibility for individual circumstances. In general, team members agreed that sanctions are effective and support participants’ recovery needs. In general, current and former participants reported that the sanctions used by the court were effective deterrents that helped to motivate compliance. Barriers One team member reported that there is a need for sanctions that promote healthy behavior, rather than relying solely upon punishment to change behavior. One team member felt that sanctions should take into account individual needs and circumstances. Two former participants (successful graduates) reported that sanctions were too strictly and suddenly applied (e.g., 24-hour incarceration for first positive urinalysis) Sanctions

SanctionsRecommendations: • Team members could discuss the possibility of developing sanctions that promote healthy behavior at a team retreat or other designated session. They could use this opportunity to explore the range of sanctions currently being used by other courts. • The team should consider monitoring the manner in which participants are made aware of the consequences of rule violations from the beginning of their enrollment in the court. Adopting the use of a contract may facilitate the court’s ability to provide assurances that participants have been made aware of the protocol regarding the use of sanctions.

Strengths An incentives grid governs the distribution of incentives for participants, assuring consistency and fairness in enforcement. All team members agreed that incentives are fair, effective, and are delivered consistently across participants. All of the current and former participants agreed that the incentives were valued and appreciated, especially the Judge’s verbal praise, early release from court, and gift certificates. The team receives donations from local businesses for use as program incentives. Barriers Because the incentives grid is largely based upon progression through treatment phases, the manner in which the team applies the incentives grid to participants receiving treatment from the Duke Family Care Program, for which there is no phase system in place, is not clear. Incentives

IncentivesRecommendations: • Implementing a phase system that addresses the progress of participants who receive treatment through the DFCP would provide a better structure for gauging the achievement of various hallmarks that are associated with progression through treatment phases. • Document the manner in which the court works with local businesses to secure donations for use as incentives, as many courts have reported challenges in this component of the program.

Treatment Strengths • A thorough intake and clinical assessment form the basis for the development of an individualized treatment plan. • Clinical team meetings and clinical supervision provide opportunities for feedback and revision of the proposed treatment plan for participants receiving treatment through CJRC. • Gender-specific process groups are offered for participants in Phases I through III of treatment at CJRC. • Treatment services are in place that address the unique needs of pregnant mothers and mothers with young children. • One-third of team members identified treatment as the most helpful component of the program. • Team members perceive treatment services to be equally suitable and effective across demographic factors such as race and gender.

Treatment Strengths • All successful graduates identified treatment as the most helpful component of the program, and articulated specific aspects of treatment that were helpful, including drug education, relapse prevention, and parenting skills. • Team members and participants reported that community-based 12-step recovery groups meet the needs of participants and are easily accessed. • Annual focus groups with participants receiving treatment through DFCP are conducted to help determine the most and least helpful aspects of treatment. • Upon graduating from the DTC, participants are not required to immediately exit treatment services from either agency. Participants may attend treatment groups at CJRC up to one year after discharge, and for as long as they need to at DFCP.

Treatment Barriers • One team member identified treatment as the least helpful program component due to the limited number of types of treatment available to the participant. • Individual therapy is currently provided on an “as-needed” basis for participants receiving treatment through CJRC. • Half of team members interviewed felt that the drug court is not as effective for younger participants as it is for older participants. • Team members disagreed as to the ideal length of the program; half of the team members felt the program should be lengthened. • Team members discussed negative aspects of the pending transition in the provision of treatment services, including increased administrative burden and general lack of education about how to access treatment services.

Treatment Barriers • The provision of clinical supervision and clinical team meetings for treatment services provided through DFCP was not reported during this process evaluation. • There is currently a need for additional group therapy sessions for women who are further along in the recovery process (DFCP). • There is currently no phase system in place for participants receiving treatment services through DFCP. • It is unclear how the results of focus groups conducted with DFCP participants are used to assess participants’ learning and retention of information presented in classes and groups. • There are no current Memoranda of Understanding in place for the court’s two treatment agencies. • The lack of available aftercare options to help maintain recovery weighed heavily on active participants’ minds.

TreatmentRecommendations: • The court might consider evaluating its ability to provide individual counseling services to all participants. This might allow for easier identification of individual issues that should be addressed to increase the effectiveness of treatment services for each participant. The Drug Court Key Components suggest that participants should be matched with treatment services based on their individual, specific needs. • Monitor the amount of individual therapy provided to participants, and review in light of the Memorandum of Understanding that outlines expectations for the provision of treatment services to participants. • Update and maintain current contracts or Memoranda of Understanding for all treatment agencies providing treatment services to the court. Evaluate the effectiveness of the court for younger vs. older participants. • Currently, on average, the amount of time required for successful program completion is slightly over 15 months. The court may wish to consider and discuss the feasibility and cost-effectiveness of lengthening the program.

TreatmentRecommendations: • Team members may wish to work with the AOC and the NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services (MHDDSAS) to develop a written protocol for accessing and providing treatment services to participants in order to address team members’ unease with upcoming transitions. • Review and document the type of clinical supervision that is provided to Treatment Providers who work through Duke Family Care Program (DFCP) to provide treatment services for DTC participants. • Develop and enforce a timeline for implementing a phase system for the drug court program as a whole, and for the DFCP in particular. • Utilize the exit interview as a tool for gaining greater insight into participants’ perspectives regarding the strengths and challenges of treatment services currently offered by the court. • Prioritize the development of aftercare services for participants, and formalize the alumni program to integrate successful program graduates into the program in a meaningful way that helps to maintain their motivation for recovery.

Ancillary Services Barriers • Securing adequate drug-free, affordable, permanent housing for participants is an ongoing barrier. • Felony convictions, unpaid utility bills incurred during previous tenancies, and long wait lists were identified as specific challenges to securing affordable housing through the Durham Housing Authority. • Team members reported that the employment services that are offered to participants do not provide or lead to “good employment options.” • Two team members identified affordability as a barrier to securing mental health treatment services for participants, since most participants do not have private health insurance and are not eligible for Medicaid. Strengths • A number of ancillary services are available to drug court participants, including services in the areas of housing, social services, vocational rehabilitation, employment, parenting and life skills, and education. • The Case Manager and Treatment Providers facilitate access to and enrollment in ancillary services. • Team members reported that, because of positive relationships with community agencies, there are no barriers to securing residential treatment services for participants.

Ancillary Services Recommendations: • The court should consider inviting a member of the Durham Housing Authority to attend a special Local Management Committee meeting designated to address the issue of housing. The court might also consider inviting a member of DHA to be a member of the Local Management Committee. • The court might benefit from recruiting a consultant on housing issues to aid in identifying more housing options for low-income participants. • The court might also benefit from recruiting a consultant to aid in finding suitable job placements for participants, or in establishing collaborations with other local job placement agencies. • The court should contact the NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services (MHDDSAS) to discuss a protocol for securing mental health treatment options for participants, and possibly, to problem-solve around the issue of affordability of services.

Strengths The DCADTC Core Team is comprised of the individuals and agencies required by the AOC Best Practices Guidelines. DCADTC team members appear to be fulfilling their roles and duties as required. In observations of team meetings, each team member’s role was clearly evident based on his or her theoretical perspective and contributions to the discussions. Team members have observed other DTC’s and participated in national and state conferences that provide both role-specific and general training. All team members described the competence, respect, and professionalism of team members as a key program strength. The Local Management Committee is comprised of members required by the AOC Best Practices Guidelines. Barriers Many team members stated that Law Enforcement is a key agency that is missing from the Core Team. The absence of Law Enforcement was perceived by team members to detract from the credibility of the program, and to increase the length of time required to fulfill Orders for Arrest. The Local Management Committee was reported to play more of a “guiding” role in the drug court during the court’s early stages. Currently, the committee hears reports from the drug court and considers budget issues. The court faces challenges with regard to regular attendance of committee members at Local Management Committee meetings. One Treatment Provider is not yet a Certified Substance Abuse Counselor. II. Program Facilitation Team MembersComposition, Roles, Background Training & Education

Team MembersComposition, Roles, Background Education & Continuing EducationRecommendations: • The team may wish to consider having a facilitated meeting with the Durham Police Department and the Durham County Sheriff’s Department to identify the potential benefits of and barriers to including law enforcement as a core agency within the drug court team. • The team may also wish to consider developing a Memorandum of Understanding to outline the specific roles and functions of law enforcement liaisons within the drug court program. • Setting the annual calendar of Local Management Committee meetings at the beginning of the year, and reserving alternative or additional dates for Committee meetings, would facilitate adherence to a regular schedule of meetings, and may result in better attendance. • Proactively developing a list of topics and concerns that need to be addressed by the LMC would help to structure the agendas for these meetings in such a way as to allow the court to gain the maximum benefit from the LMC in terms of guidance and policy decisions. • The court should capitalize on the diversity of membership of the LMC by utilizing committee members as “ambassadors” for the drug court program within their respective service agencies, and determining ways to maximize the information-sharing potential of this group of stakeholders. • Continue to provide support and structure (e.g., set timelines and expectations) regarding Treatment Providers’ efforts to obtain certification in order for the program to be in compliance with 2005 Guidelines for NC Drug Treatment Courts.

Team MembersTeam Functioning Strengths • Team members are very committed and dedicated to the drug court model and the needs of participants. • Most of the team members reported that team relationships are “ good” to “pretty good.” • Team members reported that needed information is generally communicated in a timely and efficient manner. • The DCADTC team utilizes a consensus-based decision-making process in which all team members are given equal opportunities to provide input into decisions. • Elements of work, family, environmental stressors, and treatment are integrated and discussed with input from team members who are present in making decisions about participants. • Participants described team members as helpful, dedicated, respectful, concerned, and professional. Barriers • There is not sufficient time to discuss issues that pertain to the program as a whole that arise during pre-court staffing meetings. • Although, in general, team relations were described in positive terms, most team members also mentioned “personality conflicts” and occasions in which individuals with “strong personalities get their way” in decision-making about participant cases. • Much less time is spent processing factors that contribute to successful progress, in comparison with the amount of time spent processing non-compliant or “problematic” participant cases. • Occasionally, during the observed team meetings, the discussion became very loud and animated, making it difficult to hear due to multiple ongoing conversations. • One team member stated that, occasionally, boundaries between participants and team members are inappropriate.

Team MembersTeam FunctioningRecommendations: • Suggestions for making team meetings more efficient are: • Discuss the possibility of increasing the length of pre-court meetings to allow for sufficient time to discuss program-wide issues or questions. • Consider holding a separate monthly or bi-monthly meeting to discuss general issues that impact the functioning of the court, and to analyze factors that contribute to program completion. • Monitor and address instances in which multiple conversations take place at the same time, to help ensure that all team members have the same information about participant cases. • The team might wish to consider discussing whether it is necessary to attend a short workshop on conflict management within the workplace in order to address team members’ concerns about “personality conflicts” and “strong personalities.” • The team should monitor and document cases in which the resolution of participant cases is heavily influenced by “strong personalities.” • The team should establish a consensus regarding appropriate professional boundaries between participants and team members, document instances in which these boundaries are violated, and establish a protocol for addressing boundary violations.

Case Management & Judicial SupervisionCompliance with DTC Requirements

Case Management & Judicial SupervisionDrug Test Results

Case Management & Judicial Supervision Barriers • One terminated participant raised concerns regarding the accuracy of drug test results. • The team has occasionally had questionable drug test results for tests that were not administered by a member of the core drug court team. • The absence of the Law Enforcement liaison results in slower processing of Orders for Arrest, allowing non-compliant participants to remain outside of the program and treatment services for longer periods of time. • One-third of the current participants interviewed felt that interruptions to the court schedule (e.g., due to holidays or events) can be stressful and trigger relapse due to the disruption in schedule and lack of accountability. Strengths • The Case Manager and the Probation Officer meet regularly with participants to monitor participants’ status and offer case management and support. • Most team members identified the structure and accountability that emerge from case management and judicial supervision as the most important aspects of the program. • The Judge uses the court session as an opportunity to educate participants about the benefits of compliance and the consequences of noncompliance. • Drug testing is administered regularly and randomly to provide accountability and monitor abstinence. • Participants reported that the random testing that is accomplished through use of the “color” system is an effective deterrent to drug use. • All participants, including terminated participants, reported positively on the value of the court sessions and on the effectiveness of the Judge.

Case Management & Judicial SupervisionRecommendations: • The Team might consider periodically auditing the the accuracy rate of the laboratory used to analyze drug tests. • The team may also wish to consider developing procedures for handling participants who challenge drug test results, and procedures for administering drug tests to DTC participants when no core team members are available. • The team should consider utilizing the Local Management Committee as a vehicle for advocating for the return of the Law Enforcement liaison with Durham Police Department, and the Durham County Sheriff’s Department, if appropriate. • Review the annual calendar of court sessions and determine whether it is possible to minimize interruptions to the bi-weekly court sessions, and consider ways to increase accountability during times in which there is a break in the normal routine.

III. Consumer SatisfactionConsumer Satisfaction Questionnaire Description of the Sample A total of 10 current participants completed a Consumer Satisfaction Survey regarding their experience with the DCADTC. • There were three female participants and seven males. • Their ages ranged between 25 and 55 years with the average being 41. • 60% of the participants reported their race as African American (6 participants), while three were White and one reported “Other.” • Seven participants reported their living status as “living independently,” while three reported that they resided in community housing. • Two participants reported that they were unemployed, while the others either had a full-time (5 participants), or part-time (2 participants) job. • Nine participants had completed high school or obtained a GED; one reported not having completed high school. • The most common primary drugs of choice were crack (3 participants), alcohol (three participants) and heroin (three participants). One participant reported marijuana as the primary drug of choice. • Half of the participants reported that they had received substance abuse treatment in the past, and seven of the participants reported having a criminal history before entering the DCADTC. • On average, the length of time spent in the drug court was 8.9 months.

Consumer Satisfaction Questionnaire Client Reports of Level of Satisfaction with Program Components Response Scale: 1=Very Unsatisfied, 2=Unsatisfied, 3=Satisfied, 4=Very Satisfied

Consumer Satisfaction Questionnaire Client Reports of Level of Satisfaction with Program Components Summary of Results • The mean rating of participant satisfaction with various program components was 3.47. Thus, overall, participants were “satisfied” to “very satisfied” with the program components assessed. • Based on the mean values, participants were least satisfied with vocational treatment services, mental health treatment services, and drug testing; however, mean ratings of satisfaction with these program components correspond to a value of “satisfied.” • Lower ratings for drug testing and vocational treatment services may correspond to comments made about the inaccuracy of drug tests and the inadequacy of vocational treatment services. • The participants were most satisfied, on average, with their interactions with the Judge and the drug court program overall.

Consumer Satisfaction Questionnaire: Client Reports of Level of Difficulty in Fulfilling Program Requirements. Response Scale: 1=Very Easy, 2=Easy, 3=Somewhat Hard, 4=Difficult, 5=Very Difficult

Consumer Satisfaction Questionnaire: Client Reports of Level of Difficulty in Fulfilling Program Requirements (Continued). Response Scale: 1=Very Easy, 2=Easy, 3=Somewhat Hard, 4=Difficult, 5=Very Difficult

Consumer Satisfaction Questionnaire Client Reports of Level of Difficulty in Fulfilling Program Requirements. Summary of Results • On average, participants reported that all but four of these requirements were “very easy” to “easy” to complete. • The remaining four items were rated as “easy” to “somewhat hard” to complete. • Mean scores indicated that the most difficult requirements, on average, were paying fines, paying court fees, staying away from bad influences, and staying clean and sober. These responses are reflective of active participants’ descriptions of barriers to full program participation. • The easiest requirements to complete, on average, were cooperating with substance abuse treatment services, attending other services, and attending meetings with the Probation Officer and with the Case Manager. • These results are somewhat incongruent with active and former participants’ responses that described the most difficult aspects of the program to be the requirement to attend “so many different meetings at so many different times.”

Summary of Challenges Reported by ParticipantsFindings from Interviews and Focus Groups • Difficulties in fulfilling program requirements while maintaining full-time employment and taking care of children was cited as a barrier by two participants. • A few participants stated that, initially, the high number of program requirements can be overwhelming to the point of discouragement. • Paying drug court fees and probation fees was identified as a barrier by one group of active participants. • One terminated participant who was agorophobic was not able to comply with any program requirements due to her fear of crowds.

Life Improvements Attributed to the ProgramFindings from Interviews and Focus Groups Current participants and successful graduates reported many positive changes in their lives that resulted from their participation in the DCADTC program. These include: • Improved relationships with spouses, family, and children • Ability to recognize relapse triggers • Reduced or stopped using drugs and alcohol • Refrained from criminal behavior • Improved health • Improved financial stability and employability • Learned responsibility and honesty • Learned good “day-to-day” skills • Pursued further education • Increased self-confidence • Able to help others who are struggling with the disease of addition • More positive attitude and outlook on life Terminated participants did not identify any positive life changes that could be attributed to the drug court program.

Suggestions for Improving the DTCFindings from Interviews and Focus Groups Current and former participants shared their suggestions for improving the drug court program. These include: • Participants should have more choices regarding their treatment services. • Increase court sessions to once per week. • Allow a panel of peers to decide the penalties for non-compliance when a fellow participant relapses. • “More people from the State should come observe the court sessions to see what really goes on and how the program is changing lives.” • Four participants stated that no changes are needed to the program: “It’s just fine the way it is.”

Durham County Adult Drug Treatment Court (DCADTC)