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I am very honored to be here, and particularly to be asked to address the challenging topic of the relationship between research and policy in the area of criminal justice and drug treatment.
Coming to this conference in Los Angeles, I reflected on the conference that many of us attended in April, 1997, in New Orleans on a similar topic. I distinctly recall that there was a feeling at that conference of new beginnings -- of exciting new challenges -- of new partnerships. I recall that for many people, it was the first time that they had been engaged in a sustained conversation with their colleagues in their own states about the relationship between the corrections professions and the treatment professions. In fact, some correctional administrators met their state's substance abuse director for the first time in New Orleans. Much has happened since that conference, and many of the panels at this conference reflect the hard work that you have been doing to implement some of the program initiatives you discussed there.
It is particularly gratifying to see that the invitation list for this conference has expanded to include many more policy makers -- legislators, representatives of governors' offices, budget directors, and other professions in the criminal justice system. The staff of the Corrections Program Office, particularly Steve Amos, should be congratulated for making this a reality. The inclusion of these new perspectives on the topics under discussion is particularly welcome, because these governmental officials are key to the success of the conference theme -- Enhancing Public Safety through Reducing Substance Abuse. These officials are essential to helping the corrections and treatment professionals develop public support and public funding for the initiatives that you are advocating.
I am also pleased to see that researchers and research are central figures in the discussions at this conference. Not too long ago, it would have been difficult to find a national conference on these topics where researchers and practitioners were engaged in a shared pursuit of useful knowledge. Today, that is no longer the case, and I am very proud of the role that NIJ has played in bridging the gap between these two communities.
My task this morning is to begin a discussion of the relationship between research and policy on the topic of substance abuse and criminal justice policy. In preparing these remarks, I have in mind the legislators, budget officers, judges and other state policy makers -- the people who asked the most penetrating questions at yesterday's panel presentation. You are a very important set of stakeholders in this national discussion, because in thinking about the difficult process of translating research findings into policy, we need to recognize that you must weigh many competing demands on the public dollar and on the public authority of government.
I recognize at the outset that my talk with you this morning is followed by a truly remarkable lineup of heavy hitter researchers. In the spirit of the season, we could call them a World Series class team -- at first base we have Feucht from the National Institute of Justice, known for his long reach to snag tough throws from the infield; at third base is Simpson from Texas Christian University, a man with a strong arm who can throw well even when off balance; Lipton, Wexler and Jainchill from National Development and Research Institutes are our outfielders who can cover lots of ground quickly; Dembo from the University of South Florida is our steady and reliable catcher; Anglin and Jaycox from the UCLA Drug Abuse Research Center round out the infield at shortstop and second base and have demonstrated ability to move equally well to the right or the left. And Mario Paparozzi is our pitcher for all seasons.
I feel a little bit like the unfortunate batters who were in the batting lineup right before Mark McGwire and Sammy Sosa as they chased the new home run record. The people who follow me are the true stars on the research team and you are fortunate that you have this rare opportunity to interact with them on issues of interest to you.
As a New Yorker who is currently a guest in the state of California, with the Yankees leading two to nothing, I will resist making any other baseball references.
This morning I would like to accomplish two tasks. First, I want to outline the four compelling policy propositions that I believe form the basis for development of a new relationship between criminal justice policy and drug treatment policy at the state and local level. Each of these propositions reflects our current state of knowledge, the state of our research findings, and attempts to translate those research findings into broad policy statements. However, because the translation from research to policy is always imperfect, and because the state of knowledge is imperfect, I also want to recognize that these sound bite statements mask a number of caveats -- important cautionary notes that one should keep in mind while engaged in policy debate on these issues. I expect these caveats and nuances will be further developed by our research panel.
Second, I want to share some of my thoughts about the potential for these policy initiatives. Where do we hope to be in five or ten years? What are some of the unanswered policy questions? What is the possible reach of the discussions you are engaged in within your states and within your professions? How far can we hope to travel on a road that starts at the intersection of criminal justice policy and drug treatment policy?
The core notion behind this conference is that if we bring together two professions -- the corrections profession and the treatment profession -- in common purpose -- to reduce drug abuse among the offender population -- and thereby to reduce crime -- we can make a significant difference in our communities. This is a powerful notion -- and we are only now beginning to understand the full reach of this concept. But we must recognize that a consensus between these two professions -- and the researchers as well -- will not translate into policy without the active involvement of elected officials, budget officers, and chief executives. So, my hope for this conference is that we can move beyond consensus and begin to paint a fuller picture of how this concept can be translated into a reality.
I. The Four Propositions.
My first task -- stating the four fundamental, research-based propositions that should govern policy -- was made considerably easier by Judge Richard Geblein of Delaware at yesterday's session. With some editorial license, I want to restate the observations that he made. According to Judge Geblein, we know four things. Let's call them Geblein's Guidelines.
First, we know that treatment works.
Second, we know that coerced treatment works.
Third, we know that length of time in treatment is correlated with successful treatment.
Fourth, we know that treatment under post-release supervision is essential to successful treatment in prison.
After Judge Geblein made these assertions yesterday, someone in the audience said, "Good, now we can go home." It's not quite that easy -- these statements need some amplification, some modification, and lots of cautions about the things we still do not know. More importantly, these statements, by themselves, do not translate into a policy for integrating treatment into the criminal justice system.
Let's pay some brief attention to the cautionary notes.
1. How far can we run with the statement that "treatment works?" First, we must acknowledge that treatment is not a vaccine. "Works" is a relative term. We are talking about risk management, about reducing the possibility of relapse in the face of powerful forces, both societal and biological, that mitigate against treatment success. We must also acknowledge that not all treatment works equally well -- and that the world of "treatment" is a multi-splendored thing. As yesterday's panel made clear, there is a world of difference between a twelve-step program and a therapeutic community. As I am sure this morning's panel will demonstrate, research is just now starting to differentiate the levels of success for different treatment modalities for different profiles of drug users. As we become more sophisticated in our ability to match treatment programs to drug users, and can differentiate treatment settings that are appropriate for juveniles, for poly-drug users, for the mentally impaired, for different cultural and ethnic groups, we will have a much better understanding of what kind of treatment works for whom.
Then, as this knowledge base becomes firmer over time, we will need to invent a new role in our midst, an honest treatment broker whom we have authorized to allocate scarce treatment resources according to the best match between participant and provider based on scientific evidence of effectiveness and solid diagnostic profiles of clients. We are a long way from knowing how best to conceptualize this important role in our society, much less from developing the institutional capacity to perform this function. But this role is essential if we are to move from the current Tower of Babel where dozens of treatment providers clamor for public support into a world where this valuable resource is allocated rationally.
Finally, we have to be clear that in advocating treatment, we are talking about something other than prevention, a particularly important caution when we are talking about interventions for adolescents. Primary prevention is a much more diffuse set of activities, geared toward a more diffuse set of risky behaviors, that is directed at a much broader population. There is also scientific evidence of what works in the area of prevention -- but that literature should not be imported wholesale into our discussion of treatment for the deeply drug involved populations we are discussing at this conference.
2. What does it mean that coerced treatment works? Don' t people need to decide that they want to get better? Doesn't success require an incredible act of will over a sustained period of time? Of course it is true that one cannot be made better involuntarily. We have not found the implant that will reverse a life course that resulted in addiction. There is an important scientific literature that has developed over the past few years on the effects of drug abuse on the brain that suggests we need to understand addiction as a brain disease -- a brain disease for which the social contexts in which it developed and is expressed are critically important. [I strongly urge you to read the lead article in the upcoming issue of the NIJ Journal by Dr. Alan Leshner, Director of the National Institute of Drug Abuse, on this emerging scientific understanding of addiction.]1 In this sense, the "treatment" of the brain disease of addiction requires management of behavior. The management of behavior, in turn, is often facilitated by external supports, which one could term, very loosely, "coercion." What we have discovered is that the criminal justice system can provide those external supports for behavior management highly effectively. This is the genius of drug courts -- the best drug court judges are able to apply rewards and sanctions, "carrots and sticks" that, when combined with treatment, can reduce drug use.
We should note quickly, however, that "coercion" is a broad term. It may be the coercion of losing a job or losing a relationship with a loved one that matters most. It may be that the coercion of a near death experience is the motivating experience for an individual. The policy challenge to the criminal justice system, which has in its arsenal the most coercive powers we authorize as a society, is to deploy those powers in a parsimonious, fair, and outcome-producing manner. The ultimate goal of criminal justice intervention in this context should be to strengthen, in the life of the offender, the naturally occurring coercive powers of family, work, positive peer pressures, neighbors -- what we call informal social controls.
3. So, if time in treatment is correlated with treatment success, what are the implications for criminal justice policy? Joe McNamara raised the specter yesterday of a society that, in its effort to be benevolent, exercises too much control over individuals. Clearly this is a real fear. It is rooted in our history when we declared under the Rockefeller laws thirty years ago that addicts could be sentenced to residential treatment for periods of incarceration much longer than the underlying crime would warrant. It is a fear rooted in our more recent history when the Supreme Court declared constitutional a statute that allowed mentally ill prisoners to be sentenced to mental institutions for potentially indefinite periods following a diagnosis of mental illness. But are we close to a regime in which those horrors are a reality? I think not. Here I think the research literature is in fact quite instructive. According to that literature, drug use for individuals who participated in either long-term residential or outpatient treatment programs showed reductions in criminal activity and drug use, especially for those who have been in treatment for at least 90 days.2 This research also shows that the presence of criminal justice supervision increased the likelihood that the individual would stay beyond the 90 day mark. So, we need to tailor our criminal justice supervision to these insights -- to work hard to keep offenders in treatment for at least that period, but also to accept the risks associated with terminating criminal justice supervision of the treatment when it is no longer warranted. And we need to ensure, borrowing a page from drug courts, that we don not overreact to the first sign of relapse. Relapse is the inevitable event in the life course of treatment for this population. Revocation of liberty for the first dirty urine is a waste of a valuable prison cell.
4. Finally, how should we interpret the statement that post-release supervision is an essential ingredient to prison-based treatment? First, we should stress that this is not a minor policy issue. Look at the research in this area. According to Jim Inciardi's evaluation of Delaware's Key-Crest program, those prisoners who participated in the transitional work release program after in-prison drug treatment were more than TWICE as likely to remain drug free and were ONE-THIRD more likely to remain arrest free eighteen months after release.3 These findings come at a time, as Mark Kleiman reminded us, when we are abolishing or curtailing parole, when the traditional parole function is severely under-funded, when the idea of half-way houses is seen as an unacceptable punishment policy. If we want to find a way to decrease the public risk posed by the offenders we are releasing to the community, we will increase, not decrease, the level of post-release supervision.
II. The Policy Implications of the Research Findings.
I would like to shift gears now and ask you to consider the policy implications of these four propositions. What would we do differently if we took these propositions seriously? What if we put these ideas into practice on a grand scale?
It may sound fanciful to think about this possibility. After all, it was not that long ago that much of correctional policy was plagued by the research consensus -- and political consensus -- that "nothing works." It is certainly still the case that government at all levels resists the idea of allocating additional treatment resources to drug-involved offenders. Too much of our criminal justice policy is still dominated by the sentiment that the most effective response to crime is to incarcerate more people. So, there are reasons to be pessimistic. But, if we believe that these core propositions are based in solid research and reflect good common sense, why not think that they might take hold? After all, we live in an era when seemingly intractable problems are showing encouraging signs of reversal. Who would have thought five years ago that welfare caseloads would be plummeting? That crime rates would be at their lowest levels in a quarter century? That teenage pregnancy rates and AIDS caseloads would be dropping? That the policing profession would be undergoing a fundamental transformation toward a new concept of community policing? Why not ask ourselves where we want to be in five years?
The question we should be asking ourselves, in my view, is whether we believe that the policies we are pursuing at this conference hold the promise of bringing about a significant reduction in drug use in our communities. I think the answer is yes, but only if we develop and implement a systematic, community-based strategy, informed by good data and solid research, that holds all of us accountable for the shared goal of reducing drug use and enhancing safety -- the theme of this conference.
At yesterday's panel, there was a fascinating discussion about the difficulty of integrating a treatment perspective into the criminal justice system. Ron Agelone asked penetrating questions about the justification for providing treatment to an offender while the victim has not been made whole through restitution or counseling for emotional distress. Mark Kleiman asked how we could justify drug abuse treatment when alcohol abuse remains unaddressed. Steve Belenko pointed out that offenders come into our criminal justice system with lots of problems -- illiteracy or mental illness -- or pose public health risks because they are infected with TB or HIV. How can we justify drug treatment when these needs are unmet?
These are compelling questions, and cannot lightly be brushed aside. I for one believe that the criminal justice system should be viewed as a propitious opportunity to intervene to reduce many of these harmful behaviors, particularly the public health risks, and that we need to adjust the overall relationship between the public health, mental health, and educational professions to bring these disciplines into closer working relationships with the agencies of the criminal justice system. And I believe that many of these services can be supported without significant additional costs because existing health and education systems can be brought into closer collaboration with the criminal justice system. A story from personal experience: when we established the Midtown Community Court in Manhattan, we offered space in the courthouse to all of these agencies who collocated there without additional funding because the criminal justice population was one they were established to service.
Having said that, however, I think a particularly compelling argument can be made for a fundamental realignment of our thinking that would integrate into all of our criminal justice decision -- making processes a societal goal to use the coercive powers of that system to reduce the level of drug use, and the attendant criminal behavior, of people charged with and convicted of crimes.
What is the basis for such a radical proposition?
First, we should recognize the strong nexus between drug use and the criminal justice population. As Thom Feucht will detail in his presentation, research conducted at NIJ under the Arrestee Drug Abuse Monitoring (ADAM) program shows consistently that between one half and three quarters of all arrestees we test in 35 cities around the country have drugs in their system at the time of arrest.5 We should not jump to the conclusion that if drugs were eliminated from the face of the earth, all of these folks would be law abiding citizens -- but for a significant portion, their drug use and their criminal behavior are closely linked.
We also know that this population is not under treatment supervision when they come in the front door of the courthouse. Only a quarter of drug users in prison were previously in treatment. According to one estimate, the number of drug-using arrestees who in need of treatment exceeds two million a year. We also know that periods of incarceration alone do not change the drug use behavior -- between 60 and 75 percent of untreated parolees who have histories of cocaine and/or heroin use are reported to return to those drugs within three months after release.6 If they are untreated ....
Finally, we know that these frequent drug users who are involved in the criminal justice system are responsible for consuming a significant portion of the illegal drugs consumed in this country. According to one estimate, about 60% of the cocaine and heroin consumed by the entire nation over a year is consumed by individuals arrested in that year -- SIXTY percent.7 Mark Kleiman estimated yesterday that the heroin and cocaine markets in the country would shrink by 40% if his proposal for coerced abstinence for probationers and parolees were adopted. Maybe he got a bit enthusiastic, but the potential for large effects is there precisely because the nation's consumers are walking into our courtrooms. Willie Sutton robbed banks because that was where the money was; we should reduce drug consumption by targeting the criminal justice population because that is where the heavy consumers are.
For me, these statistics add up to a compelling policy proposition -- one that approaches a moral imperative: if large numbers of our fellow citizens come under the supervisory powers of the criminal justice system exhibiting behaviors that are highly toxic in terms of the harmful effects upon themselves, their families, their communities and the larger society -- and we know that we have available relatively low cost, highly cost-effective interventions that will significantly reduce the levels of crime and other social harms, and these interventions can reduce aggregate demand for drugs -- how can we justify policies that do not make that investment?
This question becomes even more difficult to contemplate when we consider that, over the past twenty-five years, we have indeed made a massive investment in a new criminal justice policy -- we have increased, four-fold, the rate at which we incarcerate people, at a staggering fiscal and human and societal cost. So, we have demonstrated that we can sustain a new investment strategy in this country. Ironically, however, given what we now know about the high likelihood that these prisoners will relapse back into drug abusing behavior and the associated recidivism after their release, this investment strategy has simply deferred the moment when drug abusing individuals are released back into our communities to start harming themselves and the larger society again. And the final irony -- or tragedy -- is that we have lessened the degree of supervision we place over them once they are released thereby increasing the level of crime. So our challenge is quite formidable -- something akin to walking down the up escalator that is moving in the direction of more expenditures on imprisonment. Yet I think we can paint a compelling picture of a different way of getting to our destination -- less drug use and greater public safety.
Let me take a moment to sketch out a picture of how we might organize ourselves differently to align our policies with our knowledge to reach that destination. Most importantly, we would set a new goal for the criminal justice system -- reducing drug abuse among offenders under supervision in order to enhance public safety. And we would hold the entire system accountable for reaching this goal. This is a difficult concept for us to grasp. I remember sitting in the Executive Staff meeting of the New York City Police Department when the new Commissioner, Bill Bratton, told us that our goal was to reduce crime by 10 percent in the first year, and 15 percent the next. There was stunned silence in the room, but ultimately that organization took that goal seriously and the City has been transformed.
How would we move toward this goal? First, we would require that everyone arrested gets tested for drug use. Those determined to have drug abuse problems would be placed in appropriate treatment by the court -- whether they were on pretrial release or in jail, in prison post-conviction or under community supervision. All components of the system would be geared to accomplishing the goal of reducing drug use and increasing safety. At every court appearance, an offender's progress toward this goal would be reported to the courts -- both treatment progress and, that moment of truth, urine test results.
As Mark Kleiman suggested yesterday, we would require that probationers and parolees be tested frequently. I would add to his proposal the idea that all defendants on pretrial release should be required to adhere to the same condition of a drug free reentry into the community. Appropriate treatment would be made available to them, and this treatment system would be managed by the honest treatment broker I described a moment ago. For those who relapse, effective, graduated sanctions, much like those being developed in drug courts, would be administered swiftly, predictably, and parsimoniously. Jails would be required to provide treatment readiness programs for short-term detainees and would be required to link released defendants with community based supervision. Prisons would be required to provide therapeutic communities in prison -- or other treatment modalities if they are better -- for everyone scheduled for release in the next year or two.
The process of successful release would be carefully supervised, starting with furloughs, moving to half-way houses, and out-patient treatment to help the offender manage his new contact with the social and street conditions that could trigger relapse. In all conditions, the agencies of the criminal justice system would work with families, employers, and social networks to help them identify the early signs of relapse and to make them private partners in the success of this initiative. Graduation ceremonies, modeled on the drug court programs, would be held for those who successfully completed their reentry into society. We should celebrate successes, not just highlight failure by bringing only parole and probation violators back into court. Community policing officers should be involved in overseeing the conditions of probation and parole -- much like they have done with such great success in Boston where juvenile handgun violence has been virtually eliminated by using the authority of judicial, probation and police officials to keep high risk kids from engaging in antisocial behavior.
Here's a truly radical notion -- we should create a new cadre of judges who are responsible for reentry management -- for overseeing the mix of coercion and treatment that seems to be working so well in drug courts. Why not place the issue of reentry into the open forum of a courtroom? Why not take it from the hidden reaches of probation and parole offices and bring it into public view? Why not use the authority that judges command to marshal the forces of government agencies and private citizens to make sure that those who have broken the laws of the state are brought back into a more productive form of citizenship?
How would we measure progress toward our goal? We would implement ADAM or a similar system to measure levels of drug use (and other important crime and health measures) in the criminal justice population -- arrestees, pretrial defendants and those under community supervision. Treatment providers would be required to provide ongoing reports on their criminal justice clientele. Our goal would be to see actual reductions in drug use in that population. We would also implement measures of consumption to see whether the levels of use were declining and measures of addiction severity to determine whether the criminal justice population was less addicted to drugs over time. We would add measures of drug markets to see how the drug trade was shifting. These and other indicators, when put together with crime data, would constitute a new set of performance indicators for the criminal justice system that takes treatment seriously.
I can hear the reactions to this proposal. It will be too costly -- yes, but consider the benefits. According to the CALDATA study, every dollar invested in treatment produces a savings of seven dollars.8 It requires increased state control over the lives of individuals -- yes, but is it not the first obligation of government to provide for the safety of our communities? Maybe our concern about "widening the net" has reduced our ability to exercise appropriate control over criminal behavior. It will require that we change the relationship between the courts, the prosecutors and defense bar, the corrections system -- not to mention the treatment community -- yes, but a few bold jurisdictions could show us that this can be done, as happened with drug courts and with treatment for prisoners and parolees, and the rest will follow. As Laurie Robinson mentioned yesterday morning, the National Institute of Justice, with support from the Office of National Drug Control Policy, is funding five jurisdictions to implement a research demonstration program called Breaking the Cycle that represents an important first step in this approach to a system-wide effort to integrate treatment into an entire criminal or juvenile justice system. As Foster Cook can tell you from the Birmingham experience with Breaking the Cycle, implementing system wide reform is a difficult challenge, but these systems can begin to change.
These obstacles are certainly formidable ones. Probably the greatest obstacle is the difficulty of implementing system-wide reform in a system that doesn't work like a system. Yet, we should recall that we have seen fundamental shifts in our criminal justice policy in our lifetime -- from indeterminate sentencing to truth in sentencing, from rehabilitation models to retribution models. All of these have required changes throughout the criminal justice system. Certainly, then, we could begin the policy discussion over the next few years that will lead to another shift in our thinking, one that is based on solid research and promising innovation already underway.
You are the leaders in this policy discussion. You are already demonstrating that new policies can be tested. The seeds of change have been planted. A few years ago, it was not possible to talk about treatment of offenders -- now we talk about treatment as a crime reduction strategy. A few years ago, the phrase "drug courts" referred to courts that prosecuted drug cases more swiftly. Now, over 200 jurisdictions have drug courts based on a treatment model. A few years ago, it was accepted wisdom, by researchers, policy makers and public alike, that "nothing worked." Now we have a solid research base showing that treatment prevents crime.
So conventional wisdom can change in the face of good research and promising new ideas. The most daunting challenge we face is to keep our collective eyes on the big prize -- to push hard on the frontiers of policy -- and to do so without resorting to ideological posturing, but with reliance on solid research and inspiration from the promising innovations that are all around us.
In closing, I commend you for what you are doing -- and for showing the way. And I encourage you to stay the course.
- Leshner, Alan I. "Addiction Is a Brain Disease -- and It Matters." National Institute of Justice Journal. Issue 237. October 1998.
- "Findings from the Drug Abuse Treatment Outcome Study (DATOS)" presented April 7, 1997, Rockville, Maryland. National Institute on Drug Abuse.
- Lipton, Douglas S. "The Effectiveness of Treatment for Drug Abusers Under Criminal Justice Supervision." November 1995. National Institute of Justice: Research Report. U.S. Department of Justice, Office of Justice Programs, National Institute of Justice, Washington, DC.
- See "Arrestee Drug Abuse Monitoring Program 1997 Annual Report on Adult and Juvenile Arrestees" for data on 23 of the ADAM sites; preliminary (unpublished) data from 12 sites added to ADAM in 1996 reveal similar high levels of drug use among arrestees. National Institute of Justice: Research Report. U.S. Department of Justice, Office of Justice Programs, National Institute of Justice, Washington, DC.
- Lipton, Douglas, S. "The Effectiveness of Treatment for Drug Abusers Under Criminal Justice Supervision." November 1995.
- "1997 National Drug Control Strategy." Office of National Drug Control Policy, Executive Office of the President.
- Lipton, Douglas S. "The Effectiveness of Treatment for Drug Abusers Under Criminal Justice Supervision." November 1995.