Serving Two Masters: Working with Clients in the Criminal Justice System

By Joe McGuffin 02/11/16

Should drug courts, judges and probation offices be making decisions about substance use treatment? 

Serving Two Masters: Working with Clients in the Criminal Justice System

Patients who are required to attend substance use programs because of legal problems often encounter a frustrating lack of choice in the type of treatment provided. Often, judges, drug courts and parole officers, as opposed to trained medical professionals, are responsible for making important decisions about treatment and medication. This can lead to a scenario in which the treatment rendered is in keeping with the philosophy of the person who is mandating it but not necessarily an appropriate fit for the individual patient. It remains unclear if drug courts have made things more or less punitive towards those charged with drug offenses. This author works in a program that interfaces with the criminal justice system, giving him a clear picture of some important issues worth exploring. Do you have an opinion about the issues raised by this article? Please post your comments after the piece…Richard Juman, PsyD

Sam came into my office after testing positive for opiates for the third time in a week. He explained to me that he just could not seem to get past the seventh day of withdrawal. He could not sleep and the cravings got the best of him. He always went back to using. The levels measured in his urine were low, and he was not intoxicated to the point of nodding out; Sam was just maintaining, just enough to keep himself from withdrawing. His girlfriend was receiving methadone-assisted therapy, Sam said, and he wanted to try that. 

Sam’s probation officer, however, had other ideas. When Sam told him he wanted to change treatment centers and avail himself of medication-assisted therapy, he wrote in his report that Sam was “treatment shopping.” He instructed him to abide by my agency’s recommendations, which were for him to go to inpatient for at least 28 days. Sam worked as a maintenance person for his apartment complex, and his family’s apartment was tied to his job. If he went to rehab, his girlfriend and her two children would lose their home. Sam signed himself out of treatment at my agency, and went to the methadone clinic. What would his probation officer do? Neither one of us was sure, but it seemed like a pretty safe bet that he would have him arrested for violating his probation. Before he left my office, Sam said that he felt like his rights were being violated. All I could do was look down at my desk and ask him to sign his discharge papers. 

Because my agency follows an abstinence-based philosophy, I cannot recommend medication-assisted therapy to my clients, let alone make referrals; and because my agency is contracted with the local judicial system, their probation and treatment court clients have limited choices about where they receive treatment. Adherence to our recommendations is mandated under pain of incarceration. Most of the clients do not have insurance, so our county has funding specifically earmarked for substance use treatment, and many clients use public assistance funding. The traditional atmosphere, therefore, has not been one of choice. Treatment preference has been viewed as a luxury, like swimming pools and weight rooms, which only the well-heeled and self-motivated can afford. This beggars-can’t-be-choosers mentality is combined with the punitive idea that these clients are not entitled to their preferences because they have broken the law. In cases like Sam’s, the prevailing, jaded view is often that he brought this on himself and his family.

As the War on Drugs winds down and our policymakers grapple with the rising epidemic of opiate addiction in our country, we are shifting from the punitive approach to a more treatment-oriented approach. Coincidentally, our treatment methods are evolving as well. Client-centered modalities, such as motivational interviewing, stress a collaborative relationship with the client, rather than a top-down, expert-patient relationship. The proliferation of drug courts and the traditional, abstinence-based views of many in law enforcement (and managed care agencies) have resulted in a significant portion of the treatment community remaining mired in drug-war era models, in which the client is subject to the whims of the court.

The draconian atmosphere of the judicial system often creeps into agencies such as mine who serve a large population of court-mandated clients, counteracting the progressive trends of our field and perpetuating the idea that clients don’t know what is good for them. In other areas of human service, choice is an element of dignity as well as a predictor of intrinsic motivation. It is one thing not to honor a client’s preferences, and another to allow clinical recommendations to be trumped by bureaucracy.

Another individual I met with, who I will call Tyler, was an introverted and intellectual young man who suffered from anxiety and depression. He had been raised by his grandparents in the country, and was very reserved and soft-spoken. Tyler had been sent to inpatient treatment before, and was so overwhelmed by the rigorous, confrontational atmosphere that he attempted to hang himself. He was having trouble remaining abstinent in our program, and had vague suicidal ideation.

Because Tyler was participating in drug court, inpatient treatment was the only option. Because our agency contracts with the county, many court-mandated clients are sent to our multiple therapeutic communities; with no consideration of whether the programming is clinically appropriate for them. Since Tyler was utilizing the county’s funding, neither he nor I had a choice about where he went. The decision was totally random, based on the “first bed” available. (Of course, our agency tends to refer within its network of programs.) I told my supervisor that I thought a therapeutic community would be the wrong setting for Tyler. She agreed; but when the bed at the TC came open, Tyler had to take it. He lasted about 10 days before he threatened suicide and was committed to the hospital. 

Another feature of many drug courts is that they will dictate the nature of a client’s medical care, especially in the case of prescribing doctors. One client, who I will call Frank, was diagnosed with ADHD, and his prescribing doctor had given him Adderall. He had a good rapport with this doctor and had been working with her for several years. Drug court, however, insisted that he obtain his prescriptions from the psychiatrist at our agency, which caused a considerable amount of anxiety for Frank. In situations like this, clients are frequently concerned that a court-appointed provider will be forced to prescribe within a limited formulary of drug court-approved medications.

In 2014, in Long Island, New York, Robert Lepolszki was forced off of his methadone treatment regimen as a condition of entering a drug court program. Within six months, Lepolszki was dead of a heroin overdose. In September of last year, the state of New York passed a law preventing judges from practicing medicine from the bench, giving people in recovery the right to choose physician-prescribed medications as part of their treatment.

This legislation was guided largely by the latest policy from the White House Office of National Drug Control Policy, in which medication-assisted treatment is established as the new standard of care for opiate addiction. The Substance Abuse and Mental Health Services Administration has further announced that it will deny federal funding to drug courts that do not allow for MAT, and that they are working to expand access to FDA-approved medications nationwide. This trend represents a change in thinking, from viewing substance use disorders as a legal problem to treating them as a public health issue.

Still, across the country, there are many judges, parole and probation officers who are resistant to this new treatment standard, influenced by the old, misguided stigma attached to methadone maintenance therapy; and there are many abstinence-oriented agencies that are happy to oblige them. The reluctance of many to transition away from the 12-step model, which is incompatible with MAT, seems to be a massive hurdle; even as some of the larger agencies are beginning to embrace the use of medication in order to keep the channels of funding open. In many cases, there will be misguided attempts to fuse the new treatment modality with the old dogma, delivering services once again on the agency’s terms.

Where does that leave our clients? If you look at the mission statements of service agencies, they invariably use language which implies a client-centered, evidence-based approach. Everyone likes to say that they “meet the client where they are.” There is often a Client Bill of Rights, which contains all manner of blandishments to put the client at ease as they sign a sheaf of consent forms. Do they really have the right to their treatment preferences, or is this a mirage, like the swimming pool advertised by the last treatment center I attended? Are they the customers, or the commodity? Faces and Voices of Recovery has a Recovery Bill of Rights which, in my view, should be the standard.

A few weeks after Sam signed himself out of treatment at my agency, and after watching the prison rosters for his name, I emailed Sam’s probation officer to ask him whatever became of Sam. He wrote back and informed me that Sam had been allowed to seek treatment at the methadone clinic. I have to say that I was pleasantly surprised, and I give the probation officer full credit for making a very humane, non-traditional decision with this case. Individuals making these ground-level decisions are encouraging; but our systems of care need to change so that true client-centered, evidence-based treatment does not require renegade action on the part of professionals.

For clinicians like me, who must serve two masters, the line between client rights and agency alliance is fuzzy at best. As I begin my work as a graduate student of social work, I am beginning to examine the systems that serve disadvantaged people and how policy changes come to fruition. I am learning about goal displacement. I am learning how individual rights are affected by systemic oppression; how to use my voice to advocate while finding my place in the system. I don’t know the answer to these dilemmas; all I know is that our clients deserve better.

The author is a substance use counselor.

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