Implementing Evidence-Based Treatment in a TASC Drug Court System

Drug Courts for families and juveniles have proliferated in recent years due to the success of adult drug courts and the increase in juvenile alcohol- and drug use-related crimes (Henggeler et al., 2006; Hiller et al., 2010; Ruiz, Stevens, Fuhriman, Bogart & Korchmaros, 2009). From 2005 through 2009, the federal government funded 35 sites to expand the capacity of existing family and juvenile treatment drug courts, specifically with an emphasis on expanding the access and availability of quality treatment for alcohol and substance use problems. One of the key guidelines for juvenile drug courts is an emphasis on developing a coordinated system of care and strong community partnerships to support youth and families involved in the courts (Binard & Prichard, 2008; Cooper, 2002; National Drug Court Institute, 2003). This article provides a case study that illustrates lessons learned in the implementation of Evidence-Based Treatments (EBTs) at community partners led by a Treatment Accountability for Safer Communities (TASC) case management unit that is part of a Juvenile Drug Court.

TASC organizations began in the early 1970s to help address the connection between substance use and criminal justice. Subsequently, the number of TASC programs grew through funding and technical assistance opportunities made available by several federal agencies. The National TASC organization describes the goal of the TASC model as “bridg[ing] referral and service systems through screening, assessment, case management, treatment and advocacy” (National TASC, 2009). Over time, local TASC programs have evolved in different ways in response to community needs and funding opportunities. Established in 1990, the Denver Juvenile and Family Justice Treatment Accountability for Safer Communities (DJFJ TASC) of the Denver Juvenile Probation Department has served as the central assessment, prevention and treatment planning, service referral, counseling and intensive case management component for justice-involved children, adolescents and families with substance use and co-occurring mental health issues living in the City and County of Denver and currently serves more than 600 DJFJTASC families per year. The mission of this TASC program is to address the unique and various needs of offenders by coordinating multiple services designed to be individualized, culturally responsive, strengths-based and developmentally appropriate.

Drug Court Coordinated System and Roles

The development of juvenile drug courts began in Denver in 1998 through a planning process that included community members, district attorneys, human service organizations, judicial officers, the police department, probation staff, public defenders and the TASC Director. The community also has been a Reclaiming Futures site since 2009; this model helps community partners improve the way they work with youth involved in the juvenile justice and substance use treatment systems (Reclaiming Futures, 2010). Currently, one magistrate and one judge hear drug court cases. The different roles that community members and professionals fulfill in the implementation of this drug court are described below.

Community Review Board Members (CRB). These individuals are community volunteers who serve on the review board. Every drug court client appears in front of the board monthly. The board reviews each client’s progress and determines whether or not the individual is ready to move to the next drug court phase. Every youth progresses through four phases contingent upon completing individually tailored assignments, staying in treatment, and testing negatively for substance use. Sample assignments might be writing an essay on goals for one’s future or performing volunteer work. The CRB also assists clients with locating appropriate community service projects.

Magistrates and Judge. The Drug Court Magistrate hears youth drug court cases twice a month and uses this opportunity to praise youths for progress they have made and orders sanctions, if necessary. Prior to hearing court cases, he is briefed on each case during a staff meeting with the TASC case manager, probation officer, and when necessary, social service agency staff with whom the youth is involved, as well as the youth’s attorney. The magistrate also attends monthly drug court steering committee meetings and quarterly Robert Wood Johnson Reclaiming Futures conference calls that provide learning opportunities relevant to juvenile drug courts and leadership in these types of courts.

Law Enforcement Advocates (LEA). These individuals are Denver Police Officers who work overtime duty in a mentor role with youth in their homes and communities, and in this capacity, help bridge the gap between the community and the police. Interactions with the LEA officers have been instrumental in helping youth and their families increase their positive perceptions of police. The LEA assist clients in obtaining jobs, and have a good success rate placing youth in jobs since employers are more likely to hire a juvenile if he or she is accompanied by a police officer. They provide youth and family advocacy and are available to families 24 hours a day, so they are available after the probation building closes at 5 p.m. This extended availability makes it possible for youth to access a supportive individual when they are faced with triggers to use or need help with family issues.

Partner Agencies. TASC contracts with several community treatment and mental health agencies. Since these agencies are not under the jurisdiction of the courts, they are in a position to provide treatment services and/or mental health evaluations. Clinicians at the partner agencies are targeted for training in EBTs for use with youth referrals from the drug court. Since the geographical area served by the drug court is large and there are a number of different agencies in the county serving different geographical regions, clinicians must be trained at multiple agencies.

Probation Officer. All drug court clients are on probation and probation officers monitor if youth are following the terms and conditions of their probation. Probation officers and TASC specialists are part of the same department and work closely together. The role of the probation officer is to monitor, supervise and/or provide investigatory work related to offenders ordered to probation in the Colorado Judicial Department. They will formulate case plans with the youth offender with the goal of establishing pro-social behavior and repairing the harm caused to the community and victim(s). They work to motivate the youth to complete probation requirements and manage the youth’s probation period using a continuum of sanctions and incentives. When appropriate, the probation officer recommends extension or termination of probation.

TASC Specialists. These individuals play a critical role in providing information to the court and linking youth and families to needed services. TASC specialists are certified addiction counselors who provide assessment, referral to treatment providers, educational interventions, outreach services and case management services to youth and families referred by the juvenile justice system. The Adolescent Community Reinforcement Approach (A-CRA) was chosen to be the intervention used across the board for all Drug Court clients. Based on the individual youth’s needs, additional interventions may be put in place at anytime throughout his/her drug court stay. TASC clinicians are trained to recognize mental health problems and can refer youth to a partner agency for an in-depth mental health evaluation and/or medication evaluation. It is important to note that TASC Specialists are in a non-adversarial  role, serving as advocates for clients’ treatment needs.

TASC EBT Clinical Supervisors. In the latest implementation of an EBT, the A-CRA, TASC has identified staff members to pursue certification as A-CRA clinical supervisors. This process helps ensure sustainability of the EBT at the four partner agencies implementing the model because the supervisor certification process includes training in how to supervise ongoing implementation and how to train and certify new A-CRA clinicians (See Godley et al., in press for a description of the training and certification process).

Impetus for Implementing Evidence-Based Treatment

Since the court relies on TASC to link youth to effective treatments to address their substance use, the TASC administrator became interested in implementing evidence-based screenings and assessments, as well as evidence-based treatments (EBT) to improve the screening and assessment services and the treatment services for youth at partner agencies. Although partner agencies felt their existing models were effective, there was no standardization across clinicians or agencies and no data supporting quality implementation or outcomes of the existing approaches. To fund implementation of an EBT, TASC applied for and won a SAMSHA Effective Adolescent Treatment grant in 2003, which provided funds to implement the Global Appraisal of Individual Needs (GAIN, Dennis, Titus, White, Uniscker & Hodgkins, 2003) for screening, assessment and follow-up, as well as the five-session Motivational Enhancement Therapy/ Cognitive Behavior Therapy (MET/ CBT5). The latter was one of five interventions evaluated in the Cannabis Youth Treatment study (Dennis et al., 2004; Sampl & Kadden, 2001). Besides providing funding for clinical positions, the SAMHSA grant also provided access to staff training and certification in the assessment and intervention at no cost to the site. The funding was for a three-year period, and after the funding ended, Denver TASC continued to offer MET/CBT5 until the decision was made to transition to A-CRA/ACC in 2009.

New funding opportunities became available in 2009. Denver TASC applied for and received two SAMSHA grants to implement A-CRA. This treatment is based on the theory that it is possible to help individuals change their environment to one that is reinforcing without the use of alcohol or other drugs. Clinicians are trained to help youth understand the role of environmental contingencies that contribute to their substance using behavior, so that youth learn to identify the positive and negative consequences of using, as well as external and internal triggers to use. They learn skills that help them avoid or address known triggers to reduce or eliminate their substance use. They also are helped to replace negative behaviors/coping strategies with positive, healthy coping strategies and behaviors.

There were several aspects of the model that were appealing to the TASC administrator. For example, A-CRA can be paired with case management and be offered in the home and community-based settings as an assertive model, which is similar to the TASC case management model. The underlying premise of A-CRA is that it helps youth identify possible rewards for non-using behaviors and incorporate positive lifestyle changes. This approach complements the TASC contingency management system. Youth also respond well to a treatment that lasts for a fixed time since they like to know that treatment will not go on forever and there are specific goals to obtain in order to complete their treatment. The breadth of A-CRA procedures was considered advantageous since the multiple procedures addressed skills in juveniles’ lives that usually need improvement (i.e., pro-social behavior, problem-solving skills, job-seeking skills, etc). One procedure results in mutually agreed upon client goals and timeframes that are attainable and changeable as youth achieve goals. Sessions with caregivers alone and with youth and caregivers together are outlined and involvement of family is one of the key components of TASC case management strategies. Another procedure, sobriety sampling, is a way to introduce abstinence for a specific timeframe and allow the clients to explore what it is like not to use, which fits well with the harm reduction approach taken by TASC. Finally, the Assertive Continuing Care (ACC) model (Godley, Godley, Dennis, Funk, & Passetti, 2007) builds on and extends A-CRA procedures by providing a needed structured aftercare component.

Lessons Learned about EBT Implementation

During the initial experience implementing MET/CBT5 across multiple partner agencies, we gained insights regarding the clinical assessment process, working with clinical staff, clinical supervision, planning for sustainability, and selecting appropriate clients to participate in drug court that informed decisions in the A-CRA/ACC implementation effort. These lessons are reviewed below.

Assessment. The use of the Global Appraisal of Individual Needs (GAIN; Dennis et al., 2003) was required by the federal funder for the intake assessment, and a related version of the measure was used for followup at three, six and 12 months after intake. This tool was an enhancement to the previous assessment approach. Previously, Denver Juvenile Probation had always used the Colorado Juvenile Risk Assessment (CJRA; Ludwig, n.d.). The latter is an instrument that is administered at the initial point of contact and includes 2 to 16 questions in 12 domains: criminal history, demographics, school history, use of free time, employment history, relationships, drug and alcohol history, mental health history, attitudes/ behaviors and aggression/skills. The CJRA is a valuable screening tool for: measuring a youth’s risk to the community and to self; developing the justice case plan; and ensuring that only those youth posing the most serious risk are detained. The CJRA does not provide sufficient information, however, to support clinical decision making related to diagnosis, treatment planning, placement and referral for additional assessment by other specialists (e.g., psychiatrist, TANF, school counselor), which the GAIN is specifically designed to address. The GAIN family of measures includes a follow-up version for re-assessment and follow-up interviews. This feature is important since individuals change and re-assessment becomes important for clinical and program evaluation reasons. The quality of the information available from the GAIN enhances the TASC clinicians’ ability to identify possible DSM diagnoses that need further assessment by the appropriate professionals.

Clinical Staff. In order to successfully implement an EBT, clinical staff must be willing to learn an intervention and deliver it in a way that is faithful to the model. Initially, clinical staff at the partner agencies were resistant to changing their practices, adhering to a set curriculum, recording their therapy sessions, and being evaluated based on their in-session performance. One of the positive developments we have noticed is that staff resistance to the implementation process diminishes over time with exposure to the intervention and the training process. Staff learn that participating in fidelity monitoring is a job expectation and when there is organization support, the process becomes ingrained in the organizational culture. Since TASC has federal grant funds that allow it to contract with community partner agencies, TASC has the ability to work closely with these agencies in the selection process of clinicians for the EBT implementation. During the interview process, clinician candidates learn about the training and certification processes and are questioned to help determine their readiness to accept a position with these requirements. Many clinicians see the training and certification process as a way to enhance their clinical skills, and appreciate that A-CRA is a flexible intervention that allows them to use their clinical expertise while choosing from a menu of procedures based on the strengths and issues that each individual youth and caregiver brings to a session (Godley et al., 2001).

Sustainability. When the federal government provides funding to organizations to implement an EBT, it does so with the hope that the EBT will be sustained after the federal grant funding ends. In the first implementation effort, TASC learned that staff turnover was high. Most of the clinical staff trained in the assessment and intervention left the partner organizations, and TASC did not have the ability to train new staff for sustainability. Staff turnover still occurs, but with the implementation of A-CRA, TASC also has implemented additional procedures to enhance sustainability. Before new clinicians are trained, they are asked to make a commitment to stay for the remainder of the grant period. To help plan for better monitoring of the implementation of A-CRA at the partner agencies and for sustainability after grant funding ends, select TASC staff have pursued A-CRA clinical supervision certification. Attaining this status means that staff can access session recordings (with permission from clinicians and TASC clients) and are able to rate these recordings for fidelity and provide feedback during regular supervision sessions to clinicians. Certified A-CRA supervisors can also train and certify additional clinicians in the model.

Client Selection Criteria. TASC also learned to work with the court to carefully screen clients for the program to ensure that the most appropriate candidates were being identified. This process ensures that clients’ presenting concern is substance abuse, and any violent offenders or sex offenders are excluded.

Recommendations for EBT implementation in a Drug Court/TASC System

• Before implementing an EBT, provide a rationale for the specific EBT and educate all judicial and community partners in the particulars of the EBT and what will be required to attain good implementation of the model.
• Choose partner organizations with a strong internal champion for implementing the chosen EBT.
• Since turnover in clinical staff trained in the chosen model will occur, determine how the model will be transferred and sustained with new staff.
• If supervisors can be certified to provide training and certification in the model for sustainability, give careful consideration to where supervisors are located (e.g., in the partner agency or at TASC or both).
• If clinicians are located at partner agencies that receive funds from the court to implement the intervention, consider contract contingencies to ensure that clinicians make expected progress towards certification deadlines and the processes required to meet deadlines (e.g., regularly recording sessions and submitting sessions for review during the certification and fidelity monitoring process).
• In choosing the EBT, consider the training and process related to assessing clinician competency, and attention to cooccurring problems and gender and cultural responsiveness.
• If an implementation project has access to a program evaluator, then involve the evaluator throughout the planning and implementation process. Use process and outcome data to monitor implementation progress to inform the decisions made by various partners and project management (e.g., by the Drug Court Steering Committee) to improve implementation and outcomes.

Due to the need to coordinate multiple interested parties and services, drug courts can be very complicated systems. Since treatment drug courts are designed to help youth change their lives not only through legal consequences, but also through treatment, it is critical that treatment be available and evidence-based. It is also important that the EBT(s) available in the community are supported with good training procedures that maximize its implementation across multiple treatment agencies, clinicians and supervisors in a drug court service area and that careful consideration is given to how the EBT and clinician fidelity to the model will be sustained.

Acknowledgements: Funding for these projects was provided by the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT), Office of Juvenile Justice and Delinquency Prevention, Bureau of Justice Assistance; the CSAT and SAMHSA juvenile drug court grant (1H79TI020921); the CSAT and SAMHSAAAFT 3 grant (1H79TI020910-01); and the SAMHSA Effective Adolescent Treatment Grant contract (5 H79 TI-15479). The lead authors would like to offer special thanks to Randolph Muck, Branch Chief of Target Populations, SAMHSA/ CSAT, for his ongoing support and patience as we went from struggling to succeeding; the Robert Wood Johnson Foundation, Reclaiming Futures National Program Office; the State Court Administrators’ Office for their support in our grant applications; Presiding Judge, Karen Ashby, for her support in our development of new and innovative projects; Chief Probation Officer Shawn Cohn for her innovative ideas, continued support, and encouragement to the TASC Project; Magistrate Bartlett, the juvenile drug court magistrate, for his willingness to quickly adopt our model and participate in every conference call, meeting, webinar, and conference; Lieutenant Steven Addison with the Denver Police Department for helping train, guide, and support the Law Enforcement Advocates and the Law Enforcement Advocate Program; our Community Review Board Members(Retired Division Chief Steve Cooper, Jan Wilson, Hanna Westen, Nick Citriglia, Juan Miller, Gary Stiefler, Kathy Cartra, and Ralph Larson ) for their countless hours of volunteer time to the program; Chestnut Health Systems for providing incredible training and technical assistance in the GAIN and A-CRA Model; and Dr. Bob Meyers and Dr. Jane Smith for providing ongoing technical assistance with the A-CRA/ACC model. We also thank Stephanie Merkle for editorial assistance. Please note that the opinions are those of the authors and do not reflect official positions of the contributing grantees/project directors or government.

References

Binard, J. & Prichard, M. (2008). Model policies for juvenile justice and substance abuse treatment: A report by Reclaiming Futures. Retrieved
from http://www.reclaimingfutures.org/sites/default/ files/documents/RF_Model_Policies.pdf.
Cooper, C. S. (2002). Juvenile drug treatment courts in the United States: Initial lessons learned and issues being addressed. Substance Use and Misuse, 37, 1689-1722.
Dennis, M. L., Godley, S. H., Diamond, G., Tims, F. M., Babor, T., Donaldson, J. & Funk, R. R. (2004). The Cannabis Youth Treatment (CYT) Study: Main findings from two randomized trials. Journal of Substance Abuse Treatment, 27, 197-213.
Dennis, M. L., Titus, J. C., White, M., Unsicker, J. & Hodgkins, D. (2003). Global Appraisal of Individual Needs (GAIN): Administration guide forthe GAIN and related measures. Bloomington, IL: Chestnut Health Systems.
Godley, M. D., Godley, S. H., Dennis, M. L., Funk, R. R. & Passetti, L. L. (2007). The effect of Assertive Continuing Care (ACC) on continuing
care linkage, adherence and abstinence following residential treatment for adolescents. Addiction, 102, 81-93.
Godley, S. H., Garner, B. R., Smith, J. E., Meyers, R. J. & Godley, M. D. (in press). A large-scale dissemination and implementation model for
evidence-based treatment and continuing care. Clinical Psychology: Science and Practice.
Godley, S. H., White, W. L., Diamond, G., Passetti, L. & Titus, J. (2001). Therapist reactions to manual-guided therapies for the treatment of
adolescent marijuana users. Clinical Psychology: Science and Practice, 8, 405-417.
Henggeler, S. W. & Halliday-Boykins, C. A., Cunningham, P. B., Randall, J., Shapiro, S. B., & Chapman, J. E. (2006). Juvenile drug court:
Enhancing outcomes by integrating evidence-based treatments. Journal of Consulting and Clinical Psychology, 74, 42-54.
Hiller, M. L., Malluche, D., Bryan, V., DuPont, M. L., Martin, B., Abensur, R. & Payne, C. (2010). A multisite description of juvenile drug
courts: Program models and during-program outcomes. International Journal of Offender Therapy and Comparative Criminology, 54, 213-235.
Ludwig, V. (n.d.). 17th Judicial Colorado Juvenile Risk Assessment procedures. Retrieved from
http://www.cdhs.state.co.us/dyc/PDFs/SB94_PP_17JD_CJRA.pdf.
National Drug Court Institute. (2003). Juvenile drug courts: Strategies in practice. Washington, DC: U.S. Department of Justice.
National TASC. (2009). History of TASC. Washington, DC: National TASC. Retrieved from http://www.nationaltasc.org/history.php.
Reclaiming Futures. (2010). The solution. Retrieved from http://www.reclaimingfutures.org/model.
Ruiz, B. S., Stevens, S. J., Fuhriman, J., Bogart, J. G. & Korchmaros, J. D. (2009). A juvenile drug court model in southern Arizona: Substanceabuse, delinquency, and sexual risk outcomes by gender and race/ethnicity. Journal of Offender Rehabilitation, 48, 416-438.
Sampl, S. & Kadden, R. (2001). Motivational Enhancement Therapy and Cognitive Behavioral Therapy for adolescent cannabis users: 5 sessions.
Cannabis Youth Treatment (CYT) Manual Series Vol. 1 (DHHS Publication No. (SMA) 01-3486). Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration.