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Trauma and Justice: Treatment and Recovery Through the Delivery of Behavioral Health Services

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM

09 Trauma and Justice

Ask the Expert:  H. Westley Clark , M.D., J.D., M.P.H., CAS, FASAM, Director of the Center for Substance Abuse Treatment under the Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services

1) Question: Are there any plans to present a conference on substance abuse, mental health, and the child welfare system?

Answer: We need to look at the barriers to family-based treatment in and outside of the home, with and without the children present, and how mental health needs when properly diagnosed and treated improve the chances for sustained recovery with support in the community. Is this in the works for some time soon? I would love to work on this project.
A conference on substance abuse, mental health, and child welfare, entitled "Putting the Pieces Together for Children and Families: The National Conference on Substance Abuse, Child Welfare and the Courts," was recently held on September 14-16, 2011.  Smaller training events are continually scheduled by the National Center on Substance Abuse and Child Welfare, a program sponsored by SAMHSA and ACYF.  Check the website at for information about upcoming events.

2) Question: Why is it so difficult for soldiers to get appointments for confidential treatment?

Answer: Community-based organizations are under the authorities of the HIPAA and Title 42 Part II., Confidentiality of Alcohol and Drug Abuse Patient Records.  Therefore, any American citizen accessing services through community-based organizations should not be concerned about privacy issues.  However, the Department of Defense (DOD) TRICARE providers and VA providers are not under these authorities. A provider’s TRICARE contract with DOD does not include confidential protection when an active duty service member accesses treatment.  The contract between DOD and TRICARE providers allows open communication to DOD.   All services rendered must become a matter of record.  The VA, on the other hand, although not under obligation to protect the privacy of active military service members, may not readily forward confidential information to the DOD.  However, should the DOD request confidential information from the VA, the VA is obligated to provide this information.  Military service members that choose to access community-based organizations should contact the state Single State Authority for Substance Abuse Treatment or Mental Health to obtain assistance in locating a local community-based organizations.  They may also access the SAMHSA treatment locator from the SAMHSA website at

3) Question: How can recovery be sustained for once convicted felons of drug abuse that are certified as being in recovery - with their prison based treatment and faith-based after care intervention, and HUD sponsored public housing agencies providing them with living quarters in a model community of recovery? 

Answer: Recovery from substance use and abuse disorders is a lifelong process which can be sustained with a range of social, professional, and community supports.  Recovery begins with treatment. The question indicates that prison based treatment occurred and that faith-based services were provided in aftercare.  The scenario is one that is consistent with what we know works for all populations.  Getting an addicted person to stop abusing drugs is just one part of a long and complex recovery process. When people enter treatment, addiction has often taken over their lives. The compulsion to get drugs, take drugs, and experience the effects of drugs has dominated their every waking moment, and drug abuse has taken the place of all the things they used to enjoy doing. It has disrupted how they function in their family lives, at work, and in the community, and has made them more likely to suffer from other serious illnesses. Because addiction can affect so many aspects of a person's life, treatment must address the needs of the whole person to be successful. This is why the best programs incorporate a variety of rehabilitative services into their comprehensive treatment regimens. Treatment counselors select from a menu of services for meeting the individual medical, psychological, social, vocational, and legal needs of their patients to foster their recovery from addiction.

HUD Sponsored living quarters that cultivate a community of recovery are environments where recovery from addiction can be sustained when supportive services are accessible to individuals.  The following list represents examples of key supportive services that support sustained recovery from addiction.

Cognitive Behavioral Therapy. Seeks to help patients recognize, avoid, and cope with the situations in which they are most likely to abuse drugs.

Motivational Incentives. Uses positive reinforcement such as providing rewards or privileges for remaining drug free, for attending and participating in counseling sessions, or for taking treatment medications as prescribed.

Motivational Interviewing. Employs strategies to evoke rapid and internally motivated behavior change to stop drug use and facilitate treatment entry.

Group Therapy. Helps patients face their drug abuse realistically, come to terms with its harmful consequences, and boost their motivation to stay drug free. Patients learn effective ways to solve their emotional and interpersonal problems without resorting to drugs.

Relapse Prevention. While quitting drug use is possible, addiction is a long-lasting disease, and treating it takes time-and just because someone gets treatment and stops using a drug does not mean that these strong cravings go away for good, especially when certain cues are present.  These cues vary from person to person and can trigger a relapse.  Relapse prevention focuses on the education and identification of unique triggers that may result in relapse for the person in recovery.  The idea is that once a person is aware of these triggers they can develop specific strategies to cope with them successfully and avoid relapse.  Conversely, if relapse does occur during recovery, it is viewed not as a failure, but rather as an opportunity to learn and change recovery strategies.

4) Question: How do you deal with a 7 year old girl who is acting out because her alcoholic Father refuses to have anything to do with her?

Answer: It’s difficult for a child to understand rejection by a parent and it can be especially confusing when a parent displays erratic behavior associated with alcoholism.  There are excellent resources for helping children understand the nature of addiction and that they are not responsible for their parent’s addiction, nor can they “cure it.”  One such resource is the SAMHSA “Children’s Program Kit” that can be ordered for free at the SAMHSA Clearinghouse. To order, visit  and go to the publications section. The ordering code number for the Children's Program Kit is CPKIT-D. For the Native American version of the Kit, use order code NCPKIT-D. Other excellent resources are available through the National Association of Children of Alcoholics (NACOA) and the Betty Ford Center Children’s Programs which can be reached at 800-854-9211.

5) Question: From your perspective, what role does the use/abuse of mood-altering substances play in the success or failure of criminal justice involved individuals being monitored in the community?  More specifically, if there is a documented history of substance abuse issues; alcohol use/abuse; domestic violence; mental health issues; and /or sexual violence; from your perspective, would a prohibition against all alcohol use decrease the likelihood of antisocial behavior under supervision and increase the chances of long term success?  Can you point me to any publications or studies that have looked at this issue?

Answer: The attached document, Determining Your Clients Likelihood of Success  from the Office of Defender Services/Training Branch, Administrative Office of the United States Courts shows that a history of illegal drug use or alcohol abuse is one of seven predictors that an offender will reoffend or have a revocation.  Please see the following:

The Federal Judicial Center developed the Risk Prediction Index (RPI) after several years of study and testing in eleven districts. Pat Lombard and Laural Hooper, RIP FAQ’s Bulletin (1998). U.S. Probation officers may use a computerized version of the RPI during their initial assessment of newly released offenders to “estimate the likelihood that an offender will be arrested or have supervision revoked during his or her term of supervision.” U.S. Probation, The Supervision of Federal Offenders, Monograph 109, III-10, (March 2007 Update), available at The RPI measures seven variables: (1) the offenders’ age at the start of supervision; (2) the number of arrests before the instant offense; (3) employment status; (4) history of illegal drug use or alcohol abuse; (5) prior history of absconding from supervision; (6) whether the offender has a college degree; and (7) whether the offender was living with a spouse and/or children at the start of supervision. It assigns a value to each variable. The values are then totaled to arrive at an RPI score between 0 to 9. The RPI score can then be compared to the scores of other offenders to assess the risk of recidivism. Lower scores are associated with lower recidivism rates.

With this said, a condition of probation/parole/community supervision is usually no alcohol use.  The first few paragraphs of the paper provide some more specific information about the tool.

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