County stakeholders attributed Proposition 36 program success to strategies that comprised four broad categories, those that: (1) fostered program engagement, monitored participant progress, and sustained cooperation among participants; (2) cultivated buy-in among key stakeholders; (3) capitalized on the role of the court and the judge; and (4) created a setting which promoted a high-quality treatment system, utilization of existing resources, and broad financial and political support for the program. Each strategy is discussed as to overall goals and the practices stakeholders used to achieve implementation.
3.1. Strategy 1 – Foster program engagement, monitor participant progress, and sustain cooperation among participants
One goal of this strategy was to quickly engage participants in the program so that receipt of services occurred within one to six days after the triggering conviction. Stakeholders in all counties felt that rapid participant engagement minimized opportunities to not show for treatment and also built immediate trust and buy-in among participants by underscoring that the Proposition 36 team was willing to “go the extra mile” on behalf of participant interests. To promote rapid engagement, stakeholders reported the use of several practices.
All six counties reported efforts to make treatment entry easy by simplifying pre-treatment processes. For example, offenders were handled in a dedicated Proposition 36 court (discussed further in Section 3.3), a clinically trained court-based unit conducted rapid assessments, agency staff (from court, probation, and assessment offices) were co-located so that participants could easily walk to each office, and escorts accompanied participants through procedures to ensure each step was completed successfully.
As another practice for increasing program engagement, five of the six counties reported the provision of an orientation session that explicitly described program processes, expectations, legal obligations, current criminal justice status (i.e., on probation, parole, or both), benefits such as linkages with local supportive services (e.g., CalWORKS, Medi-Cal, Veterans Affairs, etc.), and next steps in the process. Orientation was conceptualized as a “pre-treatment” intervention, a drug education class, or a special session with probation staff. Regardless of the mechanism for providing information, participants became aware of program rules and expectations “upfront” and “before they even hit the treatment door.”
A second goal of this strategy was to monitor participant progress so that participants did not “get lost in the system,” “veer off the path,” “go off the court calendar,” or “slip through the cracks.” In all counties, oversight systems were established to “keep real close tabs” on participants in order to detect and respond to behavior appropriately and immediately (problem behavior was to be “nipped in the bud”), thereby facilitating “continual engagement” and preventing relapse to drug use and criminal recidivism. Stakeholders reported the use of several practices to monitor participants.
In half of the counties, participants were required to appear before the judge weekly and/or at program milestones (e.g., after orientation, after assessment, at specific intervals during treatment, at treatment completion, at regular intervals while on probation post-treatment, at Proposition 36 program graduation). Face-to-face supervision by the court as opposed to other officials was thought to be of greatest benefit. Stakeholders explained that regular judicial review provided an opportunity to assess status and need for additional services and were also “a huge motivator [for participants] to stay on the path” to recovery.
Five counties reported the use of a specialist who acts as a “bridge” between participants and stakeholders to facilitate communication regarding participant progress and outstanding needs. This role was fulfilled by probation in two counties and by “engagement and retention” or “case management” staff in three counties. This specialist eliminated bureaucratic delays by being empowered to call for reassessment when appropriate, knowing “who to contact” and “how to get things done,” being available for other stakeholders to contact directly and receive a response from at a moment's notice, and by linking participants to community resources that support recovery. The specialist also “contains the participants” by staying in touch with them from intake through program graduation, increasing interactions as needed and especially when relapse risks increased (e.g., change in level of care, treatment exit, after assignment to a “banked” probation caseload where they could “fall off of probation's radar.”).
In all counties, stakeholders highlighted the need for drug tests at random and for cause, frequently, in all settings (e.g., court, drug treatment, probation), and to continue to do so until Proposition 36 program graduation. Drug testing was reported to keep participants “honest” and “accountable” and was “absolutely essential” to program success. Ideally, testing occurred on-site with immediate results tied to a quick response (by treatment, probation, and/or the courts) that was therapeutic (e.g., intensify treatment) rather than punitive.
Finally, stakeholders in all counties emphasized that program success was attributable to efforts designed to cultivate and sustain cooperation among participants. Participants were shown that when inappropriate behavior occurred, oversight staff would not seek to “punish” or make them “pay the consequences” but that there would be a “swift and sure response” targeted toward doing what was needed for them to succeed. To further this strategy, stakeholders treated participants “as human beings instead of as defendants,” included them as being “a part of the Proposition 36 system” so that they and stakeholders had a “shared goal,” and showed them that the “adversary” was drug addiction and not the participant per se. Stakeholders reported several practices for creating a “non-adversarial” environment for sustaining participant cooperation.
Stakeholders reported the intent to create a culture of respect for participants. Described by one county as creating a “family feeling” between participants and stakeholders, these practices included asking about the important people and events at each interaction, involvement of family members in courtroom proceedings, and physical contact and encouragement (a handshake or a hug). The physical space of the courtroom was also used to cultivate participant cooperation: for example in one county the judge sat at a table that was “on the same level” as participants and in two counties photographs were posted of successful participants standing with the judge and other key stakeholders (e.g., Sheriffs' deputy, probation officer).
As another practice for sustaining cooperation, stakeholders in five counties reported working together as a “united front” to send a consistent message. Also referred to as stakeholder “solidarity,” participants were shown that stakeholders from different agencies (e.g., courts, probation, treatment) “really care,” worked together to “support treatment” and further the goals of recovery, communicated regularly with each other, and were “on the same page” regarding participant status such as treatment assignment and noncompliance. Treatment staff were comfortable contacting probation or the courts to provide a “hammer” or “leverage” for dealing with noncompliant behavior and, likewise, the courts and probation respected decisions regarding treatment planning made by treatment staff. Stakeholders in two counties curbed the tendency among some participants to “program shop,” and thus postpone treatment entry while “burning up” limited treatment resources. For example, it was made clear that treatment assignment was based on assessed significance of need for services and not “dictated” by participant preference, and participants were reassured that a similar type and quality of care was offered by programs within the same treatment level.
Stakeholders in five counties also reported the importance of implementing activities that build motivation and hope among participants. Such activities made participants “so proud” of their behavioral improvements and were in turn perceived by stakeholders to enhance the likelihood of continued program buy-in and retention. In three counties, activities included simple and inexpensive, but “symbolic,” practices such as small rewards for good behavior (candy, fruit, opportunities to participate in raffles) and verbal praise and celebration of successes in open court. Other practices to increase participant motivation included: using motivational interviewing techniques for all communications (not just treatment interactions), “packaging” fees and fines (i.e., pay multiple fines for the price of one) to motivate graduation with a “clean slate,” requiring those unemployed to seek employment and to complete community service hours, linking them to child protective services so that they understood the steps for regaining custody of children after program completion, reducing the number of unnecessary treatment interactions, structuring program graduation ceremonies to include local “dignitaries” (e.g., county sheriff, police chief, county supervisor, mayor), and providing Proposition 36 alumni meetings.
A final practice endorsed by all counties for facilitating continued program engagement was to maximize opportunities for treatment success. Stakeholders reported avoiding a “strict interpretation,” or overly rigorous application, of the Proposition 36 law. For example, one county mentioned giving participants a “grace period” to get oriented to treatment processes before being held accountable to program requirements. In four counties, relapsed participants were placed in a non-medical detoxification setting and considered for further treatment instead of being terminated from Proposition 36. In two counties, minor but multiple related treatment infractions (e.g., positive urine test, missed treatment appointment) were “bundled” or “wrapped” to be considered as a single violation. If a participant was facing a third and final program violation (an event that could trigger program termination) but seemed amenable to further treatment, stakeholders in four counties reported an extension of the probation period or other sanction options were considered so that the participant was given an “extra chance” at fulfilling treatment requirements.
Although not allowed as a response to Proposition 36-type infractions, four counties allowed continually noncompliant participants to be considered for receipt of short remands to jail on a concurrent non-Proposition 36 offense (“flash incarceration”) or “catch and release” practices (i.e., brought to court and, after remaining in court all day, released). Such interventions were felt to be a “healthy sanction” for teaching participants that responses follow inappropriate actions, i.e., “if you do this, this is what happens,” for motivating them to take treatment seriously, and for “interrupting” unhealthy lifestyles that may have re-surfaced during recovery.
In summary, stakeholders credited Proposition 36 program success to multiple integrated practices that facilitated engagement, monitored behavior, and sustained cooperation. To promote program completion, stakeholders minimized barriers to treatment utilization, helped participants to navigate the relevant criminal justice and healthcare systems, and provided them with support and encouragement (in lieu of punishment). More broadly, these practices may be best characterized as designed to motivate participants to experience Proposition 36 as a “turning point” in their lives, that is, it was presented as a unique chance to access substance abuse treatment and other needed services and thus allow them to be better equipped to make and sustain significant behavioral changes. In effect, the policies and practices that were developed were not designed to “make” participants change but instead were aimed at cultivating the desire to want to change. In addition, the supportive role played by key stakeholders was perceived as being a crucial element of program success.
3.2. Strategy 2 - Cultivate buy-in among key stakeholders
The goal of this strategy was to build productive relationships among stakeholders. Stakeholders explained that the Proposition 36 “statute is impossible to work with” procedurally unless “everybody [on the team] buys in to the higher purpose” and all work together to “tweak the legal system to make it work with drug treatment.” Variation in program operations by region within each county underscored that program consistency depended on stakeholder buy-in and cooperation. Despite this variation, stakeholders in all counties aimed to achieve a “critical mass” of colleagues who “believe in the program,” trust and value one another as equals, establish open and easy lines of communication, and were eager to collaborate to fine-tune the program as challenges arose. Stakeholders identified several practices for achieving strong collaborative relationships.
In all counties, there were educational opportunities for stakeholders to optimize understanding about program processes as well as one another's expertise. Word of mouth from a trusted colleague regarding program strengths and weaknesses was often more powerful at influencing stakeholder buy-in than attendance at formal educational events. Inter-related activities were essential to this practice. For example, opportunities were provided for stakeholders to witness the program in operation first-hand via attendance at court sessions and graduations. The program established a “brain trust” of knowledgeable local experts who provided training on the principles of effective substance abuse treatment. Program data was used to monitor outcomes in the county, address misinformation about program requirements, and identify systemic failures and responsive fixes. Stakeholders interacted outside of usual work roles, for example via informal get-togethers (potlucks, retreats), team attendance at statewide conferences, and site-visits to observe program processes in nearby counties.
Another reported practice promoting stakeholder buy-in was to acknowledge philosophical differences between stakeholders. Some stakeholders may feel it is not their job to act as a “social worker” or “do not believe in treatment,” and others could be placed in a position where their typical role requirements conflicted with their Proposition 36 role. For example, there may be some probation officers opposed to the provision of drug treatment to repeat offenders, some judges reluctant to allow opiate-dependent offenders to receive narcotic replacement therapy, some public defenders uncomfortable advising clients to accept conviction without a trial, and some treatment professionals uneasy reporting program noncompliance to probation, parole, and/or the courts. Stakeholders in three counties indicated that as the program “evolved” over time, stakeholders acting in good faith eventually worked out such differences and achieved mutually acceptable compromises.
Stakeholders in all counties emphasized the value of maintaining a core group of staff to operate the program. Staff who had invested time and effort in the Proposition 36 “baby” would make extra efforts to “fine-tune the program” and make it “roll along.” Four counties reported that experienced staff lent “consistency” and “stability” to program operations, allowing stakeholders to move beyond the mechanics of program implementation and instead to focus on program improvement. Mid- to senior-level staff were identified by two counties as being better equipped to make the most of their longstanding relationships and knowledge of county resources and processes, and “veteran” staff were perceived to be more inclined to “give treatment a chance.”
In summary, Proposition 36 success was attributed to strong and enduring relationships between the key staff responsible for operating the program, resulting in higher levels of collaboration and coordination. Proposition 36 was seen as a work in progress that required active management as well as periodic assessment and adjustment. Furthermore, stakeholders operated the program in a manner that was congruent with the intent of Proposition 36, despite historical differences in institutional roles and attendant philosophies. In effect, program success was attributed to the creation of genuine “collaborative justice,” meaning stakeholders worked together to analyze operational problems and create responsive solutions that would have been impossible to achieve without the proactive coordination of the involved stakeholders (Collaborative Justice, 2009
). Moreover, program success was often attributed to the courts and to one key stakeholder in particular: bench officers or “the judge.”
3.3. Strategy 3 – Capitalize on the role of the court and the judge
Stakeholders in all counties credited success to the establishment of a Proposition 36 court and to the role played by an involved Proposition 36 judge. They explained that success depended on a court staffed with a core group of individuals who oversaw a calendar dedicated to handling all Proposition 36 cases on specified days each week. All key stakeholders appeared in this “dedicated court” to “hammer out” the best course of action for each case and, as an added benefit, this process was perceived to “make participants more eager to participate…because they see all the caring…from the whole team.” An effective courtroom was viewed by participants as being “accessible” and “the place to go” if they were struggling and needed help. A dedicated court precipitated engagement as early in the program as was possible, standardized the handling of cases, and helped expedite case processing. The courtroom was also used as an arena for celebrating success as well as for showing “the Proposition 36 community” (i.e., other offenders) what occurred when a participant did not appear in court or was noncompliant with specific program requirements.
Furthermore, stakeholders in all counties described “judicial leadership” as an important component of program success. The judge was described as “the hub of everything…who holds everything together…and is central to successes.” Stakeholders identified the personal characteristics for choosing an effective judge: service on a public health oriented collaborative justice court; familiarity with drug court components; and knowledge about drug addiction, co-occurring disorders, behavior modification, and the principles of effective treatment. The judge was identified as the central player in several main activities, for example, as personally connecting with participants, facilitating communication between key stakeholders, and garnering broader political and financial support for the program from the local community.
Judges who could connect with participants were often described as charismatic, plain speaking, and “parental” when appropriate, and setting clear boundaries for participants while showing the judge cared about the individual and his or her success. At times referred to as the “black robe effect,” stakeholders in all counties emphasized that an effective judge motivated treatment involvement, showed that he/she would not “give up” on participants, and structured oversight procedures to make it harder for participants to opt out of treatment than to stay in it. For example, to participants who wanted to drop out early because jail seemed less onerous, the judge in one county would offer a jail sentence that was higher than expected and the judge in two counties would explain that he/she would be on the bench when the participant was released from jail on probation, ready to “harass [them] to sobriety” if needed to prompt more active program compliance. Stakeholders in two counties explained that traits like these created participant attachments to the judge, causing some to view the judge as a personal advocate (e.g., “my judge”) who they did not wish to disappoint, often resulting in an increased desire among participants to “earn the respect” of the judge and other stakeholders by completing program requirements.
Judges who facilitated communication between key stakeholders were cited as being an important component of program success. An effective judge created a “community of equals” or a “culture of collaboration,” using his/her position to encourage all stakeholders to come to the table, communicate with each other, and reach consensus. Stakeholders in three counties explained that the judge showed respect for their expertise and made a point to value contributions made by probation and avoid “undermining” the recommendations of treatment professionals. Furthermore, the judge monitored the operation of program elements, visiting other stakeholders at their workplaces to better understand program aspects that existed outside of the courtroom.
Finally, the judge was identified as being critical to garnering political and financial support for the program. In three counties the judge provided testimony on program operation and outcomes to the County Board of Supervisors and was an invited speaker at local, state, and national venues. The judge was described as an advocate or the “squeaky wheel” that educated others less familiar with the program while lobbying for its support.
In summary, program success was ascribed to having created a court that not only expedited Proposition 36 case processing but also was viewed by participants as a place to access help and to celebrate accomplishments. Moreover, it was led by a judge who created rapport and buy-in, not just among participants but also among other stakeholders and the larger community as well. Respected by stakeholders and participants alike, the authority of the court and the judge, and use of that authority to advance rather than thwart the goals of the Proposition 36 program, was identified as a major component contributing to program success. The contextual setting in which the program was operated was identified as a final reason for program success.
3.4. Strategy 4 - Create a setting which promotes a high-quality treatment system, utilization of existing resources, and broad financial and political support for the program
Stakeholders in all counties emphasized the importance of a high-quality treatment system that could promptly provide services when and where needed, for as long as needed, and in response to different types of participant needs. Many practices were cited. For example: using standardized, multi-dimensional treatment assessments and placement criteria to determine participant needs; ensuring treatment stay was of sufficient length to impact behavior (many participants needed at least 12 to 18 months of treatment); matching treatment setting and services to participant needs; ensuring different treatment levels were available (especially residential and narcotic replacement in addition to outpatient treatment) and adjusting treatment level in response to individual progress; encouraging treatment programs to collaborate as a system of care to refer participants within and among themselves; locating treatment programs in the neighborhoods where participants live; minimizing or eliminating the use of treatment waiting lists; making treatment affordable by waiving enrollment fees and using a sliding scale to determine drug testing fees; structuring program availability to accommodate participant work schedules; enhancing cultural competency of program staff; training staff to use evidence-based best practices; providing transportation to ancillary services; providing housing when needed; and employing certified drug treatment counselors.
Utilization of existing resources was cited as a means to complement and thereby enhance the operation of the Proposition 36 program. Participants may be eligible for, and can benefit from, social services offered by other health and human services agencies. In particular, linkages with other types of court-supervised treatment were cited as contributing to success. Several stakeholders viewed these linkages as comprising an “integrated continuum” such that participants could be routed to services offered by different providers as needed. For example, in three counties participants who were continually noncompliant with Proposition 36 requirements were “transitioned” into drug court. Four counties reported having “revolutionized” the way participants with co-occurring disorders were handled. The change was described as moving away from a “judicial system [that] put round pegs in square holes and hammered them until they splintered up into a million pieces” toward a system that routed dually diagnosed offenders to the “right cubbyhole,” i.e., to a mental health court or another type of specialty court that offered needed supportive services (e.g., psychiatric medication, evaluation by a psychiatrist, housing, mental health treatment). Once stabilized, participants were returned to Proposition 36 substance abuse treatment.
Stakeholders in three counties attributed program success to having made special efforts to effectively treat parolees as well as probationers. Parole agents can make parolees “tow the line” however, state parole tends to operate outside of the county-level Proposition 36 infrastructure and some parole agents lacked knowledge of Proposition 36 requirements. To address this disconnect, stakeholders implemented practices to engage parole in local program operations. For example: parole agents were invited to attend stakeholder meetings, treatment provider staff developed close working relationships with local agents, educational sessions were provided to agents, and agents were located on site at treatment programs. One county described working with treatment providers to ensure a welcoming environment for parolee participants, i.e., one that gave parolees “time to adjust,” “decompress,” and “adapt to treatment.” Also, treatment staff were trained on parolee needs and, in particular, how to address persistent parolee resistance to treatment. Two counties contracted with treatment programs that specialized in treating parolees.
Stakeholders in five counties reported working together to generate broad financial as well as political support in their communities, strengthening the network of resources available for operating program elements. Broad political, community, and auxiliary support helped to maintain key components of the Proposition 36 program despite unexpected funding reductions and political uncertainties. Stakeholders used several practices to generate community support and access to resources.
Collaboration and coordination activities require adequate resources and a plan for allocating administrative costs was an important component of program success. Although dedicated staff are needed to navigate funding maintenance and growth, to ensure that program elements are “laid out clearly,” and to “allocate resources properly,” four counties reported that they refrained from using Proposition 36 funding to support administrative program costs. Instead, they “made funding for treatment a priority” and had stakeholder agencies contribute staff and/or funds so that they could “put every penny into providing drug treatment.” In some cases, however, this focus was reported to weaken monitoring efforts, particularly probation activities, and thus strained oversight efforts.
Stakeholders reported creative ways to mix and match funding streams, thus diversifying treatment service options for participants. For example, if a participant was on parole and probation simultaneously (dual supervision), counties tapped into available parole sources of funding for treatment and/or monitoring to supplement Proposition 36 resources. If the participant was also involved with the child welfare system, stakeholders worked with that system to minimize treatment barriers and expand service options. Two counties sought alternative sources of funding and submitted proposals to state, federal, and private sources to enrich and increase available resources.
As a final practice, stakeholders built relationships and trust between the Proposition 36 program and the County Board of Supervisors. Two counties regularly provided their county Board with data on Proposition 36 program accomplishments and outcomes and invited Board members to participate in the Proposition 36 oversight committee. It was important that a Board “trusts the judgment” of stakeholders in how the program was being operated and know that the program was “a good investment…even in bad [economic] times,” making the “process [of operating the program] a lot easier.” Educating the Board was also used as an opportunity to seek additional funding to supplement Proposition 36 resources and to obtain assistance with influencing and/or navigating county processes (e.g., treatment contracting requirements).
In summary, stakeholders identified the environment in which the program operated as impacting its success. In particular, success was attributed to a high-quality treatment system, use of existing resources to complement and enhance program components (e.g., especially for participants who were persistently noncompliant, mentally ill, or parolees), and securing broad financial and political support for the program. Creative and resourceful program administration enabled stakeholders to amass diverse resources and cut through bureaucratic red-tape, enhancing program resilience and resulting in a program that was better equipped to weather political and financial uncertainties.