Drug Treatment Court Funding Program, Summative Evaluation
4. Findings
This section of the report presents evaluation findings and combines information from all lines of evidence that were described in Section 3.0.
4.1. Program Relevance
This section reports on the relevance of the DTCFP. It discusses the alignment of the DTCFP with federal priorities and the continued need for the program.
4.1.1. Alignment with federal priorities
The federal government has a long history of working to address the issue of drug abuse in Canada. The Canada Drug Strategy (CDS), in effect from 1987 to 1992, was a $210 million strategy intended to address the supply and demand sides of drug abuse in Canada. It comprised six strategic components: education and prevention, treatment and rehabilitation, enforcement and control, information and research, international cooperation, and a national focus.
Phase II of the CDS was launched in 1992. This phase of the CDS placed increased emphasis on impaired driving offenders. Although this strategy included $270 million in funding over five years, less than half of the funding was allocated to the strategy due to changes in government priorities. The Toronto and Vancouver DTCs were initially introduced as part of Phase II of the CDS with funding from the Crime Prevention Investment Fund of the National Crime Prevention Strategy.
In May 2003, the CDS was renewed and included an investment of $245 million over four years. The aim of the renewed CDS was to "have Canadians living in a society increasingly free of the harms associated with substance abuse" (Health Canada, 2004). The Strategy comprised four pillars, and as part of the treatment pillar, the DTCFP was expanded to fund four new courts.
With the October 2007 announcement of the National Anti-Drug Strategy, the government has again renewed its commitment to programs such as DTCs and the DTCFP that combine treatment and enforcement through such measures as extra-judicial treatment and diversion programs. The Strategy represents a significant commitment to addressing Canada's drug problems; it includes $300 million in new funding over five years, as well as $576 million over five years in reoriented funding and funding from the CDS. The goal of the Strategy is to "contribute to safer and healthier communities through coordinated efforts to prevent use, treat dependency and reduce production and distribution of illicit drugs". The DTCFP falls under the Treatment Action Plan, the objective of which is to "support effective treatment and rehabilitation systems and services by developing and implementing innovative and collaborative approaches" (DOJ, 2008).
4.1.2. Continued need for the DTCFP
The relationship between drug use and crime is complex. Although few Canadian studies have examined the direct relationship between drug use and crime, other research reports, particularly from the United States, have indicated that the two are clearly related. In fact, studies of incarcerated persons in the United States show that approximately a third of convicted offenders committed their crimes under the influence of drugs (excluding alcohol). The few Canadian studies that have been conducted show similar findings. For example, one study conducted by Pernanen, Cousineau, Brochu, and Sun (2001) found that 32 percent of inmates in Canada were addicted to illicit substances, and 35 percent were intoxicated with drugs or some combination of drugs and alcohol at the time that they committed their most serious offences (Newton-Taylor, Naymark, & Coote, 2007, p.3).
What these studies suggest, and what proponents of DTCs argue, is that even though drug dependency does not inherently lead to criminal behaviour, the high cost of obtaining illicit drugs does result in increased criminal activity–particularly crimes of acquisition, drug-related violence, and non-commercial trafficking. In addition to its relationship with criminal activity, addiction has also been linked to numerous socioeconomic and behavioural outcomes including homelessness, unemployment, violence, family conflict, as well as mental and physical health issues. Drug-related crime is particularly visible in urban centres, where unsafe drug use has been linked to numerous public health issues, including HIV/AIDS, and is related to public disorder which affects the community as a whole (Werb et al., 2007, p.12; TDTC & CAMH, 2005, p.4). Advocates of DTCs argue that untreated dependency costs the public a great deal, mainly through the direct and indirect costs of crimes that are committed to finance drug dependency (Informal expert working group, 1999).
The main rationale given for DTCs is that the traditional judicial system does little to treat addictions, even though the rate of recidivism among people with drug dependencies is very high, and these dependencies are thought to cause, or at least contribute to, much drug-related crime. As an alternative to the traditional system, DTCs are based on therapeutic jurisprudence. This approach provides court-supervised treatment as an alternative to the criminal justice system that emphasizes incarceration, probation and parole without provisions for accompanying treatment (Hora et al., 1999; Canadian Centre on Substance Abuse, 2007). The belief is that through a combined system of enforcement and treatment, where non-violent offenders receive intensive treatment instead of incarceration, offenders will be better able to overcome their addictions, avoid future criminal behaviour, and improve their socioeconomic situations.
This view was firmly held by key informants and survey respondents to this evaluation, most of whom are experienced criminal justice professionals or addictions treatment specialists. Key informants referred to the regular court system as a revolving door because it does not address the causes of criminal behaviour for this population: addictions coupled with the expense of maintaining the addiction and getting drugs. They indicated that one of the strengths of DTCs is that they provide participants with focused, intensive treatment. Additionally, they give participants access to coordinated services such as treatment counsellors, nurses and psychologists. These programs also increase participants' social stability by helping them find suitable housing, income assistance, education and employment. Even if participants do not graduate from the program, many of them have reduced their drug use and learned skills to cope with and manage their addiction and criminal thinking behaviours. Correspondingly, 14 percent of survey respondents considered the regular court system as effective as DTCs in breaking the cycle of drug use and criminal recidivism and almost nine-tenths believe DTCs provide a needed alternative to incarceration for drug-related crimes.
Literature has indicated that specialized drug courts have shown promising results, particularly for reducing recidivism (United States General Accounting Office 2005; Gottfredson, Najaka, and Kearley, 2003). In fact, four recent meta-analyses of research studies concluded that DTCs have reduced recidivism on average by approximately 7 to 14 percentage points (Aos, Miller, and Drake, 2006; Latimer, Morton-Bourgon, and Chretien, 2006; Shaffer 2006; and Wilson, Mitchell, and MacKenzie, 2006).6 As a result of these signs of success, the number of drug courts has continued to increase. For example, in the United States the number has grown from about 700 in February 2000 (James and Sawka, 2000) to over 2,100 today (http://www.nadcp.org).
Given their experience and the available evidence, most key informants believe there is a continued need for the DTCFP. They indicated that without designated funding, some DTCs would likely shut down and others would need to reduce the number of participants they serve or reduce the level of programming they offer. The nature of the DTCFP funding recipients makes this outcome likely; two of the six funding recipients are provincial government departments, three are treatment providers, and one is a charitable foundation. At many of these DTCs, the provincial governments typically make in-kind contributions as opposed to monetary contributions, which means federal funding is critical for their ongoing operations.
4.2. Program Design and Implementation
The evaluation considered the design and implementation of the DTCFP as well as the DTCs.
4.2.1. Ability of the DTCFP to support and deliver the program
The main activities of the DTCFP are to develop and manage contribution agreements with DTCs; to conduct communication activities to disseminate information on DTCs; and to support research, performance measurement and evaluation activities (Department of Justice Canada, 2006, p. 6)
Development and management of contribution agreements
The evaluation found that the DTCFP has effectively developed and managed the DTC contribution agreements. In accordance with its mandate under the renewed CDS, the DTCFP has continued funding the original sites of Toronto and Vancouver and has expanded the number of DTCs to other regions of Canada. The DTCFP issued a call for proposals in December 2004 and seven proponents responded by the January 2005 deadline. After a review process, four expansion sites were funded – Edmonton, Winnipeg, Ottawa and Regina.
The evaluation did not find many concerns with the administration of the contribution agreements. While most key informants were not sufficiently involved to provide comments, those few that could noted the flexible approach taken by the DTCFP that allowed the DTCs to determine their model and address local concerns.7 DTC sites also supported the more intensive interaction with the DTCFP when they were beginning operations (e.g., biannual Director meetings and monthly teleconferences). As would be expected, the level of consultation has diminished as the program has matured. However, some key informants did think that more opportunities for in-person meetings or conference calls among different DTC groups (e.g., Directors, Crowns) would be useful.
Of the few key informants who could comment on the reporting requirements under the contribution agreements, most found the expectations reasonable and not difficult to meet. That being said, some did note that they had occasionally been late with the reports due to competing priorities in operating the program.
The DTCFP has experienced some challenges in administering the contribution agreements that were unanticipated. The original expectation was that provincial government departments would apply for funding. Instead, NGOs are the funding recipients in four of the six DTC sites. This has created a few unforeseen situations to which the DTCFP has responded to the extent it can; however, some of these situations are outside of its direct control.
First, the original terms and conditions of the contribution program limited the federal government's contribution to 50 percent of eligible expenses. This limitation proved onerous for NGOs as start-up costs were substantial and the provincial contributions were primarily in-kind (court costs) and would come only after the DTC was operational. The situation jeopardized the start up and operations of the new DTCs. As a result, the DTCFP successfully requested that the terms and conditions be changed to allow for federal funding to cover up to 100 percent of eligible costs to the maximum annual funding allowed per site.
Financial issues remain, however, due to some NGO funding recipients' limited access to cash flow. Both the Treasury Board Secretariat's Transfer Payment Policy, which was in effect at the inception of the DTCs and restricted advances to one month for contribution agreements of this amount, and the 10 percent holdback of funds until receipt of the audited financial statements and annual progress reports from the DTCs, have proved burdensome for some NGOs. Although the new transfer policy (October 2008) has relaxed the restriction on advances, the DTCFP must continue to operate under the existing terms and conditions of the program until new terms are approved by the Treasury Board. The original intent was that funding recipients would be able to cover costs and be reimbursed according to the terms of the contribution agreements. One suggestion for lessening the financial burden on funding recipients was including a cost-of-living adjustment in the contribution agreements; however, cost-of-living adjustments are difficult to provide because the DTCFP is operating under a funding cap.
Another unanticipated effect of the funding recipients being NGOs is that the Department cannot require them to provide financial statements of provincial costs. Without this information, it is difficult for the Department to determine accurate global costs of the DTCs, limiting its ability to conduct a thorough cost-effectiveness study.
Communication activities
The DTCFP has three main communication activities, which primarily target DTC staff or members of the CADTC.
- The purpose of the DTC electronic bulletin board is to provide an accessible space to promote dialogue among DTC stakeholders. Hosted through the Department's Web site, users must register and receive a password in order to access the site.
- The purpose of the CADTC is to support and promote DTCs by providing a forum for sharing best practices and by disseminating information on DTCs. CADTC meetings/conferences are primarily funded by the Department. To date, there have been two conferences and one roundtable. These meetings address a variety of topics and include informational sessions on DTCs in Canada and elsewhere as well as opportunities to share best practices.
- The purpose of the Department research reports on DTCs is to provide supplemental information that would be useful to stakeholders and others interested in testing alternative approaches to incarceration within the criminal justice system.
The evaluation found varied limited awareness/use of these activities, depending on the stakeholder group or type of communication activity. Members of the DTC team were more likely than other stakeholder groups to have used most of these DTC information sources, as shown in Table 6.
| Overall | DTC team | DTC governance | Other stakeholders | |
|---|---|---|---|---|
| % used source | ||||
| (n=88) | (n=22) | (n=25) | (n=41) | |
| CADTC meetings/conferences | 51% | 73% | 52% | 39% |
| DOJ research reports on DTCs | 38% | 50% | 56% | 24% |
| DTC electronic bulletin board | 25% | 50% | 8% | 22% |
The evaluation found through the interviews and the survey that the CADTC meetings/conferences are very useful. Key informants who had attended them agreed almost unanimously that the conferences provided excellent opportunities for networking and sharing information and best practices across the DTCs. Just over 70 percent (n=32) of survey respondents who had attended considered them to be useful.
Few key informants commented on the other DTCFP communication activities, although some noted that usage of the electronic bulletin board spikes around the CADTC conferences and then drops off substantially, which limits its relevance. However, a few key informants found the bulletin board to be a good forum for posting questions. Survey results also reflected the lack of enthusiasm for the bulletin board with just over one-third (36 percent, or n=8) of users rating it as useful. Departmental research reports received little comment in interviews. Survey results showed that 39 percent (n=13) of users found them useful.
Collect information and data on the effectiveness of the DTC
This activity is central to one of the objectives of the DTCFP, which is to collect information on DTC effectiveness "in order to promote best practices and the continuing refinement of approaches" (Department of Justice Canada, 2006, p. 4). The DTCFP and the DTCs have undertaken substantial work in this area, but the current systems and processes in place to collect information on the effectiveness of DTCs require improvement.
Although the Overview of the National Performance and Evaluation Reporting Requirements (Department of Justice, 2006) anticipates the ability to aggregate the information from the site progress and evaluation reports, current data are not consistently and reliably kept, and the methods of reporting outcomes do not result in comparable information. As a result, the evaluation cannot provide cross-site comparisons or combined results across sites for most of the outcomes identified for the DTCFP. This situation is a long-standing issue for evaluating DTCs. These courts have been in use longer and studied more extensively in the United States, but decades later, lack of uniform measures and weak empirical evidence still makes drawing generalizations about the effects of DTCs difficult (Heck, 2006; United States General Accountability Office, 2005).
Until the recent advent of the DTCIS, the primary method for generating performance information was the individual DTC process and outcome evaluations. The DTCFP allocates $50,000 annually to each DTC site to enable it to meet its performance and evaluation reporting requirements (Department of Justice, 2006, p. 36). Five of the six sites produced process and outcome evaluations in 2007-2009.8
The evaluation reviewed these individual DTC evaluation reports and found working with the information challenging. The DTCFP requires that DTC sites develop their own evaluation plans, and although the Overview of the National Performance and Evaluation Reporting Requirements (Department of Justice, 2006) provides some guidance for performance measures, the outcome evaluations demonstrate that more detailed direction is necessary in order to ensure that site evaluations report on comparable data. For example, abstinence or reduced drug use can be measured in a variety of ways (e.g., average length of sobriety from drug screens, average number of failed tests during a particular time period, self-reporting) and reported on for different groups (e.g., all participants, only graduates) and different timelines (e.g., last 30 days, comparisons by different intervals during the program). Because the sites report on results using different measures, different groups and different time frames, teasing out generalizations about the findings is challenging. In addition, some outcome measures are particularly subject to interpretation (e.g., enhancing social stability). To enable evaluations to present comparable findings will require central coordination on key measures to track. This is not to say that sites cannot also develop other outcomes and measurement strategies, but for the purpose of the DTCFP evaluation, some common measures would be appropriate.
The DTCFP has worked to develop a system to gather consistent performance information through the development of the DTCIS. By building standard measures into that system, the issue with comparability of the site evaluation findings will be largely moot. Although the ability to use the data is currently limited (see Section 3.5), the database will produce useful statistics over time. The DTCIS was designed to capture dates and other information surrounding key activities such as court appearances, treatment activities and urine drug screening. As ongoing and consistent data entry evolves at each DTC site, an analysis of these activities over time will be possible.
In addition to its role in gathering performance data, the DTCIS has a case management component. The Department developed the system in consultation with representatives of the individual DTCs. In spite of this, none of the sites reported using the DTCIS as a case management tool and instead prefer their own case management forms or systems. Shortcomings associated with the DTCIS include that it does not capture necessary qualitative information for case management, and that the database does not adequately capture the work of the DTC program. DTCs were divided on whether the DTCIS provided helpful statistics for their purposes. The system is primarily considered a method for generating reports for the Department. Survey results supported these findings with just under half of respondents reporting that the DTCIS was useful to the management and operations of the DTC, although just over one third did not provide an opinion.
4.2.2. Design and implementation of DTCs
The individual DTC process and outcome evaluations provide extensive descriptions of the program elements of each DTC. Therefore, this evaluation considers the main design features across the sites, noting any major differences, and focuses on common themes in implementing the DTCs.
Program reach
Specialized drug courts serve high-needs clientele. In addition to having criminal backgrounds and serious addictions, participants face additional challenges, such as poor employment history, low levels of education, health and/or mental health problems, and lack of stable housing. The DTCFP also targets certain marginalized groups: youth (operationalized as 18 to 24 year olds), Aboriginal men and women, and street prostitutes.
Attracting individuals from these backgrounds into a highly structured, demanding program requires effort, particularly when some potential applicants may be facing only fines or minimum imprisonment (e.g., offences relating to prostitution). The evidence shows that the program is reaching some of these populations, although it is facing challenges with several groups. Data from the site outcome evaluations shows that the program is reaching economically disadvantaged individuals, as many are unemployed upon entry and/or have unstable housing situations. Many participants also report mental health issues and physical health concerns. The program is generally having the most success attracting men and older adults. Youth and women have proven to be more challenging groups to reach. Table 7 provides results.
Table 7: Participant characteristics
| Toronto* | Edmonton | Winnipeg | Ottawa | Regina | |
|---|---|---|---|---|---|
| Gender (% M/F) | 79/20 | 49/51 | 60/40 | 77/23 | 63/36 |
| Age(average or distribution) | 37 | 27% 18-24 63% 25-44 9% 45+ |
31 | 36 | 31% 18-29 45% 30-39 24% 40-53 |
| Toronto* | Edmonton | Winnipeg | Ottawa | Regina | |
|---|---|---|---|---|---|
| Caucasian | 66% | 49% | 59% | N/A | N/A |
| Aboriginal | N/A | 45% | 40% | N/A | 67% |
| Other | 34% | 6% | 1% | N/A | N/A |
| Toronto* | Edmonton | Winnipeg | Ottawa | Regina | |
|---|---|---|---|---|---|
| Less than high school | 18% | 26% | 3% | N/A | 36% |
| Some high school/completed high school | 70% | 55% | 88% | 61% | 61% |
| Some post-secondary | 12% | 19% | 7% | N/A | N/A |
| Other | -- | -- | 2% | -- | -- |
| Unemployed at entry | 69% | 82% | 66% | 87% | 55% ** |
| Mental health concerns (self-reported or suspected) | 41% | N/A | N/A | 56% | 68% *** |
| Physical health concerns | 44% | N/A | N/A | 62% **** | 45% |
| Housing–no fixed address or shelter | 40% | 27% | N/A | 72% | N/A |
Source: Site outcome evaluations.
The site evaluations and interviews shed light on the difficulties attracting target groups to the program:
- Youth are less motivated to address their addictions because they have not yet experienced many of its negative consequences. Although it was recognized that youth would likely benefit from separate programming, this is not currently available at any of the DTCs.
- Attracting Aboriginal men into the DTC program is not generally identified as a concern, although attracting women is an issue as well as retaining Aboriginal people.9 Sites have tried to encourage participation by either directly offering or referring Aboriginal participants to Aboriginal-specific programming. However, some key informants identified the need for more culturally appropriate programming, including separate Aboriginal groups. Three sites have one Aboriginal staff member (community and cultural liaison worker at Regina, intake worker at Vancouver, and a counsellor at Winnipeg).
- Some sites consider attracting and retaining women to be an issue, which is supported by the data, as men comprise the vast majority of participants in four of the five DTCs for which there are data (see Table 7). Women present unique challenges because many have multiple issues such as past victimization and prostitution. Compared to men, they experience greater degrees of poverty and mental illness. They are also more likely to have difficulties focusing on their recovery because of children and family responsibilities (D'Angelo and Wolf, 2002).
In addition to these personal barriers facing individual women, the DTC program has additional obstacles due to lack of gender-specific programming and adequate housing for women. Sites recognize the issue, although not all have the resources to address it.
Toronto has considered attracting and retaining women a long-standing challenge. It has formed the Women and Children's Sub-Committee of its Community Advisory Committee, which has assisted the program in assessing the needs and issues of female participants. As a result, Toronto now offers separate programming for women and has a peer facilitator. These are recent developments so their success cannot yet be assessed. Ottawa is also planning to develop gender-specific programming.
Other sites desire to provide separate programming for women but have found it logistically difficult. Smaller sites like Regina and Winnipeg do not have sufficient staff to offer gender-specific programming for all phases of the program. Even larger sites like Vancouver have had to reduce their responsiveness to women's concerns. While Vancouver used to provide separate court dates for men and women, the size of the program and scheduling considerations caused them to halt this practice.
The DTCs are also intended to target sex trade workers, who are particularly difficult to attract because the sentences they would receive are typically short, reducing the incentives to enter the program, and there are strong monetary incentives for remaining on the street. They are also even more likely to have suffered some form of abuse. Some sites believe they are successful in recruiting this target group. In particular, the Edmonton evaluation found that approximately 41 percent of eligible female applicants were involved in prostitution,10 and 37 percent of female participants in the Regina evaluation report past prostitution charges. Ottawa, Toronto and Vancouver did not have comparable data, but DTC team members generally believe they are reaching this group. The Winnipeg evaluation concluded that the program has not been successful in recruiting sex trade workers. Regardless of success in recruiting sex trade workers, all sites report that retention is a factor and again point to the need/desire for specialized programming.
Survey results reflect these challenges as about one third of respondents consider the DTCs effective in reaching its target groups.
Eligibility and admission
As noted in Section 2.0, the eligibility criteria across the sites are similar. The most common criteria are that the offence must be non violent, motivated by the drug addiction, cannot be for commercial gain, and must not involve children under the age of 18. The fundamental intent of the DTC program is to divert serious drug-addicted offenders out of the correctional system and into treatment in order to halt the cycle of addictions and criminal behaviour. Also at the core of the program is that offenders admitted to the program should not pose a public safety threat. Based on the information available, the DTCs are admitting appropriate individuals into the program.
The DTCs have admitted individuals with serious drug addictions. By far, the most common drug used is some form of cocaine, as shown in Table 8.
| DTC | Drugs |
|---|---|
| Toronto | 78% Crack/Cocaine |
| 50% Marijuana | |
| 11% Oxycodone | |
| 10% Heroin | |
| Edmonton | N/A |
| Winnipeg | 61% Cocaine/Crack |
| 22% Crystal Methamphetamine | |
| Ottawa | 82% Crack Cocaine |
| 27% Cocaine (powder) | |
| 10% IV cocaine | |
| 66% Marijuana | |
| 13% Oral opiates | |
| 20% IV opiates | |
| Regina | 96% Cocaine |
| 71% IV Cocaine | |
| 81% Other |
Note: Multiple drugs could be listed. Totals may sum to more than 100%.
Source: Site outcome evaluations
Based on available data, most DTC participants are involved in drug-related non-violent crimes, as shown in Table 9. This conforms to the expectations for DTC participants and indicates that the appropriate individuals are being targeted. The only site to explore this further is Winnipeg, which is using the Institutional Security Assessment instrument and the Primary Risk Assessment tool. Based on these instruments, Winnipeg can compare the level of risk with other offender groups. The site evaluation concluded from this comparison that Winnipeg is admitting appropriate individuals as they are lower risk than adult remand or sentenced offenders but higher risk than offenders with traditional probation or conditional sentences. Given that the program wants to protect public safety but also address a high risk, high need population, the level of risk was considered appropriate.
| DTC | Charges |
|---|---|
| Toronto | 58% Trafficking |
| 50% Administration of Justice | |
| 38% Property | |
| 27% Drug possession | |
| 18% Violence | |
| 9% Possession for purposes of trafficking | |
| 20% Other | |
| Edmonton | 74% had at least one Controlled Drugs and Substances Act offence |
| Winnipeg | 57% Trafficking |
| 14% Burglary | |
| 9% Fraud | |
| 7% Theft | |
| 7% Robbery | |
| Ottawa | 41% Administration of Justice |
| 29% Property | |
| 13% Drug-related | |
| Regina | N/A |
Note: Multiple charges could be listed. Totals may sum to more than 100%.
Source: Site outcome evaluations
The current profile of DTC participants shows that they are primarily charged with non-violent offences. However, some sites are exploring expanding their eligibility criteria. Vancouver has begun accepting participants with a past history of violence on a case-by-case basis, taking into consideration the safety of the public as well as the treatment staff. Similarly, the Toronto outcome evaluation suggested expanding eligibility requirements to this offender group in a way that is mindful of the public safety concern. The rationale is that the current criteria, if strictly applied, excludes individuals who should be part of the targeted client population (e.g., sex trade workers who often have criminal records that include some violence or persons with past domestic violence related offences).
Based on survey results, the admission criteria and the screening process are considered appropriate by about two-thirds (68 percent) of respondents who are members of a DTC team, but there is less consensus among DTC governance committee members (48 percent).
Court component
The court component is similar across the DTC sites. As part of the DTC bail conditions, participants must attend scheduled court appearances (which vary in frequency across the sites), submit to random urine screens and attend treatment, in addition to other conditions such as curfew, boundaries, or association restrictions.11 Progress of participants is reported at pre-court meetings that involve representatives of the court and treatment team. Decisions are made by the DTC team on whether to provide rewards or incentives for positive achievements or sanctions for non-compliance. These decisions are described as consultative or consensus-based in all sites, although some DTC team members contest whether this decision-making style always occurs (see further discussion under "Working relationships between court and treatment teams" below). Types of rewards used vary by DTC, and include verbal praise and encouragement from the judge, applause from those assembled at court, more generous curfew times, monetary items such as coffee cards or other gift cards, early leave from court (not required to remain for the entire session), or less frequent court appearances. Sanctions include admonishment from the judge, community service hours, mandatory attendance at therapeutic meetings, or bail revocation (described as a sanction of last resort). Across all the sites, rewards were used more often than sanctions.
The system of rewards and sanctions is credited with having a largely positive effect by encouraging participants to comply with DTC conditions and helping them remain in the program. The relationship with the presiding judge is considered vital to the effectiveness of rewards and sanctions. In fact, many participants acknowledged that the opinion of the judge was important to them and praise from the judge kept them motivated. As a graduate stated, "I felt the recognition of people I have been running from my entire life. People I've–for a lack of a better term–greatly disliked, for example, legal officials and the law. The fact of being recognized by them for … just showing up meant a lot, because I spent most of my life not showing up.
"
Almost all participants interviewed believe that the court appearances help keep them "on track." Court attendance provides them with a needed routine and structure, sanctions serve as a good deterrent, and rewards are motivational. A few participants commented that sanctions are used inappropriately, but they were evenly divided between finding them too tough and too lenient.
Survey results reflect general support for the structure of the court component. Most respondents agree with the intensity of the court appearances (68 percent), the appropriateness of bail conditions (68 percent), and use of rewards (61 percent). Agreement that sanctions are used when they should be is lower (48 percent). This may reflect the concern expressed in some DTC sites that sanctions are not consistently applied.
The following comments from case study participants illustrate the effect of the court component as providing needed structure and encouragement:
Going to the court twice a week I again was establishing a routine. Every Tuesday every Thursday, you know. You get that routine after a while and it helps you stabilize, you know. Some kind of regular routine is very important when you are getting off hard drugs. If you got too much time on your hands, you are in danger. [Non-completer]
They are small rewards, but they are nice rewards. They're thoughtful, and when you actually see someone receive one, it's like a boost. It actually does, it makes one want to have one themselves. And yeah, they're small rewards, but in actuality, they're huge–in what they actually do. [Graduate]
Although key informant and participant opinion supports the view that rewards and sanctions are affecting compliance with DTC conditions and helping participants complete or remain in the program, there is currently no quantitative data to support this. The site evaluations did not explore this issue, and the information required for this analysis has not been consistently entered into the DTCIS.
Site evaluations' assessment of participant compliance
The site evaluations offer some additional information about participants' compliance with DTC conditions. Three sites reported on this issue, although they used different measures. With the exception of Edmonton, none of the site evaluations analyzed differences in compliance among graduates and other participants, nor did any of them investigate what factors might compel participants to breach their conditions. Edmonton reported that:
- 41.3 percent of participants attended court every time they were expected to attend
- 51.5 percent of participants were entirely abstinent according to drug screens.
The Edmonton evaluation also found that graduates were compliant a greater percentage of the time compared to those who withdrew from the program. This finding is not particularly revealing in itself, since we would expect that participants who continually breach their conditions will eventually be discharged from the program. In fact, the Toronto evaluation reported exactly that: the percentage of participants breaching conditions increased over time, then decreased sharply in the final months–a pattern the evaluation attributed to attrition.
Site design changes related to the court component
Recognizing that relapse is part of treatment and reflecting a decision to use specific program elements to engage participants and help stabilize them, one site (Vancouver) has changed its approach to both bail conditions and sanctions in the last two years. For bail conditions, Vancouver found that participants were often being placed in detention for violations (e.g., violating curfew) which kept them out of treatment. As a result, bail conditions were largely reduced to reporting to the treatment centre and abiding by its conditions, which they believe has enhanced their ability to stabilize participants. As for sanctions, Vancouver only uses them to reengage the participant in treatment, so missed urine screens or appointments are not sanctioned if the participant is engaging in treatment and has a good relationship with treatment providers.
Treatment component
The DTCs have two main types of delivery models for the treatment component: the brokerage model and the direct service model. Each site thought that its delivery model was generally working well in meeting participants' needs.
- The brokerage model does not provide services directly but instead refers participants to treatment programs. Edmonton uses this model and believes it works well by allowing them to craft individualized treatment plans for participants and by enabling participants to build relationships with community agencies that they can then continue to access once they leave the Edmonton DTC.
- The direct service model has several variants among the DTCs. This model offers treatment services directly, although the sites vary in the amount of services, treatment or otherwise, that they offer. Sites such as Vancouver and Regina are dedicated DTC treatment centres that consider themselves "one-stop shops" as they provide treatment services, cultural services, assistance with accessing social services, and some health care services. The sites with this model believe that it works well because it offers the client group the stability and structure that coming to one location every weekday provides. These sites also noted that this model is efficient as it facilitates communication among treatment staff. Some sites offer services directly but from pre-existing treatment centres, such as Toronto (CAMH) and Ottawa (Rideauwood). These sites believe they offer participants a diversity of programming through their existing resources (e.g., access to women's programs and Aboriginal group sessions). Finally, Winnipeg offers in-house treatment services on a more limited basis and refers participants to other community resources for many types of programming and services. By requiring participants to attend programming in other community agencies, Winnipeg believes that it will increase participants' chance for long-term success because they will have established links in the community.
Stakeholders generally believe that the treatment program works. Almost two-thirds (64 percent) of survey respondents believe that the treatment program is sufficiently intensive. In interviews, DTC team members emphasized the length and intensity of the program, regardless of the delivery model. Primarily this feature of the program was considered to be an attribute as it provides needed structure for participants, and, as some noted, is more demanding than many conditional sentences. However, some DTC team members acknowledged that the requirements of the treatment program can make it difficult for participants to achieve other outcomes during the program, such as education and training or employment.
Case study participants were unanimous in their praise for the program. They found the treatment staff to be non-judgmental, dependable, always available to talk, and helpful in finding supports they needed. The following are examples of the comments made:
The whole program, and especially all the counsellors, are really understanding toward being an addict. They know that you are going to make mistakes and you are going to slip up. Every other program I've been to wasn't like that–one slip and you are out usually. [Non-completer]
The program is really awesome, don't get me wrong, but it was frustrating and I was here for so long and I just couldn't stay off the drugs. I think I wasn't doing enough on my own to coincide with the program. For me, it was just trying to stay clean that was the hardest part. Maybe if it had been a little more like a 12-step program. I find it is always easy when you're here, but it's so hard when you walk out the doors. [Non-completer]
The site process and outcome evaluations also judged the treatment programs at the DTCs to be effective, although most offered recommendations for improvements. The sites have made changes to the treatment component to respond to the earlier site process evaluations and the outcome evaluations have suggested some additional improvements. Table 10 shows that there are few themes for improving the treatment component as one might expect given that each operates so differently. The few commonalities across at least two sites are working to provide programming responsive to the target client groups, particularly women and Aboriginal people, and to build more flexibility into the treatment component when warranted.
| DTCs | Improvements (response to process evaluation) | Recommendations |
|---|---|---|
| Toronto | Process and outcome evaluation conducted simultaneously | Toronto developed a women's treatment stream and hired a peer facilitator. The program should continue its work to attract more women into the DTC. The program should consider establishing a quit date for substance use to serve as a goal for participants. The program should consider increasing the use of substantial compliance exit mechanism so those in program for a substantial period who have made improvements can have a dignified way of leaving the program. Increase peer support and mentoring. |
| Edmonton | Not included in outcome evaluation | None offered. |
| Winnipeg | Winnipeg responded by increasing the flexibility in the program by modifying group times, tailoring the length of the program to the individual, and developing individualized markers of success for which participants could receive rewards. The DTC also expanded community involvement through its Treatment Committee and more referrals. | The program may be unnecessarily stringent for low-risk participants who are doing well. The program should consider developing race and gender-specific programming to better reach targeted populations like Aboriginals and women. |
| Ottawa | Ottawa responded by increasing its programming and building in a focus on criminogenics (criminal thinking and behaviour). New clients in Phase 1 of the program are now involved in treatment, treatment-related, or court activities from 9 a.m. to 3 p.m. Monday to Friday. | Ottawa should consider more structured program for Phase 2 participants as part of relapse prevention. Phase 2 should also work toward integrating participants into the community and with community resources in order to build their resiliency. |
| Regina | Regina introduced the Criminal Thinking and Lifestyles Program as well as Aboriginal-centred programming (Grief and Loss, Traditional Parenting, and the Medicine Wheel and 12 Steps). | None offered. |
Working relationships between court and treatment teams
The DTC therapeutic jurisprudence model requires a multidisciplinary approach that includes legal and treatment professionals. However, in this innovative setting, the scope of practice is not as clearly delineated, and in areas of overlap, such as defining progress for participants, determining sanctions/rewards, and deciding whether to retain participants, tension can arise. Most DTCs are taking proactive approaches to ensure good communication so that disagreements in approach do not fester. Critical to the sense of professional respect needed to avoid discord is open dialogue at the pre-court meetings.
Developing an understanding of roles and responsibilities tended to be a more immediate problem in the expansion sites. Older sites referred to this challenge as one of their "growing pains," although they acknowledged that issues can still arise. Sites that identified this challenge referred to the relationship between court and treatment teams as "not well-defined," "lacking effective collaboration," and "not consultative." On occasion, the treatment team believes their professional judgment is not properly considered, and the court team emphasizes the fact that the program is part of a court process. Another issue concerns differences of opinion on the amount and type of information that the treatment team should share with the court team. Some treatment team members perceive the court team as wanting more information than they would share at case management meetings. The only site that did not mention experiencing these difficulties was Edmonton, which does not directly provide treatment services.
Most sites have undertaken ongoing measures to reduce tensions and increase understanding of roles. These activities include cross-training, regular retreats with the court and treatment teams, and even mediation. Some sites noted that the lack of continuity in the DTC team has exacerbated the problem, which is why orientation training and written policies and procedures (activities considered lacking) are important.
In spite of this challenge, survey results generally show strong collaboration, although fewer respondents believe that the collaboration is strong between the teams or that the roles and responsibilities are clear. Please refer to Table 11.
| Overall | DTC team | DTC governance | Other stakeholders | |
|---|---|---|---|---|
| % Agree | ||||
| (n=88) | (n=22) | (n=25) | (n=41) | |
| There is strong collaboration among the court team. | 72% | 82% | 72% | 66% |
| There is strong collaboration among the treatment team. | 67% | 82% | 64% | 61% |
| There is strong collaboration between the court team and the treatment team. | 59% | 73% | 52% | 56% |
| The roles and responsibilities of each DTC stakeholder group are sufficiently clear. | 53% | 73% | 48% | 46% |
Note: Percentages shown represent those who rated their level of agreement with each statement as a 4 or 5 out of 5.
Governance structure
As with any new program, the expansion DTCs continue to work on developing their governance structures. In the process evaluations, two sites received suggestions for improving these structures (Winnipeg and Regina) and both have responded. Winnipeg developed policies to clarify and document the structure and composition of the Steering Committee. Regina has reduced the size of its governing body, which the process evaluation had found to be too large, and has begun to meet more frequently.
There is a wide range of governance structures across the six sites. Smaller sites have one formal committee overseeing the program (Regina), while larger sites are more likely to have a layering of committees. For example, Vancouver has a Steering Committee for higher-level policy matters and an Operations Committee to handle line-level operational issues. Across the sites, committee meeting schedules range from twice a month to about once every three months.
Governing committees also vary in terms of their composition. Some include more DTC team representatives and/or community representatives, and others focus more on partner representatives at the provincial ministerial level. This difference appears to be due to the type of funding recipient, but also partly to the delivery model. For example, the "one-stop shops" with provincial department funding recipients tended not to include community members, while the direct service delivery models with NGO funding recipients either have community advisory committees that include partner organizations and agencies, such as women's programs, housing/shelters and community health centres, and/or have community members who serve on their governing committee.
Comments in some sites demonstrated some concern about the mix of treatment and court representatives on the committees and the need to ensure that the positions of each program component are represented at the governance committees. Only one site, Toronto, had an alumnus on a governance committee.
These differences and the continued evolution of governing committees demonstrate that the oversight structures of the DTCs are responding to the needs of each DTC. The evaluation did not find major concerns about the adequacy of the governing structures. Survey results support this finding, as two-thirds of the DTC team and governance committee respondents believe that the governance structure ensures that the DTC operates efficiently and effectively.
Gaps and challenges
Two of the main challenges identified in the site evaluations as well as this evaluation have already been discussed: reaching target groups and understanding roles and responsibilities between treatment and court teams.
Housing. In addition to those areas, the evaluations identified lack of safe housing and treatment beds as a major challenge in four of the six sites. Lack of adequate housing compromises the DTCs' ability to stabilize the participant. DTC team members reported poor success with participants who are in shelters or remain on the street (see additional discussion in Section 4.3 under outcomes). These high-risk environments continue to expose participants to the people and situations that have contributed to their addictions. At some sites (e.g., Edmonton), the lack of housing and treatment beds also limits the number of clients the program can accept because offenders must remain in custody until housing and/or treatment space is available.
Of the DTC sites, only Regina and Winnipeg did not report substantial difficulties finding suitable housing or treatment beds for participants. Regina has a financial worker who assists clients with housing and has strong links to provincial agencies and to landlords. Winnipeg attributed its ability to address participants' housing needs to its relationship with Addictions Foundation of Manitoba, which provides access to residential treatment, and its partnership with the Manitoba Housing Authority. That being said, the site outcome evaluation reported that participants interviewed identified housing as a major issue that staff sometimes overlooked.
Drawing from early progress reports, the DTCFP recognized this challenge early in the mandate and worked to develop an MOU with the Homelessness Partnering Strategy of Human Resources and Skills Development Canada (HRSDC). This MOU recognized that the mandates of each program complemented one another and, together, would enhance the federal investment in this marginalized population. From this partnership, funding was provided to three DTC sites (Toronto, Vancouver and Ottawa). Although sites are addressing the housing issue, they all believe that more effort and funding are needed. For example, Ottawa has four beds through the John Howard Society and one priority spot with the Elizabeth Fry Society for a program with about 30 participants. Toronto has eight beds for men through the John Howard Society. Vancouver has hired a housing case manager to assist with finding housing for participants and has funds through HRSDC that provide subsidies for housing; however, that money ends in March 2009. Key informants also noted that the lack of safe and suitable housing for women is particularly acute and likely affects the ability of some sites to retain women in the program.
Other lines of evidence support these findings. When asked about unmet needs or potential improvements to the DTC operations, survey respondents identified housing as an area that needs to be addressed. In addition, case study participants suggested that offering "clean" housing would assist participants.
Resource issues. Most sites consider staffing and funding to be issues that affect program delivery. The level of funding limits the number of staff below optimal levels in some locations. Key informants cited heavy caseloads that limit the effectiveness of treatment staff, the ability to offer more specific programming (e.g., Aboriginal and women's groups), and the capacity of the program as three primary effects. In addition, many sites consider the housing issue to be so acute and to have such an effect on the ability to achieve outcomes that additional funds directed to housing are necessary. Survey results also reflect these concerns as only one-fifth (19 percent) of respondents believe that the DTC can handle more clients given its current caseload and resources.
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