Manual Updated August 13 th 2008 Table of Contents
s: Program Overview Program History Client Throughput/Decision Point Map Retreats Eligibility Referral Application Screening Bail Treatment Roles and Responsibilities Urine Screens Treatment Process Court Roles and Responsibilities Court Procedures Governance and Community Overview Governance Documents CAC terms of reference Diversity Committee Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7 Appendix 8 Appendix 9 2 to 16 17 to 32 33 to 44 45 to 52 53 to 57 TDTC Application Form Crown Questionnaire TDTC Instruction List TDTC Rule and Waiver Form TDTC Bail Progress Report Form Police Recommendation Form (TPS 481 form) CAC List Application for Readmission 1
Program Overview Program History 1of 2 A Drug Treatment Court (DTC) is a unique substance abuse intervention model that operates within the criminal justice system. Drug Treatment Courts are premised on the basis that traditional sentencing standards do not influence recidivism in drug dependent offenders, since the core problem influencing their conflicts is addiction. With the approach of a Problem Solving Court, DTC s provide addicts in conflict with the law with an opportunity to engage in a judiciallysupervised treatment program. Originating in the U.S.A., the first DTC was established in Miami, Florida in 1989 to deal with non-violent, substance-abusing offenders who repeatedly cycled through the judicial system. After observing a similar revolving door cycle that drug dependent offenders went through within the Canadian court system, in summer of 1997; through the initiation and leadership of Honourable Justice Paul Bentley, a committee comprising of representatives from Federal Department of Justice, defence bar, Legal Aid Ontario, Toronto Public Health, Centre for Addiction and Mental Health, Ministry of Community Safety and Security (Probation Department), Court Services and various community agencies commenced exploring the possibility of establishing a DTC in Toronto. After several months of discussions, as part of its commitment under Canada s Drug Strategy, with a goal to reduce the social and economic costs of illicit substance abuse, the federal government through the National Crime Prevention Centre agreed to fund a four-year pilot. On December 1 st 1998, Canada s first Drug Treatment Court commenced operation in Toronto. Since then DTC s have been established in several other jurisdictions, including Jamaica, Bermuda, Brazil, Scotland, Ireland, Australia and a total of 8 to date in Canada. 2
Program Overview Program History 2 f 2 Toronto Drug Treatment Court (TDTC) was the first DTC to be established in Canada. It began operating on December 1 st 1998. The TDTC offers an alternative to incarceration for non-violent offenders addicted to cocaine, methamphetamine, heroin and/or other opiates. The program aims to improve social stability and reduce criminal behavior associated with substance dependency. Treatment and Judicial stakeholders work collaboratively to facilitate change in lives of those whose conflicts with the law are influenced by their addictions. Using the holistic approach to rehabilitation and social development, stakeholders work together to provide clients with relevant supports, structure and access to resources. Traditional roles of stakeholders involved in program delivery are enhanced through a shared understanding of others members roles and responsibilities, knowledge of judicial processes and addiction treatment. This approach is aimed at helping drug dependent offenders break the cycle of drug addiction, criminal behavior and incarceration. The program relies on the collaboration of Judges, Crown Prosecutors, Duty Counsel, Police Officers, Probation as well as other Court officials, treatment staff from the Centre for Addiction and Mental Health (CAMH) and Community agencies, that provide specialized substance abuse treatment and ancillary services such as housing, health services and job training. Originally the program was limited to non-violent persons charged with drug related offences. The target group for the pilot was vulnerable groups of offenders that included youth, prostitutes and visible minorities. 3
Since October 2004, the Ministry of the Attorney General s office for the province of Ontario has approved the participation of non-violent drug dependent offenders charged only with criminal code offences. 4
Program Overview Client Throughput/Decision Point Map 1 of 1 5
Program Overview Retreats 1 of 1 Bi-monthly the Court Team and the Treatment Team, also known as the Program Delivery Team, come together to engage in cross-disciplinary training, make team decisions on proposed service delivery changes, resolve challenges and build/sustain healthy relationships. 6
Program Overview Eligibility 1 of 2 Eligibility criteria is designed to assess the suitability of applicants as program participants. The TDTC eligibility criteria include the following: Applicant with cocaine, methamphetamine, heroin and/or other opiates as the primary drug of addiction. Applicant is non-violent offender whose addiction is primary reason of offending. Applicants with propensity for violence and/or charged with violent offences such as residential break and enters are ruled out. In cases where there are mitigating factors, applicants with history of violence may be admitted. These include determination that applicant does not pose a threat to herself/himself or others, dated prior convictions for violent conduct, that is absence of convictions for violent behaviour in recent five years, degree of remorse, age, mental/medical/physical condition, family or community support available, applicants willingness to engage in treatment, etc. Trafficking offences will ordinarily have been committed primarily to support the drug habit. Applicant trafficking for commercial gain are excluded. Applicants who involve young persons under the age of 18 in their offences are excluded. Applicants committing their offences on or near school or playgrounds will generally be excluded. Applicants consuming drugs in a motor vehicle or with drugs on open display in a motor vehicle will generally be excluded. 7
Program Overview Eligibility 2 of 2 For applicants who have previously been in program, the onus will be on them to convince the court as to why they should be given another opportunity. The applicant s participation in the TDTC program must be voluntary and will occur only after the applicant has received legal advice from a lawyer. Applicants who have not used illicit drugs in six months preceding application, are generally excluded from participation. Extenuating or mitigating factors in the applicant s circumstances may warrant an exception for admission. Applicants serving a custodial or conditional sentence, on parole, or on immigration hold will generally be excluded. They may re-apply after the resolution or completion of these matters. Applicant must agree to have all outstanding criminal charges brought into TDTC. Any factors that may prevent an applicant from participating and meeting program expectations will generally be excluded. 8
Program Overview Referral to Program 1 of 1 Any person can refer and/or inform an individual charged with an eligible offence to the program. This includes: Judges Justices of the Peace Defence/Duty Counsel Other Court officials Police officers Probation officers Treatment providers Social workers Prosecutors Correctional officers Community Agencies Referrals generally come through Defence/Duty Counsel, Crowns office, outreach work of Treatment, Probation and Police Liaisons, as well as through arresting officers. 9
Program Overview Application Process 1 of 1 The TDTC is a voluntary program. As such, it is up to the individual to make an application for admission to the program. Application does not guarantee acceptance. Each application must pass through a screening process before an individual is admitted. If approved, he/she will be required to comply with set criteria in order to be formally accepted into the program. The Application form consists of two documents: TDTC Application Form: Appendix 1 Crown Questionnaire Form: Appendix 2 Upon completion, these documents are submitted to the TDTC Prosecutor s office. The Application form provides legal information around eligibility as well as biographical, personal and addiction related information. Individuals must return to court on a Tuesday or Thursday the week following their application to determine if they are eligible. Applications are generally screened within five business days from date of submission. Exceptions may occur where it is determined at any phase of the TDTC screening process that additional information or additional time to assess or access resources is required. 10
Program Overview Screening Process 1 of 6 Screening Objectives: The screening process is designed to achieve the following objectives: To identify and engage eligible participants as soon as possible after their arrest. To identify/address preliminary case management issues and/or factors that may present barriers such as housing, physical health, family circumstances, nature/extent of drug addiction, cognitive ability, readiness and willingness to engage in treatment, etc. To provide applicants freedom of choice and an opportunity to determine whether the program is suitable for them. Screening Phases: There are six phases in the screening process: Phase I: Crown Screening Program Overview Screening Process 2 of 6 The Prosecutor(s) reviews and screens client file to determine whether applicant is appropriate for the program. Prosecutor considers factors/information relevant 11
to determine if applicant participation is in interest of the public. Factors and types of information considered include: Applicant s criminal record, any violence-related convictions on that record. Allegations related to applicant s current charges and circumstances of offence(s). Police input as to whether applicant is a known addict and could benefit from the program and any recommendations for bail conditions. Prosecutor determines whether applicant is appropriate to proceed to next phase and accordingly notes decision on the application form. Prosecutor indicates screening results on TDTC Instruction List (Appendix 3) which is distributed to Prosecutor(s) and Duty Counsel in remand court(s) for purpose of remanding eligible applicants to the next phase. Crown screening results are also provided to TDTC program Duty Counsel, Court Clerk, Treatment/Community Court Liaison and Probation Liaison for the purpose of further screening. Program Overview Screening Process Phase II: Preliminary addictions assessment: 3 of 6 This assessment is conducted by the Treatment/Community Court Liaison at the court house. 12
Factors and types of information considered are individual demographics, substance use history, previous treatment involvement, family history, social history, community supports (i.e housing/identification needs), child welfare concerns and any other possible risk factors _ Generally most applicants are screened in custody prior to their first appearance in Drug Treatment Court Phase III: TDTC Team pre-court discussion Assessment information and recommendations are presented to TDTC Judge in the pre-court meeting held immediately prior to applicant s first appearance in Drug Treatment Court. This includes input from the Crown, the Treatment/Community Court Liaison, Probation, Duty Counsel/Defence Counsel, and Bail Program. Includes information from addiction assessment, probation/correctional records as well as information with regards to the offences and applicants understanding of the legal requirements of the program Program Overview Screening Process 4 of 6 Phase IV: In-court interview by the TDTC Judge on applicants first court appearance: The Judge engages in an informal, in-court interview with the applicant to further assess applicant s suitability. The inquiry involves understanding of: Applicant s history Applicant s motivation for wanting to participate in the TDTC program Applicant s comprehension of the nature and expectations of the TDTC program 13
Whether the applicant s decision to enter the program and to plead guilty is voluntary. That the applicant has had legal advice regarding their decision to participate and signed the TDTC Rule and Waiver Form (Appendix 4) If applicant is found eligible, he/she is arraigned and enters a guilty plea to the charge for which the prosecutor requires a plea If applicant is found ineligible or chooses not to proceed, his or her matters are returned to the regular court stream. Program Overview Screening Process 5 of 6 Phase IV: (ctd) Applicant is placed on TDTC bail Phase V: In-depth Clinical assessment conducted at Centre for Addiction and Mental Health. This generally takes place between applicant s first and second appearances in TDTC. The Clinical Assessment involves a comprehensive review of the applicants.. After completion of the assessment, applicant returns to court 14
Program Overview Screening Process 6 of 6 Phase VI: A 30-day assessment period This phase relies on the outcome of the clinical assessment. If applicant has attended assessment, is deemed appropriate and wishes to proceed he/she will enter the 30 day assessment period. The 30 day assessment period allows the team an opportunity to review/monitor client s involvement and progress, adherence to program requirements and ability to engage effectively. The 30 day assessment period also provides the applicant an opportunity to decide whether this program is appropriate and meeting their needs. At the end of the assessment period, the applicant is either formally accepted as a client of the program or given the opportunity to strike their pleas and return to the normal court stream If the applicant is not appropriate to proceed, treatment can still make recommendations and facilitate other treatment referrals as appropriate If applicant attends assessment but is deemed inappropriate or does not wish to proceed in the TDTC program the applicant has the option to either be sentenced or have their pleas struck and return to the regular court stream. 15
Program Overview TDTC Bail 1 of 1 In order to facilitate participation all applicants are placed on a TDTC bail (Appendix 5). For an applicant to enter a TDTC bail; The applicant will ordinarily be released on his or her own recognizance, though in some cases the Court may require a surety bail. The bail conditions are designed to assist applicants engagement in the program and can include: Attending and actively participating in treatment Attending for urinalysis as required Abstaining from use of alcohol and drugs and honestly reporting all drug and alcohol use, including any prescribed medications. Being honest with treatment providers and with the court Attending court as required Living at a specified address that is program approved and not moving without court s approval; Advising the court of any other charges that the applicant has or incurs while in the program Being subject to curfews, boundaries, and/or non-association conditions. Participants who breach bail conditions may be sanctioned, or may be expelled from the program. Treatment Roles and Responsibilities of Treatment Team 1of 6 Program Manager: According to Policies and Procedures of the CAMH, performs duties of clinical Program Manager. As well as coordinates all aspects of program operations, and engagement of Community/Judicial stakeholders involved in program delivery. 16
Duties include: - Facilitating development and implementation of procedures which support an efficient, effective, holistic rehabilitative response. - Developing and maintaining access to resources and rehabilitative programs that meet client needs and enhance their engagement. - Supervising program evaluation/evaluator and coordinating committees engaged in enhancing efficiency and effectiveness of the program. - Managing program budget and providing reports to the funding organization. - As member of Operations Committee, engaging in decision making. - Coordinating at CAMH, inter-departmental interactions relevant to treatment and rehabilitative needs of the program. - Ensuring treatment policies/procedures as well as recommendations/decisions are in congruence with ethics and standards of clinical disciplines, CAMH and DTC. - Clinical staff supervision and performance management. - Providing opportunities for professional development and inter-team education. - Advocating for interests and perspectives of treatment within the program, its governance structure, CAMH, treatment community, and communities in general. - Facilitating effective communication and collaboration between service providers and other appropriate community and/or justice stakeholders. - Engaging in educating about health and safety impact of program to various levels of, government, CAMH, treatment community and communities in general. - Facilitate community consultation regarding program policy and direction. - Develop and coordinate publications, documentation and website maintenance. Treatment Roles and Responsibilities of Treatment Team Case Manager/Therapist: (Case Manager) 2 of 6 The cornerstone of service delivery, the Case Manager reports to the Program Manager. He/She within parameters of judicial requirements of the program provides holistic care to meet client needs and facilitate their transformations. Along with Addiction Therapist responsibilities set out in the of CAMH, the TDTC Case Manager 17
coordinates access to resources and provides supports for the well-being, rehabilitation and reintegration of program clients as productive members of their communities. Duties include: - Completing comprehensive client program suitability and needs assessments. - Comprehensively managing client cases. - Providing individual counselling/therapy sessions. - Facilitating group counselling/therapy sessions. - Participating in treatment team case conferences. - Preparing progress reports for court. - When required attending pre-court case meetings or court sessions - Providing clients with program procedural information - Providing clients support to meet and follow through with program expectations, recommendations and decisions. - Documenting client s participation in all individual and group sessions. - Documenting all contacts relevant to client s involvement in the program. - Consulting with Court Liaison and/or Urine Screening Assistants about client s drug test results. - Participating in professional development and educational sessions. - Participating when required, in program activities such as graduation ceremonies, committee work and retreats. - Ensuring client, stakeholder and public interactions are in congruence with ethics and standards of clinical disciplines, CAMH and DTC. Treatment Roles and Responsibilities of Treatment Team Treatment/Community Court Liaison (Court Liaison): 3 of 6 With extensive understanding of substance abuse, treatment issues and judicial process, the Court Liaison, functions primarily as the communication link between the Court, Treatment providers and the Community. He/She reports to Program Manager. Duties include: 18
- Co-ordinating collection and dissemination of information from treatment team and ancillary service providers to court and vice versa - Ensuring that the highest possible case management standards are upheld - Co-ordinating and monitoring community service hours assigned to clients - Co-ordinating all information pertaining to monitoring of client urine screens - Updating and maintaining court dockets - Planning, scheduling and co-ordinating client graduations - Conducting initial assessments of potential clients at Court/ Level II of screening and where applicant is deemed appropriate, coordinating schedule for next level of assessment at CAMH. - Participating in pre-court meeting as well as in case conferences at treatment. - Providing clients with support at court, including, co-ordinating relevant referrals to detoxification units, housing, etc. - Participating in Community Advisory and other program related committees. - Building community partnerships to enhance program service provision. - Develop mechanisms to increase participation of alumni and community members - Disseminating outreach information to outside agencies and community forums. - Participating in professional development and educational sessions. - Participating, when required, in program activities such as retreats. - Documenting all contacts relevant to client s involvement in the program. - Ensuring client, stakeholder and public interactions are in congruence with ethics and standards of CAMH and DTC. Treatment Roles and Responsibilities of Treatment Team Urine Screening Assistants: 4 of 6 Urine Screening Assistants (one male, one female) monitor the random drug-testing component of program to deter and/or detect sample substitution or adulteration and communicate drug test results to Medical Review Officer, Court Liaison and Case Managers. Duties include: 19
- Organizing and implementing collection of urine drug screening - Observe client s providing screening samples - Monitor client random screening attendance - Package specimens for transport to the laboratory - Update and maintain client information on computer database - Print client drug screen reports for Medical Review Officer and Court Liaison twice weekly and/or when required. - Provide weekly urine screen updates to Case Managers Nurse Practitioner: Based at the Centre for Addiction and Mental Health, the nurse practitioner provides health promotion and basic medical support to program clients. The role is established since a number of clients do not have family doctors, and in fact have little or no access to ongoing medical care. Drug dependent clients are faced with wide range of associated health risks, due to actions of drugs themselves, the ways in which the drugs are administered, and the street lifestyle led by many. HIV/AIDS, tuberculosis, various forms of hepatitis, and sexually transmitted diseases are just a few of the medical problems that clients could be dealing with. The Nurse Practitioner provides program clients with appropriate information, education, and referral assistance to deal with such issues. Treatment Roles and Responsibilities of Treatment Team 5 of 6 Nurse Practitioner (ctd) Duties include: - Meet with new clients to obtain their medical histories regarding communicable diseases, STD s, acute medical problems, etc. and make appropriate referrals. - Administer and read tuberculosis skin tests for all new clients. 20
- Liaise with referral sources and provide relevant information to clients as well as to therapist/case managers. - Provide general education to staff and clients regarding medical issues associated with substance use. - Provide clinical and educational support to staff and clients in relation to basic healthcare and health promotion issues. - Provide consultations to staff regarding precautions in response to any local breakouts of infectious diseases (e.g. tuberculosis, SARS) - Provide consultation to therapist/case managers regarding appropriate responses to medical issues experienced by individual clients. Department Secretary The primary role of the Secretary is to serve as an associate and provide administrative support to the Program and program Manager. As well provide support for program related financial, administrative and publication responsibilities. Treatment Roles and Responsibilities of Treatment Team 6 of 6 Medical Review Officer (MRO) The role of the MRO, a medical doctor with an understanding of addiction medicine and familiarity with the clinical uses of drug testing is to supervise the court-ordered testing component of the TDTC program. The drug-testing aspect is an important component of TDTC. While acknowledged drug use leads neither to sanction nor to expulsion, test results are important and objective 21
markers in verification of reported use, detection of unreported use and documentation of client progress. Duties include: - Supervise collection and testing of biological samples, typically urine. - Supervise randomization procedure of testing and sample integrity - Review test results and confirm whether samples fall within physiological limits (ph, Temperature, Creatinine). If required, based on clinical context, recommend and/or authorize further testing. - Liaise with Laboratory Personnel and Court Liaison to discuss specific lab results. - Meet with Treatment Team to provide assistance in clinical use of test results and assist in training with respect to interpretation of test results. - While not responsible to dictate drug testing strategies, assist TDTC program in understanding implications of its choices - To maintain validity of an impartial opinion, ensure no direct clinical contact with clients. - Advise program on general matters of drug testing and recommend drug testing related resources. - When needed assist program in developing new and revise or modify existing policies pertaining to the drug testing program. - Advise Prosecutor(s) and defence counsel on test results pertaining to expulsions. Treatment Urine Screens 1 of 3 Urine screens are an integral part of the TDTC Program. Participants are required to leave urine screens on a random basis and whenever directed by the Court or Treatment Providers. Unlike some jurisdictions, a positive urine screen is not cause for incarceration or expulsion from the program. Instead the urine screen process is a catalyst to encourage honest and timely disclosure of drug use by the participants. Failure to provide a urine 22
screen or tampering with urine screens may result in court imposed sanctions, generally at the 1 st court attendance after team becomes informed. These sanctions range from admonishment by the judge to increased court attendance, performing community service hours, written essays or revocation of bail. Urine Screen Procedure/Reporting Process Treatment Urine Screens New clients are assigned one of five colour groups as part of their participation in the random urine screen program (red, green, blue, yellow or orange). The Court Liaison assigns the colour based on existing lists & attempts to keep the numbers under each colour group evenly distributed. The new client s information is then added to the client list this includes their name, file number, date of birth, case manager, assessment date and urine screen colour this list is updated regularly and distributed to the treatment team including urine screen attendants. The client is informed of colour group at the 1 st Court attendance after the clinical assessment, and he/she is instructed as to how random screening program works. Once a colour is assigned it is noted on client s progress report. Once a week all results are reviewed with the Medical Review Officer (MRO). The Court Liaison will pick up urine screen results from laboratory along with record of attendance twice a week on the day before court. 2 of 3 Urine Screen Procedure/Reporting Process (ctd) Once reviewed, the results are transcribed onto each client s progress report it is at this time that the Court Liaison attempts to assure the results are congruent with what is noted on the report. 23
In addition to looking at attendance, as well as positive/negative urine results, the Court Liaison must monitor creatinine levels. Anything less than 1.8 is considered a low creatinine. Where results are not congruent with reporting, the Case Manager is contacted to clarify the possible discrepancy with the client - if there continues to be concern the results must be reviewed with the MRO Where there is discrepancy between clients s reported drug use and urine screen result (positive result & no reported use), the urine sample will be retested. If the sample remains positive but client continues to report no use, he/she will be placed in court on a urine collection process known as No Further Challenge Status. Missed urine screens are recorded on progress report as a NO SHOW and the Case Manager is informed of the missed urine. Without legitimate reason (medical reason supported by a doctor s note) missed urine will usually result in a court imposed sanction. Generally a bail revocation, however client s progress and program participation are taken into consideration to determine the type of sanction. In addition to receiving cumulative urine screen reports from the lab the CLO also receives copies of urine screen results to distribute to the Case Managers on a weekly basis. Treatment Urine Screens 3 of 3 Challenging Results of Urine Screens Participants agree to accept validity of the urine screen results prior to entering the program, when they are reviewing the Rule and Waiver Form. If there is a dispute with respect to a result, the urine screen is retested. If the retest confirms the presence of the disputed drug, then the client is placed on the No Further Challenge Status method of 24
urine collection. If the participant disputes a subsequent screen result, he/she may be expelled from the program. 25
Treatment Treatment Process 1 of 7 The treatment for clients of TDTC Program is delivered and coordinated by the TDTC treatment team, all of whom are employees of Center for Addiction and Mental Health (CAMH). The core treatment service delivery team includes the Program Manager; Treatment/Community Court Liaison and 4 Case Managers/Therapists. Treatment Programs at the Centre for Addiction and Mental Health Clients may participate in cocaine dependency treatment program, an opiate dependency program or individualized combination of both programs if they are addicted to opiates and cocaine. The core treatment takes place at Centre for Addiction and Mental Health, Addiction Research Foundation site at 33 Russell Street in Toronto. When appropriate or required, clients may be referred to other CAMH sites, other treatment facilities, as well as to community resources. Clinical Assessment All clients receive a comprehensive, face-to-face standardized assessment at (CAMH). This assessment investigates client s substance use history and its impact on the client. It identifies any physical and mental health concerns, and explores client s strengths and social supports. If as an outcome of the assessment, the client is found appropriate to participate in the Drug Treatment Court Program, the client enters into an initial 30-day assessment phase of the treatment program, during which time both client and program teams (either court, treatment or both) can decide whether this treatment arrangement will be a good fit. 26
Treatment Treatment Process 2 of 7 Cocaine Treatment Treatment for cocaine addiction in TDTC utilizes the cognitive-behavioral approaches, relapse prevention, life skills, psycho-educational sessions, and group support. It is a multi-phased treatment program, with case management, random urinalysis and court attendance as ongoing treatment elements throughout the phases. Assessment After completion of clinical assessment (described previously), client is assigned an individual Case Manager with whom he/she works one on one. The frequency of individual sessions is based on client needs. Generally once a week early on in the program, additionally client will attend group treatment in the following phases; Orientation and Stabilization Phase There are two types of groups in this phase. Getting Started is a group attended by clients on one occasion following assessment. In this group, clients learn program norms, expectations and benefits. Behaviours that can incur sanctions are discussed. Also, in this session clients can start addressing their most urgent social needs such as housing. Group size in Getting Started is small because, the group is held on as needed basis, depending on number of intakes in a given week. Clients also attend, Preparation Group, this phase. This group is co-facilitated by two therapists and consists of 2-hour support group sessions, three times per week for four to eight weeks. In this phase clients work on eliminating their use of cocaine and developing techniques for dealing with drug cravings. Clients also work on developing links with community resources (i.e. housing) in order to achieve stability they will need to be able to work on their drug use/issues in the next, intensive, phase of the program. Preparation Group provides an opportunity for clients to start identifying their substance use issues and to learn how to work in a group setting. Motivational counselling, group discussion, and psycho-educational approaches are used during this phase. There is no limit on the size of this group. If it becomes too large, it can be split into two smaller groups. 27
Treatment Treatment Process 3 of 7 Intensive Treatment Phase This phase consists of 2-hour group sessions, four mornings per week for three weeks. Utilizing a cognitive-behavioural perspective, clients are helped to recognize triggers to drug use, to become aware of the functions of drug use, and to develop alternative coping strategies. The consequences of drug use are explored, and clients begin to set lifestyle goals. Sessions are semi-structured, and homework assignments (i.e. weekend planning) are used throughout the phase. The optimal group size in this phase is approximately 12 clients. Maintenance Phase 2-hour group sessions twice per week for three months focus on maintaining positive lifestyle changes, Relapse prevention strategies, and continued goal setting. The groups are less structured, and provide opportunities for exploring personal and interpersonal issues. Continuing Care Phase These 2-hour sessions occur one evening per week, for the remainder of a client s participation in program. They provide ongoing group support to maintain change and continue the focus on preventing relapse, as well as continuing to provide a forum for discussion of lifestyle and personal issues. Clients can attend more than one type of group concurrently in order to obtain additional support (i.e. Stabilization and Intensive groups). This includes court attendance. The program is competency-based, in that as clients progress through the program and demonstrate increasing ability to control drug use, the court attendance frequency is also reduced. 28
Treatment Treatment Process 4 of 7 Opiate Treatment Treatment of opiate addiction (primarily heroin addiction) primarily utilizes individual rather than group support. As with treatment of cocaine addiction, case management, weekly urinalysis, and attendance at court are ongoing features of the work with opiate clients. Following the standardized clinical assessment described earlier, clients are offered the option of beginning a methadone maintenance program. Some clients choose not to, and others are already involved with such program, either at CAMH, or at another methadone clinic. If latter is the case, clients can continue receiving their methadone at the outside clinic, and will also be connected with the Drug Treatment Court opiate therapist for case management. Clients who elect to begin methadone maintenance at CAMH are first given a urine screen to determine that they are in fact opiate users, and a letter is also sent to the College of Physicians and Surgeons to find out whether or not the client is already getting methadone somewhere else. This takes one day. Within two days of the clinical assessment, clients have a medical assessment and a nursing assessment at the Centre. If the doctor decides that methadone treatment is indicated, the client begins treatment that same day. Clients are told about providing urine specimens (twice weekly initially) to monitor compliance with methadone regimen. They must see the doctor again within three days to assess the response to initial dosage level of methadone (for example, to see whether the client has been experiencing withdrawal symptoms). The dosage is steadily increased until there are no withdrawal symptoms. Clients initially come for their methadone on a daily basis, and often do so for quite some time. With increasing compliance with treatment, and reduced use of opiates and other drugs, clients receive carries for varying lengths of time, i.e. they can bring their doses home with them, so that they don t have to come as often to the clinic. 29
Treatment Treatment Process 5 of 7 Opiate Treatment ctd. Clients are also connected with TDTC opiate therapist, who acts as their case manager. Together they develop a treatment plan, which evolves over time. This plan includes linkages with community resources to respond to client s social needs. While getting stabilized on methadone, clients may see their case manager daily, and gradually reduce to one visit per week. Clients who choose not to go on methadone maintenance also meet with their individual case manager, and work on social needs, relapse prevention skills and coping strategies (as do methadone clients). As with cocaine, TDTC opiate clients may be connected with other services at CAMH or in the community. For example, some opiate clients may also be abusing cocaine, and may attend the cocaine treatment program. Referrals to External Treatment Programs Generally, clients will receive treatment in the TDTC dedicated treatment program at CAMH. Under some circumstances, a referral to another program within CAMH, or to an outside treatment agency, may be indicated. This could be the case if: 1. The client has experienced little or no progress in dedicated program, and the treatment staff feel that an intensive (i.e. a residential program) or specialized program (e.g. women s, Spanish) would better meet client needs. 2. The client requires a different kind of program at the outset, as determined by screening and assessment, and by client preference. For example, a client might state a strong preference for an all-women s program, or a program for gay males, or they may be dealing with issues best addressed in a specialized program. Some clients may be involved in other treatment programs at time of their admission (e.g may be receiving methadone at an outside clinic), continuation in those programs may make the most sense clinically. 30
Treatment Treatment Process 6 of 7 Procedure If a client is referred to another program during the course of treatment in TDTC, the case manager will connect with the new treatment provider on a regular basis to determine client progress. He/she will also complete progress report for client s court appearances. In general, He/she will liaise between TDTC program and the other treatment provider, and will deal with any problems that arise. A representative from the alternative treatment provider will be invited to attend pre-court case conferences, and court sessions, to familiarize themselves with the TDTC program. The client will provide urine specimens at CAMH, unless there is an approved process in place for obtaining supervised urines at the other treatment program. Case Conference The case conference occurs twice per week, generally on a day prior to court. This meeting involves members of core treatment team. If they choose, Court team members do have the option to attend. The purpose of this meeting is for Case Managers to provide the CLO with updated information on clients scheduled for court the next day. Additionally, as a team collaboratively review client progress and provide any relevant recommendations. This information is written on a Progress Report Form (Appendix 6) and can include: Last court date Drug use Treatment Phase Attendance at treatment sessions Cancellations or no shows (missed) Participation in the treatment process Punctuality 31
Treatment Treatment Process 7 of 7 Information that can be included in Progress Report Form (ctd.) Attendance at other meetings such as 12 steps which are not a formal component of the treatment program but are recommended for additional support. s and results of urine screens and/or missed urine screens Referrals to other treatment as well as any current and/or emerging issues related to family, social supports, employment, education or health Recommendations for sanctions for failure to meet program expectations Recommendations regarding client s readiness to graduate from the program Recommendations regarding a client s suspension or expulsion from the program Treatment team can make recommendations for sanctions, for client s failure to meet program expectations, but the ultimate decision will rest with presiding Judge. Treatment team can also recommend which areas of client progress should be highlighted in court. At this meeting, the court liaisons also provides treatment team with information about issues that arise at court and give feedback and input regarding court team discussions and decisions. 32
Court Roles and Responsibilities of Court Team 1 of 7 Court Team comprises of: Judge, Crown Prosecutor, Duty Counsel, Probation Liaison and Treatment/Community Court Liaison, Crown s Assistant/Paralegal and Court Clerk. It should be noted that the Treatment/Community Liaison participates as member of both treatment and court team. Presiding Judge: In addition to responsibilities of a Judge mandated by Attorney General, the presiding Judge in would have the following attributes: Would ensure fundamental rights of participant offenders remain protected within the collaborative system Is consistent Is impartial Is motivating Is a good listener Is empathetic Has an understanding of addictions Has ability to work as part of a team Duties include: The Judge presides in Drug Treatment Court, chairs Pre-Court meetings and participates in program development, training, education, and decision-making activities. Also, participates in committee work, including in Community Advisory Committee as well as the Operations Committee, the decision making body of the program that he/she chairs. 33
Court Roles and Responsibilities of Court Team 2 of 7 Prosecutor(s) Federal Prosecution Services of Canada as well as the Provincial Prosecution Services under the Attorney General of Ontario are both stakeholders of the program. To maintain consistency in the Prosecutor s function, one prosecutor participates in Pre- Court meetings and in Court. One prosecutor is assigned to the client service delivery aspect of the program for a minimum of twelve consecutive months. Duties Include: Review cases at all stages of criminal justice process to identify appropriate cases where accused persons are eligible to apply for the TDTC. These are cases where there is sufficient indication that a drug addiction may be present Is the first point of screening process and determines whether preliminary DTC eligibility requirements are met. Monitors participants compliance with TDTC program requirements. Educates other members TDTC teams on relevant aspects of prosecution function Has primary responsibility advocating for the program amongst law enforcement officials, educating prosecutors and training other law enforcement officials. Has primary responsibility for identifying, communicating and addressing the concerns of police, corrections and probation officers. Participates as member of various TDTC committees Participant in TDTC outreach activities 34
Court Roles and Responsibilities of Court Team 3 of 7 DTC Paralegal/Crown s Assistant: The Public Prosecution Services has assigned a paralegal to the TDTC on a fulltime basis. The TDTC paralegal assists the TDTC prosecutor in discharging his/her prosecution function in the program. The paralegal is central to ensuring continuity of the practices and policies of the TDTC Prosecution Office. Duties: Responsible for all administrative aspects of the TDTC Prosecution Office Assists the TDTC prosecutor in carrying out all legal and non-legal aspects of the prosecution function. Updates and maintains integrity of files, ensures that TDTC prosecution packages are complete and that all application forms and crown questionnaires are filled out correctly. Conducts legal and non-legal research to support the TDTC prosecutor Facilitates exchange of information between police and TDTC prosecution office. That is, works with TDTC police liaison to ensure officers complete TDTC police questionnaire in a timely fashion, informs police of participant progress, and requests police input on aspects such as bail. Works with TDTC police liaison officers to facilitate the effective and prompt execution of TDTC bench warrants Participates in outreach activities and training sessions to train other community and law enforcement officials. Facilitates flow of information between the TDTC prosecution office and TDTC court, treatment, the police and community officers. 35
Court Roles and Responsibilities of Court Team 4 of 7 Duty Counsel: The role of the Duty Counsel is to act as defence counsel in the TDTC. This role may be the most difficult of any team member. Circumstances arise where there is conflict between, the wishes of the duty counsels client and expectations of the multi-disciplinary team of which the duty counsel is a team member. It should be noted that similar to regular court, in TDTC program, the interest and directions of the of duty counsels client take precedent to any team expectations. Duties include: Assist unrepresented defendants, in or out of custody with application process Interview defendants and provide them with legal advice about TDTC Review TDTC Rules and Waiver form with applicants before they decide whether or not to enter the program Attend TDTC pre-court meeting on behalf of every TDTC participant so as to ensure their interests are represented Assist defendant with entering guilty plea Represent participants facing penalty issues of non-compliance in absence of a private counsel. Represent defendants when they leave the TDTC program for the regular criminal justice system and/or facing expulsion. Represent defendants for sentencing purposes, after successful completion of the program or after withdrawal/expulsion from the program 36
Court Roles and Responsibilities of Court Team 5 of 7 Probation & Parole Court Liaison Officer (CLO) The CLO brings a Probation/Correctional perspective. Participates in service delivery aspects of and as ember of the operation committee engages in program development activities and decision making processes. Duties include: Assisting prosecutors by collecting information on applicant s past and/or current history, addiction, response to community supervision and relevant correctional information for assessing suitability case management. Upon request, providing information for Level I of screening and/or presenting information at Level III of screening in the pre-court meeting. Participating in pre-court team discussions Advising court of any outstanding probation charges. Providing information regarding conditions and compliance for those applicants currently on probation. Liaising with probation officers to facilitate prioritization of TDTC participation and provide information on progress in TDTC. Supervising participants with active probation after 90 days in TDTC. Supervising participants in Phase II of TDTC and providing court with update. Enforcing breaches in Phase II, where appropriate requesting variations. Liaising with other stakeholders regarding housing, employment/training, etc. and supporting client s in court to access resources, eg. detox beds. Co-facilitating change facilitation groups with CAMH staff. Where applicable conducting home visits in conjunction with Toronto Police Participating/organizing educational and outreach initiatives, including sessions in the community, probation offices and for potential clients at detention centres. Participating in program development committees. 37
Court Roles and Responsibilities of Court Team 6 of 7 Police Liaison The Toronto Police Service (TPS) has two levels of involvement. The police are first contact with potential participants. Many TDTC participants are chronic offenders and well known to Police. In addition to information about criminal charge, police often have significant information on general circumstances and character of accused. This information is helpful to screening of TDTC applications. Upon arrest of an offender, Toronto Police Force officers are required to fill out a TDTC police information form. In this Form, the police provide information on the accused person s housing situation, family circumstances, criminal, employment and drug use history, general reputation and character issues on matters such as history of violence, drug use and drug history, criminal activities, motivation for criminal behaviour, i.e. to support a drug habit or for some unrelated reason, etc. In this Form, the police also provide their opinion as to whether the accused is suitable or not suitable for the TDTC program. Toronto Police Services have also assigned a court officer as police liaison to TDTC: Duties include: Providing information relevant to screening of applicant and recommendations for supervisory mechanisms such as bail conditions Providing information in respect to compliance with program bail conditions and alert to any further criminal activity of TDTC participant. To ensure effective and prompt execution of all TDTC bench warrants. To update police information systems and ensure effective communication with TDTC. To educate partners on police procedures/ concerns, organize training sessions and prepare training material for participating in outreach activities. Member of Community Advisory Committee and other TDTC committees. 38
Court Roles and Responsibilities of Court Team 7 of 7 Court Clerk There are two clerks assigned to the TDTC. They provide administrative support for the Judge and other members of the TDTC team. Duties: Collect client files for those participants appearing before the TDTC that week and have them available for the Judge Engages program client s in TDTC in Question of the day Attend twice a week pre-court (for consistency) meetings and engage in the usual clerical and administrative functions of a criminal court clerk. Bail Program Supervisor Duties include: Providing assessment and bail supervision of appropriate clients Attending pre-court meeting and TDTC Participating in Community Advisory Committee and other Committees 39