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Substance use disorder treatment clinician and director challenges working with collaborative justice court and child welfare systems: A multisite qualitative study

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Substance use disorder treatment clinician and director challenges working with collaborative justice court and child welfare systems: A multisite qualitative study

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SUBSTANCE USE DISORDER TREATMENT CLINICIAN AND DIRECTOR
CHALLENGES WORKING WITH COLLABORATIVE JUSTICE COURT AND CHILD
WELFARE SYSTEMS: A MULTISITE QUALITATIVE STUDY

by

Dean Rivera

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(SOCIAL WORK)

August 2022

Copyright 2022 Dean Rivera
ii

Dedication
This work is dedicated to all women and their families in the United States who are in
need of family-centered substance use disorder treatment. This research is also dedicated to
giving voice to all substance use disorder treatment providers. Your treatment, care, and support
to those suffering from an addiction provides a path to individual, family, and community
restoration.

iii

Acknowledgments
I am deeply grateful to several important people for all the mentorship, support, and
guidance that I have received during my PhD studies. To Dr. Hortensia Amaro, Dr. Benjamin
Henwood, Dr. Steven Sussman, and Dr. Suzanne Wenzel, thank you for your invaluable advice
and continuous support, along with your belief in me during my research. Your expertise and
immense knowledge have been an inspiration to me throughout my PhD program. As senior
professors, each of you helped shape my scientific curiosity and scientific skill set necessary for
conducting important research that will improve the lives of those affected by a substance use
disorder. I have learned so much from you.
I would like to extend my sincere thanks to the California State University Office of the
Chancellor, the Chancellor’s Doctoral Incentive Program, and the California Pre-Doctoral
Scholarship, who supported me with funding and other important resources through the years.
Special thanks go to all the substance abuse treatment agencies, directors, and clinicians in Los
Angeles County, California, who participated in this research study. Your contributions to
science, policy, and practice relating to cross-system collaborative practices from the viewpoint
of substance use disorder treatment providers are invaluable.
To Dr. Julia Gluesing, I am thankful to have received your expert consultation and
training with ATLAS.ti. My qualitative research and analytical skills were enriched by your
expertise. To Dr. Donna Dueker, I am grateful for your unwavering patience and commitment
when training me on the use of STATA and SAS software. I also want to express my
appreciation to Eric Lindberg. Thank you for your professional editing and manuscript
preparation services.
iv

TABLE OF CONTENTS
Dedication ................................................................................................................................. ii
Acknowledgments.................................................................................................................... iii
List of Tables .......................................................................................................................... vii
List of Figures ........................................................................................................................ viii
Abstract .................................................................................................................................... ix
CHAPTER ONE: OVERVIEW OF THE STUDY .................................................................. 1
Background of the Problem ................................................................................................ 1
Statement of the Problem .................................................................................................... 2
Purpose of the Study ........................................................................................................... 9
Research Questions ........................................................................................................... 12
Importance of the Study .................................................................................................... 13
Definition of Terms........................................................................................................... 17
Organization of the Dissertation ....................................................................................... 18
CHAPTER TWO: LITERATURE REVIEW ......................................................................... 20
Collaborative Justice Courts ............................................................................................. 21
Table 4: Practice Components of Current and Initial Drug Court Model......................... 22
Collaborative Justice Court Effectiveness ........................................................................ 23
Unmet SUD Treatment Parenting and Family Needs Among CJC
Participants ........................................................................................................................ 25
The FCA in the SUD Treatment and CJC Context ........................................................... 26
Limitations of Family-Centered Treatment and FCA Practice in CJCs ........................... 27
Key Components of the FCA ............................................................................................ 28
Family Treatment Court Effectiveness Compared with Other CJCs ................................ 29
Limitations and Gaps ........................................................................................................ 31
Importance of SUD Treatment Provider Viewpoints ....................................................... 32
SUD Treatment Intra-Agency Challenges and Barriers to Collaboration ........................ 33
CW Oversight, the ASFA, and Parental SUD Treatment ................................................. 34
ASFA as Legislation That Furthers a Siloed Approach to SUD Family
Treatment .......................................................................................................................... 37
Adverse Cross-System Collaboration Challenges and Barriers........................................ 38
Dual Roles and the “Double Bind” of SUD Treatment Clinicians and
Directors ............................................................................................................................ 39
Methodological Limitations of Past Research .................................................................. 41
Theoretical Frameworks ................................................................................................... 42
Summary ........................................................................................................................... 45
CHAPTER THREE: METHODOLOGY ............................................................................... 47
Restatement of Study Purpose .......................................................................................... 47
v

Restatement of Research Questions .................................................................................. 47
Theoretical and Conceptual Framework ........................................................................... 48
Women’s Residential SUD Treatment Program Sample .................................................. 49
Clinician and Director Sample .......................................................................................... 52
Adequacy of the Protection Against Risks ....................................................................... 54
Instrumentation ................................................................................................................. 54
Data Collection ................................................................................................................. 55
Data Analysis .................................................................................................................... 57
CHAPTER FOUR: RESULTS ............................................................................................... 61
Participant Characteristics ................................................................................................ 62
Research Question One ..................................................................................................... 62
Theme One: Communication as a Challenge to Treatment Provision .............................. 65
Cross-System Responsiveness to Clinician and Directors ................................................ 65
CW Communication and Responsiveness to Patients ...................................................... 66
Theme Two: Lack of Knowledge on SUD Treatment Approaches, Goals,
and Values ......................................................................................................................... 66
Differing Views or Values Regarding SUD Treatment Approach ................................... 67
Negative Biases or Perceptions ......................................................................................... 67
Lack of Training in SUD Treatment and Trauma-Informed Care .................................... 69
Theme Three: Large Caseloads and Logistical or Resource Concerns ............................ 70
Lack of Cross-System Logistics and Resources ............................................................... 70
Heavy Workload Concerns ............................................................................................... 71
Theme Four: ASFA as a Challenge to SUD Treatment Provision ................................... 72
ASFA Timeline as a Barrier to SUD Treatment Provision............................................... 72
Child Custody Concerns and CW Requirements as a SUD Treatment
Competitor ........................................................................................................................ 73
Functions of Quality Cross-System Collaboration and Communication .......................... 74
Research Question Two .................................................................................................... 82
Theme One: Adverse Impacts on the Clinician-patient Relationship ............................... 84
Inadequate Cross-System Communication and Responsiveness ...................................... 84
Impacts of Cross-System Mandated Reporting ................................................................ 86
Impacts of Cross-System Monitoring Requirements ........................................................ 88
Theme Two: Adverse Impacts on SUD Family Treatment Planning ............................... 89
Inadequate Cross-System Communication and Responsiveness ...................................... 90
Impact of Cross-System Mandated Reporting .................................................................. 91
Impacts of Cross-System Monitoring Requirements ........................................................ 92
Theme Three: Impacts of the ASFA Timeline on the Clinician-patient
Relationship ...................................................................................................................... 94
Fear of CJC and CW Knowledge of the Patient’s Continuing Treatment
Needs................................................................................................................................. 94
Induced Psychological Stress and CW Focus ................................................................... 95
Lack of CW Communication and Responsiveness ........................................................... 95
Theme Four: Adverse ASFA Timeline Impacts on Treatment Planning ......................... 96
Unrealistic Expectations ................................................................................................... 96
Lack of CW Communication and Responsiveness ........................................................... 97
vi

Functions of Quality Cross-System Collaboration and Communication .......................... 97
Research Question Three ................................................................................................ 109
Theme One: Strategies or Recommendations for Cross-System
Collaboration................................................................................................................... 110
Cross-System Collaboration at the Treatment Level ...................................................... 111
Cross-System Collaboration at the Systems Level ......................................................... 112
Theme Two: Strategies or Recommendations for Cross-System
Coordination ................................................................................................................... 114
Cross-System Coordination at the Treatment Level ....................................................... 114
Cross-System Coordination at the Systems Level .......................................................... 116
Theme Three: Strategies or Recommendations for Improving
Clinician-patient Relationship ........................................................................................ 117
Cross-System Treatment Planning with the Patient........................................................ 118
Developing or Preserving the Patient Alliance and Rapport .......................................... 120
Theme Four: Strategies or Recommendations to Improve SUD
Treatment Planning ......................................................................................................... 121
Cross-System Collaboration at the Treatment Level ...................................................... 122
Cross-System Collaboration at the Systems Level ......................................................... 123
CHAPTER FIVE: DISCUSSION ......................................................................................... 134
Restatement of Background, Purpose of this Study, Research Questions,
and Methodology ............................................................................................................ 134
Introduction to Discussion .............................................................................................. 136
Summary of Findings ...................................................................................................... 137
Discussion of Research Question One ............................................................................ 138
Discussion of Research Question Two ........................................................................... 143
Discussion of Research Question Three ......................................................................... 151
Implications..................................................................................................................... 158
Limitations ...................................................................................................................... 164
Conclusion ...................................................................................................................... 165
References ............................................................................................................................. 168
Appendices ............................................................................................................................ 190
Appendix A: Recruitment Flyer...................................................................................... 191
Appendix B: Information Sheet (Exempt Form) ............................................................ 192
Appendix C: Interview Guide ......................................................................................... 195
Appendix D: Participant Demographic Form ................................................................. 198

vii

List of Tables
Table 1: Types of Collaborative Justice Courts .............................................................................. 5
Table 2: Description and Differences in Stakeholder Group Missions, Values,
and Goals ........................................................................................................................................ 7
Table 3: Characteristics of Women (n = 1,201) Entering Residential SUD Treatment
in Los Angeles County, CA in 2016 ............................................................................................. 15
Table 4: Practice Components of Current and Initial Drug Court Model..................................... 22
Table 5: Six Essential Components of the FCA ........................................................................... 30
Table 6: Sampling Strategy and Timeline .................................................................................... 49
Table 7: Participant Sociodemographic and Treatment Provider Characteristics (n = 24) .......... 63
Table 8: Research Question 1 (Themes and Subthemes) .............................................................. 65
Table 9: Cross-System Collaborative Mechanisms That Adversely Affects
Treatment Provision ...................................................................................................................... 75
Table 10: Research Question 2 (Themes and Subthemes) ............................................................ 83
Table 11: Cross-System Patient Monitoring, Inadequate Communication and Responsiveness
Adversely Affect the Clinician-patient Relationship and Treatment Planning ............................ 98
Table 12: Research Question 3 (Themes and Subthemes) .......................................................... 110
Table 13: Strategies and Recommendations on Ways to Improve Collaboration, Coordination,
the Clinician-patient Relationship and Treatment Planning ....................................................... 124

viii

List of Figures
Figure 1: SEM Framework: Multilevel Context of Cross-System SUD
Treatment Challenges ................................................................................................................... 44
Figure 2: Women’s Residential SUD Treatment Program Selection
Diagram......................................................................................................................................... 51

ix

Abstract
This research applied the socioecological model and two organizational theories (resource
dependence and interorganizational relations theories) as a guiding lens into substance use
disorder (SUD) treatment provider challenges when collaborating with the collaborative justice
court (CJC) and child welfare (CW) systems. The purpose of this study was to identify how
cross-system collaborative challenges adversely affect SUD treatment provision while gaining a
clearer understanding of how these challenges negatively affect the clinician-patient relationship
and treatment planning. Thematic analysis was conducted using descriptive, qualitative data
from semistructured interviews (n = 24) with SUD treatment clinicians (n = 18) and directors (n
= 6) at four women’s residential SUD treatment programs in Los Angeles, California. There
were eight main themes from this study indicating SUD treatment provision, the clinician-patient
relationship, and treatment planning are adversely affected, particularly regarding cross-system
communication and responsiveness, monitoring requirements, differing system values, and
Adoption and Safe Families Act timeline mandates. Four main themes outlined strategies or
recommendations to address these adverse cross-system collaborative conditions, particularly
related to cross-system collaboration and coordination, the clinician-patient relationship, and
SUD treatment planning. Implications include crucial contributions of child and family team
meetings and SUD treatment liaisons for enhancing cross-system collaboration and
communication among the SUD treatment, CJC, and CW systems, thereby strengthening SUD
treatment provision, the clinician-patient relationship, and treatment planning. Theoretical
implications include the utility and application of integrated theoretical frameworks
(socioecological model and organizational theories) for future research or model development.
This study provides key preliminary evidence pointing toward future research directions.

1

CHAPTER ONE: OVERVIEW OF THE STUDY
Background of the Problem
A family-centered approach (FCA; see Definition of Terms) for women and their families
that are in need of SUD treatment has been determined to be a best practice (Lloyd et al., 2021;
National Center on Substance Abuse and Child Welfare, 2021; Worcel et al., 2008). For SUD
treatment providers (clinicians and directors), this is made difficult when mothers are involved in
separate systems concurrently, such as the criminal justice (CJ) and CW systems. Unfortunately,
since 1980, there has been an increase in incarceration rates among women of 750%, outpacing
men by more than 50% (Carson, 2016; The Sentencing Project, 2022). This spike in
incarceration rates has been attributed to substance use, where more than 60% of women
incarcerated in prisons or jails are serving sentences for drug-related crimes (Covington, 1998;
2007) and 80% who are mothers (Kajstura, 2019), most of whom are the primary caretaker of
their children (Kajstura, 2019). Moreover, substance use among women has been recognized in
most states as a leading cause of child neglect and abuse (Breshears et al., 2004; Child Welfare
League of America, 1998). This brings SUD treatment clinicians and directors, who treat women
with SUDs, into the central role of navigating a challenging cross-system (CJC and CW)
collaborative environment while simultaneously addressing the complex family SUD treatment
needs of their patients.
CJCs were developed as a cross-system collaborative approach to more effectively
address the overlapping and interconnected SUD-related problems that bring many women into
the CW and CJ systems, including (a) child maltreatment and neglect that is related to addiction,
and (b) crimes that are associated with having a SUD. The evolution of CJCs arose from the
success of the drug court model for addressing SUDs. The first drug court began in Miami,

2

Florida in 1989 during the peak of the crack cocaine epidemic in the United States diverting
offenders with a SUD into treatment instead of incarceration. In response to the success of drug
courts in diverting criminal offenders with SUD into treatment instead of jail or prison, the
California judicial system implemented CJCs in 2006 to address the wider range of specific
social service needs of defendants, including the complex needs of parents and their children
with a SUD (Wolf, 2005). However, barriers to cross-system collaboration between SUD
treatment, CJC, and CW systems continue to persist challenging SUD treatment providers from
meeting the complex treatment needs of families affected by a SUD (Lietz & Geiger, 2017;
Lloyd et al., 2021; Worcel et al., 2008). Prior research in this area, however, has not adequately
explored how SUD treatment clinicians and directors working with women who have a SUD
address these cross-system challenges that can adversely affect the provision of SUD treatment,
the clinician-patient relationship, and treatment planning.
Statement of the Problem
SUD treatment providers (clinicians and directors) who focus on SUD treatment for
women with children frequently emphasize the need to treat the family as a whole, which is
called the FCA (see Definition of Terms). Approximately 50% of all adults (Lloyd et al., 2021;
Rossman et al., 2011) and 100% of all women with a CW case served by the CJC system are
parents, and recent work has documented the extensive parental and family needs that go unmet
within the CJC context (Guastaferro et al., 2020). SUD treatment providers and the CJC and CW
systems recognize the need to shift toward an integrated FCA model driven by cross-system
collaboration while balancing the well-being of the child, the treatment needs of mothers
struggling with a SUD, and family reunification goals (Lloyd et al., 2021; Rossman et al., 2011).
To help drive the implementation of family-centered care across the U.S., the NCSACW has

3

developed training curriculums designed for state-, county-, and agency-level collaborative
implementation practices (NCSACW, 2021).
SUD treatment providers and their CJC and CW cross-system partners are struggling to
meet the comprehensive family treatment needs associated with mothers in residential SUD
treatment. To increase CJC effectiveness, FCA practices in the CJC system are recommending
evidence-based approaches for treating women and their families within the CJCs (Huebner et
al., 2017; Worcel et al., 2008); however, implementation and cross-system collaborative efforts
remain fragmented or not initiated. This is often due to cross-system communication,
coordination, and collaboration challenges to cross-system relationships between the residential
SUD treatment (inpatient), CJC and CW systems (Brook et al., 2016; Clary et al., 2020; Lloyd et
al., 2021).
Importantly, prior research in this area has not adequately explored how these cross-
system challenges involving these three systems adversely affect the provision of residential
SUD treatment, the clinician-patient relationship, and treatment planning. Further, prior research
on cross-system collaboration for families involved with the CJ and CW systems has been
primarily conducted at the system level and largely from the perspectives of the CJC and CW
systems (Lloyd et al., 2014, 2021). Importantly, no known prior research has qualitatively
explored from SUD providers (clinician or director) viewpoints, challenges and barriers to
residential SUD treatment provision, the clinician-patient relationship, and treatment planning
when collaborating among different stakeholders (CJC or CW) with which the patient is
simultaneously involved (Lloyd et al., 2014, 2021; Marsh et al., 2012; Smith & Mogro-Wilson,
2008). These limitations provide the rationale for the focus on how cross-system interagency
challenges adversely affect residential SUD treatment provision.

4

CJC’s are courts that combine judicial oversight with treatment services that are
rigorously monitored and have a primary focus on the defendant’s recovery to reduce recidivism
and future crimes associated with having a SUD (Wolf, 2005). There are several types of CJCs
including drug courts, reentry courts, family treatment courts, mental health courts, domestic
violence courts, and juvenile courts to name a few. The CJCs that involve this study’s population
of interest include drug court, reentry court, and family treatment court (see Table 1). Each of
these types of CJCs mandate women with a SUD into residential or outpatient SUD treatment
while providing continuous monitoring and oversight of the parents treatment progress in
coordination with the CW and SUD treatment systems (Marlowe et al., 2016; Wolf, 2005).
CJCs are managed by a multidisciplinary cross-system team including judges,
prosecutors, defense attorneys, SUD treatment providers, and CW workers (see Table 1).
Jurisdictional oversight of the CJC and CW systems that mandate the monitoring and reporting
requirements of SUD treatment progress (e.g., urinalysis reporting, biweekly or monthly
progress reports, court attendance, and child visitation and monitoring) require SUD treatment
providers to communicate and coordinate frequently with CJC and CW workers. This is
particularly relevant to women who have concurrent child custody cases with the CW system.
For example, SUD treatment providers and patients need frequent contact and coordination with
CW workers to ensure the safety of the child and pursue family reunification, which are stated
FCA goals of the CW, CJC, and SUD treatment systems. Consequently, for women with active
CW cases, open communication, responsiveness, and FCA planning among the SUD treatment,
CJC, and CW systems and their workers are vital to the recovery success of the mother and
family reunification. Women’s SUD treatment that includes components of addressing the FCA
supports parenting roles such that in the context of residential SUD treatment programs; (a)

5

Table 1: Types of Collaborative Justice Courts

children are allowed to remain with their parent during treatment or (b) child visitation with the
mother during treatment is a coordinated and essential element of the mother’s recovery and the
family reunification process.
Currently, communities across the United States continue to experience shortages of FCA
practices, along with challenges to effective cross-system, collaborative, family-centered practice
implementation, which is required for improved treatment and reunification success (Brook et
al., 2016; Green et al., 2009; Lloyd et al., 2021). Challenges to this open communication,
responsiveness and FCA planning among systems can include, but is not limited to (a) CW case
workers and the courts being overwhelmed (e.g., large caseloads and court dockets), and (b) CW
case worker and court pessimism regarding the time and investment allowed for cases involving
Type Definition
Family
treatment court
Family treatment court is a family court where selected abuse, neglect, and
dependency cases are identified where parental substance abuse is a primary
factor. Judges, attorneys, CW workers, and SUD treatment stakeholders
collaborate with the goal of providing safe, nurturing, and temporary or
permanent homes for children while simultaneously providing parents with
SUD treatment services. Family treatment court assists parents in regaining
control of their lives by promoting long-term stabilized recovery to enhance
family reunification within mandatory legal timeframes (Development
Services Group, Inc., 2016).
Reentry court
Reentry courts use the drug court model to facilitate the reintegration of
drug-involved offenders into the community when released from county or
state correctional facilities. Reentry court participants receive services
needed to improve successful community reintegration including SUD and
mental health treatment (Tauber & Huddleston, 1999).
Adult drug
court
Drug court is a specially designed criminal court where the purpose is to
reduce recidivism and substance abuse among nonviolent substance-abusing
offenders while increasing their likelihood of successful SUD recovery
through early, continuous, and intense judicial oversight of SUD treatment;
mandatory periodic drug testing; community supervision; and use of
appropriate sanctions, rewards, and other rehabilitative services (Marlowe et
al., 2016; Wolfe, 2005).

6

women with serious SUDs and a prior CW history. Despite the shared underlying goal of SUD
treatment and family reunification, each system has differing values that cannot be overlooked,
compounding challenges to collaborative FCA best practices among systems (Children and
Family Futures [CFF] & National Association of Drug Court Professionals [NADCP], 2019;
CFF & National Drug Court Institute [NDCI], 2017). The SUD treatment, CW, and CJC systems
have differing values regarding their clients. These differing values may lead to clashes in
agency missions and priorities, and tensions regarding the direction of the patients’ family-
centered SUD treatment (e.g., active child visitation or reunification support as a key component
of SUD treatment planning, active CW engagement and responsiveness to SUD providers and
patients in family-centered treatment planning, and how substance use relapses are viewed,
whether punitively or as part of a chronic health condition). For example, there are differing
values regarding the client being represented: The SUD treatment system is primarily concerned
with the treatment and recovery of the patient, the CW system is primarily concerned about the
safety of the child, and the CJC system is primarily concerned with recidivism, public safety, and
the legal concerns of the courts (see Table 2; CFF & NADCP, 2019; CFF & NDCI, 2017;
Drabble, 2010; Green et al., 2008). This is particularly relevant to the CW or CJC systems’
acknowledgement that (a) having a SUD is a chronic condition, (b) relapses are likely and should
not be a determining factor on whether child adoption or permanency hearings ensue, and (c)
relapses be considered in the larger context of the SUD treatment progress that has been made by
the mother.
Importantly, stigma towards parents with a SUD is a pervasive problem across the court
and CW systems that can negatively impact SUD treatment entry and utilization while affecting
important legal and child welfare decision-making processes (McGinty & Barry, 2020; Weber,

7

Table 2: Description and Differences in Stakeholder Group Missions, Values, and Goals
Mission of stakeholders
Women’s SUD treatment: To help rebuild the lives of women and their children along with
communities impacted by substance abuse. To promote self-sufficiency while ensuring safety
and shelter for women in SUD treatment. (Mission statement from a women’s SUD treatment
program)
CW: Promoting child safety and well-being by partnering with communities to strengthen
families, keeping children at home whenever possible, and connecting them with stable homes in
times of need (Department of Children and Family Services [DCFS], n.d.).
Collaborative justice court: To combine judicial supervision with rehabilitation services that are
rigorously monitored and focused on recovery to reduce recidivism and improve offender
outcomes (Collaborative Justice Courts, n.d.).

Primary stakeholder values
Women’s SUD treatment: The SUD treatment and recovery of women.
Child welfare: The safety and well-being of the child.
Collaborative justice court: The reduction in criminal offending and recidivism.

Stakeholder goals

Women’s SUD treatment
The primary aim of the
women’s SUD treatment
services is to improve
outcomes for women with
substance use disorders,
their children, and other
members of their families.
To accomplish this goal,
there must be a
comprehensive model of
clinical treatment services
that addresses the complex
interconnected treatment
needs of the parent, child,
and family as a whole
(Werner, Young, Dennis, &
Amatetti, 2007).
Child welfare system
The goal of child welfare is
to (1) promote the well-
being of the child, (2)
permanency, and safety of
children and families by
helping families care for
their children successfully,
or (3) when that is not
possible, helping children
find permanency with kin
or adoptive families
(DCFS, n.d.).
Collaborative justice court
An interdisciplinary team, led
by a judge (or parole
authority), works
collaboratively to achieve two
goals: (1) Case management to
expedite case processing and
reduce caseload and time to
disposition, thus increasing
trial capacity for more serious
crimes. (2) Therapeutic
jurisprudence to reduce
criminal offending through
therapeutic and
interdisciplinary approaches
that address addiction and
other underlying issues without
jeopardizing public safety and
due process (National Institute
of Justice, 2020).

8

Miskle, Lynch, Arndt, & Acion, 2021). Stigma operates at multiple levels where individuals with
a SUD are blamed for their condition or the individuals themselves blame or fault themselves for
the disorder. This is particularly impactful because beliefs and attitudes associated with stigma
towards individuals with a SUD, notably mothers with children, perpetuate a punitive rather than
trauma-informed therapeutic approach, because the mother is seen as unfit to parent (McGinty &
Barry, 2020; Weber et al., 2021).
At each level of stigma there can be adverse outcomes. For example, at the individual
level, the mother may believe that she is an unworthy or bad person because she uses drugs, thus
delays seeking SUD treatment. At the systems level (organizational or policy level), a SUD
treatment clinician may provide a positive urinalysis drug test or other negative behavioral report
to the CW and CJC systems. Resultingly, the mother may lose trust in the clinician and abandon
critically needed treatment (Weber et al., 2021). Or, at the policy level, the criminalization of
substance use and involvement in the CW system are historically entrenched negative social
biases that have affected attitudes, beliefs, and subsequent policies, whether consciously or
unconsciously (e.g., adoption laws or incarceration for substance use). These entrenched stigmas
influence decisions on how parents with SUDs are treated with respect to decision-making
processes across the CJC and CW systems, affecting their criminal justice and child custody
outcomes (McGinty & Barry, 2020; Weber et al., 2021). It is currently unclear to what degree
and how these cross-system (CJC and CW) biases and stigmas play out across systems and
adversely affect parental SUD treatment provision.
Despite the emphasis on the importance of cross-system collaboration and FCA
principles being practiced in the SUD treatment, CJC, and CW systems, prior research has
suggested that SUD treatment providers and their patients frequently experience fragmented,

9

disempowering and even counterproductive cross-system collaboration, communication,
responsiveness, and patient involvement (Brook et al., 2015; Lietz, 2011; Lloyd, 2015). Prior
research in this area has suggested that SUD treatment clinician and director experiences of
cross-system collaboration with the CJC and CW systems are inconsistent with the stated FCA
and family reunification goals of each system and the patient (Lietz, 2011; Lietz & Geiger,
2017). Gaining a clearer understanding of how cross-system collaborative discontinuity among
the SUD treatment, CJC, and CW systems adversely affects treatment provision, the clinician-
patient relationship, and treatment planning is critical to informing the changes needed to
improve women’s SUD treatment and family reunification outcomes.
Purpose of the Study
A key purpose of this study is to gain insight into the cross-system communication,
responsiveness, and collaborative challenges that adversely affect treatment provision, from SUD
treatment provider viewpoints. Currently, most research on cross-system collaboration related to
parents involved with the CJ and CW systems is primarily conducted from the viewpoints of the
CJC and CW systems. No known studies have qualitatively explored, from SUD treatment
provider viewpoints, how current cross-system collaborative mechanisms, communication, and
responsiveness adversely affect treatment provision, the clinician-patient relationship, and
treatment planning.
Given that SUD treatment clinicians and directors have residential SUD treatment
custody of the parent and are tasked with being the primary collaborative agent between the
mother and the CJC and CW systems, their experiences are critical to understanding the
collaborative challenges that adversely affect SUD treatment provision, the therapeutic clinician-
patient relationship, and treatment planning. Although these three stakeholder systems share the

10

underlying goal of SUD treatment and family reunification, each stakeholder system has
differing historically entrenched values that cannot be ignored (CFF & NADCP, 2019; CFF &
NDCI, 2017). For example, there are differing values and perspectives on who the primary client
is that should be represented among the three systems: The SUD treatment system is primarily
concerned with the treatment and recovery of the patient, the CW system is primarily concerned
about the safety of the child, and the CJC system is primarily concerned with recidivism and the
legal concerns of the courts. These differing values may lead to conflicts in agency missions or
priorities, along with tensions regarding crucial decisions or the direction of the patients’ family-
centered SUD treatment (e.g., how substance use relapses are viewed punitively rather than as a
component of a chronic health condition). Further driving CJC and CW values are entrenched
policy level and social stigmas, particularly related to parents with a SUD, their fitness to parent,
and decision-making processes that affect their criminal justice and child custody outcomes
(McGinty & Barry, 2020; Weber et al., 2021).
Additionally, many CJC and CW systems still operate from a traditional “siloed”
approach, which can be antithetical to the necessary collaborative and cross-system
communication necessary to address the complex SUD treatment needs of parents and their
families (Child Welfare Information Gateway, 2014). For instance, the CJC, CW, and residential
SUD treatment systems can remain operationally siloed because of separate funding, legal and
regulatory mandates, and value-oriented perspectives on their respective clients (Drabble, 2010).
These silo driven influences leave cross-system collaboration fragmented, not fully implemented,
or not sustained. These historically ingrained, value-oriented, and siloed CJC and CW practices,
along with the myriad of current cross-system collaborative challenges, requires understanding
the insider’s viewpoint (SUD treatment providers).

11

Importantly, due to jurisdictional CJC and CW regulatory oversight and monitoring
requirements, SUD treatment providers have dual roles and allegiances that place them in a
“double bind,” meaning they are accountable to the CJC or CW systems and the patient
simultaneously (Burman, 2004). For example, being in a double bind where SUD treatment
providers are accountable for providing mandated treatment progress reports and updates to the
CJC and CW systems, while simultaneously attempting to maintain the confidentiality and
ethical concerns involved with their patients, challenges the quality of treatment planning and the
therapeutic patient rapport building process. For instance, when SUD treatment providers engage
in cross-system mandated (CJC and CW jurisdictional monitoring and oversight) communication
and reporting of a patient’s treatment progress to a CJC or CW worker, a client’s suspicion that
ulterior motives, such as a treatment providers commitment to the legal or CW system, may
result in the deterioration of trust or the reluctance of a patient to engage in the treatment process
and therapeutic clinician-patient relationship (Burman, 2004).
As family-centered partnerships in the SUD treatment, CW, and CJC systems progress,
treatment and family reunification planning differences are expected to emerge among the
systems (Boles et al., 2012), which can obstruct or negatively affect residential SUD treatment
provision (Drabble et al., 2013; Marsh et al., 2006). For example, the majority of CJC programs
(e.g., drug and reentry courts) remain focused on the CJC adult participant only, perhaps
reflecting the lack of knowledge or resources to collaboratively implement FCA best practices
with the SUD treatment and CW systems (CFF & NDCI, 2017). Gaining a previously unknown
or a fuller understanding, from SUD treatment provider viewpoints, on the adverse challenges
they experience in cross-system collaboration with the CJC and CW systems, along with how
these challenges affect SUD treatment provision, the clinician patient relationship, and treatment

12

planning are crucial. Along with SUD treatment provider recommendations and strategies for
improving these adverse conditions, the implications of this study will provide key findings that
can improve a FCA to SUD treatment, CJC, and CW collaboration while strengthening the
treatment providers ability to provide higher quality women’s residential SUD treatment.
The purpose of this study was to explore and highlight how current cross-system
challenges among these three systems obstruct SUD treatment provision, the clinician-patient
relationship, and treatment planning and to identify treatment provider strategies for improving
these conditions. This study used a multisite qualitative research design to pursue three goals.
The first purpose of this study was to explore questions that will generate a deeper and richer
understanding from SUD treatment clinician and director viewpoints on how current cross-
system collaborative relationships create challenges or barriers to SUD treatment provision. The
second purpose was to gain a clearer understanding of how existing cross-system (CJC and CW)
reporting and monitoring requirements, along with communication and cross-system
responsiveness, negatively affect the SUD clinician-patient relationship and treatment planning.
Importantly, a third purpose was to identify and highlight key strategies, from the viewpoints of
SUD treatment providers, to improve cross-system collaborative mechanisms that will improve
treatment provision, the clinician-patient relationship, and treatment planning.
Research Questions
This study gathered qualitative data from SUD treatment clinicians and directors on how
cross-system jurisdictional oversight and monitoring, along with the lack of treatment
coordination and responsiveness by the CJC and CW systems, create a challenging treatment
environment for providers and patients who are simultaneously involved with each system. This
multisite study investigated clinician and director experiences and viewpoints grounded in the

13

following three research questions:
1. What cross-system collaborative mechanisms involving the SUD treatment, CJC, and
CW systems create SUD treatment provision challenges for clinicians and directors?
2. How do cross-system oversight and monitoring requirements and communication and
responsiveness adversely affect the clinician-patient relationship and treatment planning?
3. How can (a) cross-system collaboration and coordination among the different
stakeholders (SUD treatment, CJC, and CW) be improved and (b) the clinician-patient
relationship and SUD treatment planning be strengthened via improved cross-system
communication and coordination?
Importance of the Study
This research study contributes to a growing body of knowledge concerning cross-system
collaborative mechanisms involving the SUD treatment, CJC, and CW systems, which
collectively are charged with providing services to mothers with SUDs. Gaining a systems-level
perspective on cross-system challenges from the individual experiences of SUD treatment
clinicians and directors will facilitate a more precise understanding in an area for which little is
known. In addition, gaining a more accurate understanding at the individual-, interpersonal-, and
organizational-levels from the SUD provider perspective will provide insight into joint
opportunities for integrating an FCA philosophy that will increase communicative and
responsiveness to the transcending goal of meeting the family treatment needs of mothers and
their children. The socioecological model (SEM) and organizational theories (resource
dependence theory and interorganizational relations theory) are well-suited as theoretical lenses
for interpreting and understanding the multilevel (individual, interpersonal, organizational, and
policy) challenges inherent within cross-system collaboration between the SUD treatment, CJC,

14

and CW systems. Communication and active collaboration across systems helps to ensure that
the parents SUD is identified and addressed with appropriate treatment in a timely manner, while
simultaneously addressing the developmental and psychosocial needs of the children. When
interagency collaboration and effective communication across systems is operating within FCA
practices, interagency coordination enables a wider array of resources to be provided than
traditionally available from any individual system alone. The implications and results of this
study provide important insights into the multilevel treatment challenges and barriers that SUD
treatment clinicians and directors experience when providing FCA practices while engaged in
cross-system collaboration.
To advance and improve current cross-system collaborative mechanisms and SUD
treatment outcomes, it is critical to explore clinician and director viewpoints and experiences on
“how and why” (a) cross-system collaborative partnerships with CJCs and CW systems
challenge SUD treatment provision by directors and clinicians; and (b) cross-system oversight
requirements, communication and responsiveness adversely affect the clinician-patient
relationship and treatment planning. In addition, it is vital to gain clinician and director
viewpoints on key recommendations for improving (a) cross-system collaboration,
communication, and responsiveness among SUD treatment providers, CW, and CJC
stakeholders; and (b) the clinician-patient relationship and SUD treatment planning through a
more cohesive family-centered service delivery approach. Addressing limitations in this area of
research from the SUD provider perspective can inform strategies for improving cross-system
collaboration among the SUD treatment, CJC and CW systems. Furthermore, this study will
provide a working understanding of how the current cross-system (SUD treatment, CJC, and
CW) collaborative framework is negatively affected by CJC and CW jurisdictional reporting

15

Table 3: Characteristics of Women (n = 1,201) Entering Residential SUD Treatment in Los
Angeles County, CA in 2016
Characteristics
n (%) or
M (SD)
Age 35.8 (11.4)
Primary drug or alcohol problem
Heroin 171 (14.5)
Alcohol 316 (26.3)
Methamphetamines 512 (42.6)
Cocaine or crack 66 (5.5)
Marijuana or hashish 54 (4.5)
Other opioids (fentanyl, etc.) 50 (4.2)
Other drugs 32 (2.4)
Criminal justice status
Does not apply 933 (77.7)
On probation or parole 232 (19.3)
Pretrial drug diversion 8 (0.7)
Incarcerated 6 (0.5)
Awaiting trial, charges, or sentencing 22 (1.8)
Mental health diagnosis (ever)
Yes 679 (56.5)
No 522 (43.5)
Children younger than 17
None 524 (43.6)
1 to 3 546 (45.5)
4 or more 131 (10.9)
Number of children enrolled in treatment with parent
None 1,101 (96.8)
1 29 (2.6)
2 or 3 7 (0.6)
Has an open child protective services case
Does not apply 64 (5.3)
Yes 386 (32.1)
No 751 (62.5)
Number of children living with someone else due to child protective court order
None 815 (67.9)
1 to 3 311 (25.9)
4 or more 75 (6.2)
Children with lost parental rights
None 1,103 (91.8)
1 to 3 80 (6.7)
4 or more 18 (1.5)
Source: Los Angeles County Participant Reporting System admissions data, 2016

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and monitoring requirements, and the lack of cross-system communication responsiveness.
Further underscoring the need for improved cross-system collaborative practices, findings
from 2016 Los Angeles County’s Participant Reporting System admissions data show an
ethnically and racially diverse sample of 1,201 women with an average age of 35.8 who entered
residential SUD treatment in 2016 (see Table 3). Of these women, 56.4% (n = 677) had one or
more children younger than 17, 32.1% (n = 386) had an open CW case, and 22.3% (n = 268)
were on probation or parole, incarcerated, awaiting prosecution, or had entered residential SUD
treatment through drug diversion. More than half (56.5%, n = 679) had a mental health diagnosis
at some point in their life, and 8.2% (n = 98) had lost parental rights to one or more children. For
these women, 32.1% (n = 386) had children living with someone else due to a CW court order.
The primary drug of choice for 42.6% (n = 512) of these women was methamphetamines, and
3.2% (n = 36) had one or more children who enrolled in treatment with the parent.
This study will provide valuable guidance about the policy and practice adjustments
needed for the CJC and CW systems to shift from independent oversight practices to a more
cohesive and integrated cross-systems FCA collaborative relationship with SUD treatment
providers and the patients they treat. This study will highlight the challenges associated with Los
Angeles County’s SUD treatment delivery system for women and its capacity to fully or partially
implement an FCA, which is an evidence-based approach, in the CJC, CW, and SUD treatment
context. Results of this study will shine a spotlight on strategies and outline key
recommendations from women’s residential SUD treatment providers on realigning current
collaborative relationships to better operate and improve treatment outcomes for women and
their children. Understanding this clinical framework from director and clinician viewpoints
when interfacing with these different systems and patients simultaneously provides a research-

17

informed contribution to improving women’s SUD treatment and family reunification outcomes.
Definition of Terms
The following terms, associated abbreviations, and acronyms are operationally defined
and used throughout this manuscript:
Adoption and Safe Families Act (ASFA): A federal child welfare law that requires, as a
condition of the title IV-E foster care program, that a state file a petition to terminate parental rights
once a child has been in foster care for 15 of the previous 22 months (ASFA, 1997).
Child welfare system (CW): The CW system is a government agency responsible for
providing child protection and intervenes in identified cases of child abuse and neglect (Child
Welfare Information Gateway, 2020).
Clinician-patient relationship: In this relationship, the primary treatment clinician
engages in the therapeutic alliance-building process to gain the trust and confidence of the
patient and family members while taking responsibility for the SUD treatment care that is
provided (Substance Abuse and Mental Health Services Administration [SAMHSA], 1997).
Collaborative justice court (CJC): CJCs are specialized courts in the CJ system that
combine judicial supervision with SUD treatment and CW services to address the underlying
SUD that is associated with criminal offending and child abuse and neglect (Wolf, 2005).
Family-centered approach: In this model, the complex needs of each family member are
met through an integrated services delivery approach. The FCA is a family-centered treatment
practice whereby SUD treatment provides a comprehensive array of clinical treatment and other
support services (e.g., parenting, housing, vocational, educational, and health care) that meet the
needs of each family member, not only the patient in SUD treatment (NCSACW, 2021).
Substance use disorder: A SUD is characterized as a chronic, relapsing disorder
involving compulsive seeking or use of a substance despite adverse social, psychological, or

18

physical consequences (National Institute on Drug Abuse [NIDA], 2020).
SUD treatment clinician: SUD clinicians are clinical specialists who treat patients with a
SUD or alcohol use disorder. Clinicians can include those with various levels of education,
including licensed clinical social workers, licensed marriage and family therapists, and certified
SUD treatment counselors.
SUD treatment director: SUD treatment directors are professionals and administrators
who work in SUD treatment programs. They may have different titles, including program
director or clinical director, but their function is to oversee the treatment provision in their
program or agency.
Treatment plan: Treatment plans are developed by SUD treatment clinicians that clearly
outline the identified SUD and associated problems and contain explicit goals and objectives for
beginning and sustaining the treatment recovery process (SAMHSA, 1997).
Treatment progress reporting: Jurisdictionally required information sharing and
treatment progress reports to the CJC and CW systems are related to patient-designated or
mandated treatment benchmarks and progress (Children & Family Futures & National
Association of Drug Court Professionals [CFF & NADCP], 2019).
Organization of the Dissertation
Five chapters are used to organize this research study. Chapter 1 (current chapter)
introduces the reader to the background and statement of the problem, the purpose of the study’s
research questions, and the importance of why this study was conducted. Chapter 2 introduces
major topics and a synthesis of the current literature, highlighting important unanswered
questions that are addressed in this research study. Chapter 3 addresses the methodological
approach and steps taken to answer the research questions, including instrumentation,

19

stakeholder and participant recruitment, data collection, and data analysis processes. Chapter 4
restates the focus of the study and reports the findings, which are organized by research
questions, while providing original insights and interpretations to what the findings mean as they
relate to the adverse impacts of current cross-system collaborative challenges on parental SUD
treatment. Chapter 5 discusses the findings based on the data and literature, describing how this
study provides solutions for addressing challenges to cross-system collaborative relationships
among the SUD treatment, CJC, and CW systems that affect parental SUD treatment provision
and family reunification.

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CHAPTER TWO: LITERATURE REVIEW
Since the late 1990s, systems-level interagency collaboration with the CJC, and more
recently with a FCA, has become an evidence-based intervention strategy implemented to coordinate
services for women with SUDs and their families who are involved with the SUD treatment, CJC,
and CW systems (Child Welfare Information Gateway, 2014). Prior research has shown that CJCs
are an effective collaborative approach for addressing parental substance abuse, child abuse and
neglect, and crimes associated with having a SUD. Despite efforts to implement a FCA in the CJC
system nationwide, insufficient collaboration among the SUD treatment, CW, and CJC systems
continues to hinder the ability of residential SUD treatment clinicians and directors from treating the
complex array of treatment needs among women and their families (Huebner et al., 2017; Lietz &
Geiger, 2017; Lloyd et al., 2021).
This chapter provides a current review and synthesis of the literature on the development of
CJCs and the FCA, highlighting the effectiveness of these evidence-based interventions for SUD
treatment while underscoring important limitations and gaps in existing research, knowledge, and
implementation efforts. In addition to describing the importance and significance of past research on
the effectiveness of these collaborative intervention frameworks (CJC and FCA) in the SUD
treatment system, past methodological and continuing problems in this area of research are discussed
as they relate to the importance of this study. For example, because SUD treatment providers
(clinicians and directors) are charged with providing family centered treatment to women and their
children, gaining key insights into current collaborative and cross-system communication challenges
with the CJC and CW systems from the SUD treatment provider viewpoint is crucial. With respect to
the limitations and gaps in the existing knowledge base, this chapter highlights important unanswered
questions that will be addressed in the subsequent results and discussion sections of this multisite
qualitative research study.

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Collaborative Justice Courts
The evolution of CJCs arose from the success of the drug court model for addressing
SUDs. The first drug court began in Miami, Florida, in 1989 during the height of the crack
cocaine epidemic in the United States. The purpose of drug courts is to reduce the number of
individuals with SUDs entering the CJ system by offering SUD treatment in lieu of prosecution
(Huddleston & Marlowe, 2011; Jones et al., 2013; Marlowe et al., 2016; Rittner & Dozier, 2000).
Best practices in the initial drug court model involved a more coercive and uniform approach
whereby participants would face prosecution upon positive urinalysis drug test results or leaving
the treatment program, and all participants received the same treatment and dosage (i.e., time
mandated or required to remain in treatment; Marlowe et al., 2016).
The current more therapeutic drug court model uses a collaborative multidisciplinary
approach to treatment that prior work has shown to be effective in reducing recidivism and
reoffending and the familial and social well-being of defendants (Green & Rempel, 2012;
Marlowe et al., 2016; Mitchell et al., 2012; Wild et al., 2016). Improved SUD treatment
outcomes are attributed to best practices which are included as key components of current drug
courts (see Table 4; Marlowe et al., 2016). In response to the successful collaborative CJ and
SUD treatment diversionary outcomes produced by drug courts, the California judicial system
created and implemented CJCs to address the wider range of social service needs of defendants
encountered by the court system such as family treatment, reentry, drug, veterans, juvenile
justice, homelessness, driving under the influence and mental health courts (Wolf, 2005).
In 2006, the first family treatment court in the CJC in Los Angeles County began as a
pilot project to address the parent-specific and complex family needs of women and their
children. However, the uptake, practice, and cross-system collaboration of the nationally

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Table 4: Practice Components of Current and Initial Drug Court Model
Adapted from Marlowe et al. (2016)
recognized FCA framework remain unclear, particularly in Los Angeles County, due to several
barriers and challenges to implementation including (a) inadequate resources, (b) lack of
coordination, (c) poor communication between staffs and agencies, and (d) different value-
oriented and philosophical approaches (Brook et al., 2016; DiBella et al., 2016; Child Welfare
Information Gateway, 2014). In addition, not all CJCs (e.g., reentry, drug, and family treatment
courts) are designed, staffed, or trained for the implementation and collaborative practice of the
FCA. Further, despite the acknowledged benefits of providing parenting and family services
(e.g., parenting classes), few CJC programs are family centered or provide the full scope of FCA
components recommended to meet the patient’s and family’s needs (Sieger et al., 2021).
With judicial oversight by the CJC, SUD treatment clinicians and directors engage with
the court and CW workers in the planning, monitoring, and reporting of SUD treatment and
parenting progress updates that occur in biweekly or monthly court hearings (Marlowe & Carey,
2012; Marlowe et al., 2016). In Los Angeles County, CJCs and SUD treatment providers are
Components of evolved drug court model Components of initial drug court model

Cross-system partners attend pre-court staff
meetings and court hearings routinely.

Violations of probation or parole, prosecution,
and possible incarceration for positive drug or
alcohol test, and going AWOL from treatment
as a means of treatment coercion.

Status hearings are conducted at least every 2
weeks until significant progress is made.

All participants received same treatment
despite SUD severity or dosage e.g., amount
of time mandated to treatment).
Frequent random drug testing is performed.

Denied participants access to needed
medication-assisted treatment medications
(e.g., opioid dependency medications &
alcohol use disorder medications).

Incentives and sanctions as a means of
external motivation.

Participants receive evidence-based treatment
that is matched to their clinical and social
service needs.

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tasked with collaborating to address the SUD challenges of women and their families within
family treatment, reentry, and drug courts (Table 1; National Institute of Justice [NIJ], 2020).
Although these courts (family treatment, reentry, and drug courts) target a different problem—
whether a CW issue, CJ issue, or both—each mandates women into SUD treatment to address
the common underlying condition of addiction.
Unfortunately, the drug and reentry courts in Los Angeles County are not designed or
resourced to implement and practice the FCA (Marlowe et al., 2016). This challenges cross-
system collaboration and communication efforts by SUD treatment clinician and directors who
are tasked with providing family-centered treatment to women and their families referred by
these courts into SUD treatment. Given the variability in types of CJCs and the different cross-
system collaborative involvement and mandated requirements treatment providers and patients
have with each, it is important to understand the cross-system collaborative and communication
challenges that SUD providers and parents experience during the treatment episode. As SUD
treatment, CW, and CJC system family-centered partnerships advance, treatment and family
reunification planning differences are expected to emerge creating collaborative friction and
tension among the systems (Boles et al., 2012). These tensions and friction can foster
communication and cross-system collaborative breakdowns that can negatively affect or obstruct
residential SUD treatment (Marsh et al., 2006).
Collaborative Justice Court Effectiveness
Prior research shows cross-system collaboration among CJC, SUD treatment, and CW
systems has improved the effectiveness of services while moving women toward SUD recovery
and greater preparedness for family reunification (Drabble, 2010; Green et al., 2008; Hodges et
al., 1999). For example, several systematic reviews have found that CJCs, particularly family

24

treatment court, significantly increase SUD treatment outcomes, decrease the time children
spend in out-of-home placements, and increase family reunification (Green et al., 2009; Lloyd,
2015; Marlowe & Carey, 2012; Marlowe et al., 2016; Worcel et al., 2008). In a study using data
from the Women, Co-occurring Disorders, and Violence Study regarding 461 participants,
findings revealed that women who reported being mandated (CJ or CW system) remained in
residential treatment longer and had a decreased risk of treatment dropout (35%) compared to
women who were not mandated into treatment (Amaro et al., 2007). In a large study
investigating treatment outcomes of women in the Alcohol and Drug Services Study, findings
regarding 2,395 SUD treatment facilities (residential and outpatient) showed treatment
completion was higher among women referred through the CJ system (Brady & Ashley, 2005).
In addition, a prior study investigating CJC mandated versus nonmandated women found that
being mandated (CJ and CW mandated groups combined) was a significant predictor of number
of days retained in SUD residential treatment (p = .032), representing a 32.8% increase
compared to those who were nonmandated (Rivera et al., 2021). In a similar study examining
treatment completion rates, findings revealed women mandated into residential SUD treatment
by the CJC system had increased treatment completion (RR = 10.74, p = .016) compared to
women who were not mandated into SUD treatment (Rivera et al., 2021). Further, in a
systematic review evaluating 154 independent drug court evaluations, results revealed decreased
rates of recidivism among drug court participants (by 12 percentage points) compared to those
who were not drug court participants (Mitchell et al., 2012). However, because most studies in
this systematic review featured mostly men (84%), in addition to methodological limitations,
findings are not generalizable to women’s gender-specific SUD treatment.

25

Unmet SUD Treatment Parenting and Family Needs Among CJC Participants
Despite prior research demonstrating the importance of addressing patient and family
needs among those referred to SUD treatment through the CJ system, CJC participants have
extensive continuing unmet parenting needs (Lloyd et al., 2014, 2021). For example, findings
from prior research indicated that 85% of CJC participants mandated into SUD treatment
demonstrated high to moderate levels of need in multiple areas associated with parenting and
family functioning including SUD treatment; CJ involvement; educational, employment, or
vocational needs; and housing and financial needs (Guastaferro et al., 2020). Importantly, parents
mandated into SUD treatment through the CJC system had significantly higher scores on child
maltreatment potential and significantly lower parent-child involvement as compared to their
parental copartners who were not involved in the CJC system (Guastaferro et al., 2020).
Traditional CJC and drug court models (reentry and drug courts) focus their service
delivery efforts primarily on the individual or defendant (CFF & NDCI, 2017). However, many
participants who enter the CJC system have children and families. Given the impact of a SUD on
the entire family, it is important for CJCs to scale up FCA practices across their courts (reentry
and drug courts) to better address the treatment needs of women and their families. For example,
a recent study of family treatment courts across the nation demonstrated that parent, child, and
family well-being outcomes improved when an FCA was implemented (SAMHSA, 2014). To
address the unmet needs of women and their children involved with the CJCs, an integration of
collaborative strategies among stakeholders focusing on a family-centered treatment approach is
crucial. Communication and active collaboration among SUD treatment, CJC, and CW
stakeholders can help ensure that parents with a SUD can receive appropriate treatment while the
child’s psychosocial well-being is protected (Child Welfare Information Gateway, 2014). These

26

unmet SUD and family treatment needs underscore the importance of understanding SUD
provider collaborative and communication challenges with the CJC and CW systems and how
they negatively affect or obstruct treatment provision, the clinician-patient relationship, and
treatment planning.
The FCA in the SUD Treatment and CJC Context
In the early 1990s, the FCA in SUD treatment emerged out of residential treatment
programs for pregnant and parenting women (NCSACW, 2021). During this period, the
Substance Abuse and Mental Health Services Administration (SAMHSA) financed the
development of several model programs that provided family-centered SUD treatment
(SAMHSA, 2015). More recently, the National Center on Substance Abuse and Child Welfare
(NCSACW) developed training curricula designed for state-, county-, and agency-level uptake
and implementation of FCA practices (NCSACW, 2021).
Since then, the FCA has expanded nationwide as CJCs have increasingly seen the need to
address the family as a whole when providing SUD treatment (NCSACW, 2021). However, most
family treatment courts have concentrated on addressing the treatment needs of parents and not
the family as a whole. Few family treatment courts provide, whether directly or through cross-
system partnerships, services that meet the complex needs of children and then integrate these
needs of the children with the mother’s needs into a comprehensive, family-centered treatment
plan (SAMHSA, 2014).
The FCA in SUD treatment for women and their children is most often implemented in
residential SUD treatment settings. In residential SUD treatment, clinicians and directors can
offer a wider range of family services including around-the-clock availability of trained
personnel (Kampman & Jarvis, 2015). Family-centered residential treatment has improved parent

27

and child outcomes for mothers and their children such as strengthening parent-child
communication, parent-child bonding, and parenting skills (Marlowe & Carey, 2012). These
family-focused programs enable clinicians and directors to directly observe and monitor
parenting skills and parent-child bonding, thereby facilitating targeted family-centered treatment
planning (CFF & NADCP, 2019). However, without aftercare monitoring, support, and family-
centered reinforcement within the family’s natural environment, these efforts and the progress
made may not be sustained long-term.
Limitations of Family-Centered Treatment and FCA Practice in CJCs
While advancing FCA practices in the CJC system are promoted, SUD treatment
providers and their CJC and CW cross-system partners continue to struggle in meeting the
comprehensive family treatment needs associated with mothers in residential SUD treatment.
This is often due to cross-system communication, coordination, and collaboration challenges to
cross-system relationships between the SUD treatment, CJC and CW systems (Brook et al.,
2016; Clary et al., 2020; Lloyd et al., 2021). Importantly, the availability of and access to FCA
residential SUD treatment programs is inadequate in urban settings, but particularly in rural areas
(Clary et al., 2020). Even residential SUD treatment programs that allow the child to remain with
the parent during treatment may be difficult to access for many parents due to child age
restrictions and the number of children allowed to accompany the parent while in treatment
(SAMHSA, 2015).
In 2019, approximately 363 residential SUD treatment programs offered family-centered
treatment for parents and their children in the same facility (Wilder Research & Volunteers of
America, 2019) out of more than 14,500 drug treatment facilities that provide behavioral therapy,
medication-assisted treatment (MAT), counseling, case management, and other types of services

28

to individuals with a SUD (NIDA, 2018, 2020). A report from the 2017 National Survey of
Substance Abuse Treatment Services showed that between 2007 and 2017, outpatient treatment
involved approximately 90% of all patients and only 10% represented inpatient residential
treatment (SAMHSA, 2018). Additionally, despite research support for the need of expanded
family treatment courts, only 7 to 10% of families involved with the CW system receive family
centered care for their SUD. This limited availability and access to family-centered residential
treatment highlights the need to expand the implementation of the FCA across CJCs (family
treatment, reentry, and drug courts) to meet the comprehensive SUD treatment needs of women
and their families (NCSACW, 2021).
Key Components of the FCA
The implementation of the FCA in SUD treatment varies in the CJC, CW, and SUD
treatment systems, which may reflect different state, county, and regional needs, along with
availability of funding and resources (Brook et al., 2016; Lloyd et al., 2021). For example,
contributing factors for the lack of family treatment court and FCA uptake may include (a) the
lack of Los Angeles County cross-system infrastructure, (b) lack of support for FCA
implementation within existing CJC operations (across CJC courts), (c) limited funding and
resources making implementation prohibitive, and (d) the lack of knowledge on family treatment
court and FCA operations and outcomes. Despite these variations, six essential core cross-system
implementation components are recommended for implementation by cross-system stakeholders
to achieve fundamental family-centered treatment benefits (see Table 5). These key FCA
components were developed to clarify to CJC jurisdictions seeking to become more family
centered the benefits of increased cross-system collaboration of family-centered treatment across
treatment courts (family treatment, reentry, and drug courts) and community SUD treatment

29

providers (NCSACW, 2021).
Importantly, it is crucial that each CJC jurisdiction conduct a thorough assessment of its
current FCA implementation and collaborative process across systems to identify elements of
these key components to adopt. In addition, jurisdictional cross-system collaborative assessment
requires identification of the current state of collaborative communication challenges that inhibit
or stifle implementation. These components can be incrementally operationalized or graduated
into a more formalized FCA among the CJC, CW, and SUD treatment systems as increased
implementation efforts develop (Lloyd et al., 2021). An important purpose of this study in Los
Angeles County, California, was to conduct a multisite residential SUD treatment assessment of
(a) the current state of informal or formal collaborative relationships among the SUD treatment,
CJC, and CW systems; and (b) the current state of collaborative challenges experienced by SUD
treatment providers, along with the current collaborative conditions that adversely affect
treatment provision, the therapeutic clinician-patient relationship, and treatment planning.
Family Treatment Court Effectiveness Compared with Other CJCs
In Los Angeles County, the FCA framework, as an evidence-based treatment approach,
in family treatment courts is meant to be the guiding philosophical approach to treat women and
their families collaboratively in the CJC system. In several large regional studies, family
treatment court, which practices the FCA to varying degrees, has been found to provide superior
SUD treatment and family reunification outcomes compared to other CJCs (e.g., drug and
reentry courts; Huddleston & Marlowe, 2011; Marlowe & Carey, 2012; Marlowe et al., 2016).
In several systematic reviews of parents involved with family treatment court, findings showed
(a) parents completed SUD treatment at rates 20% to 30% higher than those who were not
referred through family treatment court and (b) family reunification rates were approximately

30

Table 5: Six Essential Components of the FCA
Adapted from NCSACW: Implementing a Family-Centered Approach (Module 1; 2021)

Collaborative
partnerships

Collaborative partnerships are the foundation of the FCA. Successful
cross-system collaboration is built on a shared vision and mission
recognizing a single agency, on its own, will not achieve improved
outcomes for parent and family well-being. Collaborative
partnerships acknowledge that leveraging collective resources leads
to improved outcomes for families. Ideally, cross-system
partnerships will become an established collaborative that addresses
challenges, supports cross-system partnerships, and promotes
information sharing to benefit the parent and child(ren).
Adequate and flexible
funding for
sustainability

Implementation of the FCA requires new and flexible funding. SUD
treatment providers and their CJC and CW partners can work with
state and county leaders to identify funds that support family-
centered services, particularly newly available funding through the
Family First Prevention Services Act (FFPSA) and Child Abuse
Prevention and Treatment Act (CAPTA) state grants.
Performance
monitoring

Effective cross-system collaboratives develop a process for regular
performance monitoring. As SUD treatment providers, CJC, and CW
partners work together to implement and sustain comprehensive
family-centered treatment, shared performance measures can be
identified through cross-system accessible data dashboards that
monitor SUD treatment, CJC, CW, and family progress and success.
Coordinated case
management

Coordinated case management for parents and their children ensures
a collaborative partnership among the SUD treatment, CJC, and CW
systems that synchronizes their services, addresses barriers to
accessing and engaging in services, and shares information on parent
and family progress against baseline data.
Quality SUD treatment

At the core of the FCA is a high-quality SUD treatment program that
uses evidence-based and trauma-informed practices when providing
treatment services and aftercare support to women and their children.
Comprehensive array
of family services

Access to family-centered treatment services that address the
parent’s and child’s needs are essential for supporting and
strengthening family well-being across the continuum of treatment
care. Each SUD treatment, CJC, and CW system should identify the
services required to meet the needs of its clients, particularly because
services may differ depending on the target population and
geographical setting.

31

20% to 40% higher than that of parents not in family treatment court (Marlowe & Carey, 2012;
Marlowe et al., 2016). Additionally, results regarding parents referred through family treatment
court indicated children spent an average of 3 to 6 fewer months in out of-home placements and
parents were approximately 15% to 40% more likely to be reunified with their children (Lloyd,
2015; Marlowe & Carey, 2012; Marlowe et al., 2016). In a cost-benefit analysis study examining
family treatment court as compared to non-family treatment court participants (i.e., other CJCs or
CW involvement only), Brook et al. (2016) found that family treatment court resulted in a net
cost savings of $9,710 per child. Further, in a systematic review by Marlowe et al. (2016), results
clearly showed that family treatment courts outperformed traditional CW and CJC programs in
terms of providing SUD treatment to families while increasing family reunification outcomes.
Limitations and Gaps
Although substantial overlap exists between the CJC (see Table 1) approach and family
treatment court, family treatment court extends beyond its CJC counterparts (reentry and drug
courts) in both treatment court principles and use of the FCA in the treatment court setting (Lietz
& Geiger, 2017; Lloyd et al., 2021; Marlowe et al., 2016). This evidence suggests that despite
the benefits of parenting and family services offered by CJCs to parents with children, CJCs are
an inadequate approach, by themselves, to meet the treatment needs of women and their children.
Prior research has noted several limitations in CJCs that have an existing family treatment court,
such as Los Angeles County, California, yet are challenged with collaborative implementation of
a FCA across courts in their jurisdiction (Brook et al., 2016; Lloyd et al., 2021). Limitations
include poor or nonexistent cross-system relationships and communication among the SUD
treatment, CJC, and CW systems (Lloyd et al., 2021; Child Welfare Information Gateway,
2014). Further, prior research has underscored important limitations and gaps attributed to

32

limited funding, resources, and collaboration, along with the inadequate number of gender-
specific women’s residential SUD treatment programs in Los Angeles County’s CJC service
delivery system. This compounds an already challenging cross-system coordination and
collaborative treatment delivery environment. In addition, poor or nonexistent relationships
among the SUD treatment, CJC, and CW systems and staffs may prove to be significant barriers
to implementing these fundamental FCA components, thereby obstructing parental SUD
treatment and family reunification potential (Green et al., 2008; Huebner et al., 2017; Smith &
Mogro-Wilson, 2008).
Currently, research on cross-system collaboration for families involved with the CJ and
CW systems is primarily conducted at the organizational level and largely from the perspectives
of the CJC and CW systems. Previous research has not adequately explored the complex and
demanding intra-agency practice adjustments and contextual factors that SUD treatment
clinicians and directors experience when engaged in formal and informal cross-system
collaborative relationships with the CJC and CW systems (Gallagher et al., 2015; Smith &
Mogro-Wilson, 2008). Importantly, no known studies have explored from SUD providers
(clinician or director) viewpoints the intra-agency factors that create challenges and barriers to
SUD treatment provision and the therapeutic clinician-patient relationship when collaborating
among different agencies with which the patient is involved (Marsh et al., 2012; Smith &
Mogro-Wilson, 2008).
Importance of SUD Treatment Provider Viewpoints
This further highlights the importance of gaining insight into the cross-system
communication, responsiveness, and collaborative challenges from SUD treatment provider
perspectives. Importantly, given that SUD treatment clinicians and directors have residential

33

SUD treatment custody of the parent and are tasked with being the primary collaborative agent
between the mother and the CJC and CW systems, their experiences are critical to understanding
the collaborative challenges that adversely affect SUD treatment provision, the therapeutic
clinician-patient relationship, and treatment planning. Clinician and director viewpoints can also
provide crucial strategies to (a) improve cross-system collaboration, communication, and
coordination among stakeholders, and (b) strengthen the clinician-patient relationship and
treatment planning via improved communication and responsiveness between the parent and
stakeholders (SUD treatment, CJC, and CW). Although prior research has highlighted the
importance and inadequacy of current cross-system collaborative practices among the SUD
treatment, CJC, and CW treatment delivery systems, there is a paucity of research examining,
from SUD treatment provider viewpoints, how these challenges adversely affect parental and
family SUD treatment (Drabble, 2007; B. L. Green et al., 2008; Lloyd et al., 2014; Smith &
Mogro-Wilson, 2008). Understanding and acting upon SUD treatment clinician and director
viewpoints on the communication and collaborative challenges they face when providing family-
centered treatment will strengthen current cross-system practices in the Los Angeles County
SUD service delivery system.
SUD Treatment Intra-Agency Challenges and Barriers to Collaboration
Despite increased confidence in cross-system collaboration, little is known about the
intra-agency contextual challenges that residential SUD treatment clinicians and directors face
when engaged in collaborative cross-system relationships in their programs, whether formal or
informal (Lloyd et al., 2014; Rodi et al., 2015; Smith & Mogro-Wilson, 2008). For example,
efforts to establish cross-system partnerships often encounter important intra-agency challenges
regarding SUD treatment that need to be considered (CFF & NADCP, 2019; CFF & NDCI,

34

2017; Drabble, 2008), specifically based on SUD treatment clinician and director experiences
and viewpoints. These intra-agency challenges and barriers can include (a) problems with
information sharing, whether required or voluntary (e.g., scheduling and planning of child
visitation and monitoring or CW communication and responsiveness); (b) clinician-patient
confidentiality concerns; and (c) conflicting values regarding the priority of focus, whether the
parent-child relationship and family treatment, the child, or public safety (CFF & NADCP, 2019;
CFF & NDCI, 2017; Drabble, 2008). Given different cross-system requirements depending on
the CJC (family treatment, reentry, or drug court), SUD clinicians and administrators can be
further challenged by the variability and possible conflict of interagency requirements that apply
to patients on their caseload. Each challenge or barrier in cross-system collaboration has the
potential to adversely affect or obstruct SUD treatment provision, the clinician-patient
relationship, and treatment planning.
CW Oversight, the ASFA, and Parental SUD Treatment
For parents involved with the CW system, SUD treatment providers are required to
develop treatment plans that consider federal CW timeline requirements set forth by the ASFA of
1997. The ASFA requires the process for termination of parental rights to occur when a child has
been in temporary foster care settings for 15 of 22 consecutive months (Marsh & Smith, 2011).
Depending on how far along that timeline before the mother enters SUD treatment and the
severity of the parent’s SUD, and factoring in that relapses are a common occurrence with this
disorder, parental treatment and recovery may take much longer (Volkow, 2013). This can
induce tensions among the CW, CJC, and SUD treatment providers regarding the direction and
necessity of continued family treatment or the termination of parental rights despite treatment
ensuing and progress being made, which is variably unique to each parent (Green et al., 2008;

35

Marsh & Smith, 2011; Smith & Mogro-Wilson, 2007).
There is considerable controversy surrounding the ASFA timeline, particularly regarding
its influence on families with SUD problems. The ASFA timeline creates significant obstacles
for the SUD treatment of the mother and her children, along with the interagency collaborative
efforts of SUD treatment providers and the CW and CJC systems. For example, a previous study
found that although case planning and advocacy provided by CW services reduced many barriers
for families, the combined oversight from the CW workers and the CJC staff, along with
impending ASFA induced adoption hearings, negatively affected the patient’s psychological
condition in terms of increasing the stress experienced by parents (especially regarding child
visitation scheduling and the child custody legal process) and the burden of the numerous other
requirements mandated by the CW and CJC systems (Rockhill et al., 2008).
This induced stress was attributed to the overwhelming challenges of juggling the
numerous mandated CW family reunification requirements (additional CW groups, appointments
and hearings, urinalysis testing for both CW and CJC systems, etc.) that compound and compete
with the mother’s SUD treatment engagement and treatment planning (Rockhill et al., 2008). For
example, the ASFA timeline prevents the staggering of family-centered services, meaning that
mothers must meet CW and CJC requirements simultaneously with their SUD treatment
(Rockhill et al., 2008). This can be an overwhelming, acutely stressful, and often retraumatizing
experience for the parent (Rockhill et al., 2008). For example, attending court hearings produces
a great deal of anxiety for parents, particularly when they face the potential loss of parental
custodial rights, incarceration, or both. Considering these psychosocial elements are well-
established predictors associated with substance use relapse and treatment dropout for parenting
women in SUD treatment (Daughters et al., 2009; Law et al., 2016; Panlilio et al., 2019), close

36

collaboration and coordinated communication among SUD treatment providers and the CW and
CJC staffs is critical in this context. However, there is a dearth of research on SUD treatment
clinician and director perspectives and experiences regarding the collaborative and cross-system
communication challenges treatment providers experience while providing treatment to this
vulnerable population and how it affects the therapeutic clinician-patient relationship and family
treatment planning.
Additionally, parents come into SUD treatment at various stages of CJ and CW system
involvement (pre- or postincarceration). This affects how long the parents have been separated
from their children. For example, women who enter after some period of incarceration will have
been separated from their children longer. For these parents and their clinicians, this amounts to
a shorter period of time to meet the required CW and AFSA substance use abstinent and
parenting requirements within the 15 to 22-month ASFA timeline (Rockhill et al., 2008). This
further endangers treatment flexibility when relapses occur, because CW workers often
recommend and the CJC is left with no alternative but to remove the child permanently from the
parent even though the parent may have achieved notable treatment progress.
As described, for parents involved with the CW and CJC systems, residential SUD
treatment and recovery timelines may work against child permanency planning timelines
associated with the ASFA when relapses occur (Drabble, 2007; He, 2015). This places SUD
providers in the position of potentially undermining treatment progress and the likelihood of
family reunification when having to report a positive urinalysis test or behavioral problems to the
court and CW systems. Positive urinalysis tests and relapses trigger CW reassessment of the
family reunification plan. This often sets the parent back in the demonstrated treatment progress
needed to achieve child custody rights and reunification with their children. Mothers and their

37

SUD treatment providers are aware that this information can be used against them and hinder
their overall family treatment and child reunification goals. Therefore, these cross-system
conditions become an impediment and obstruction to the trust necessary in the therapeutic
clinician-patient relationship and family treatment planning process (Burman, 2004).
ASFA as Legislation That Furthers a Siloed Approach to SUD Family Treatment
Although CJCs were introduced to help improve how the SUD treatment, CW, and CJC
systems work together to improve outcomes for women and children, each system often remains
siloed in its interests and participation, making it difficult for collaboration or the provision of
the FCA in family SUD treatment (Drabble, 2010; Green et al., 2008; Smith & Mogro-Wilson,
2008). For mothers and their families affected by a SUD, the ASFA timeline requirements
emphasize adoption, creating barriers to family reunification because treatment often requires
intensive services over many months. Treatment timelines frequently conflict with ASFA child
permanency timeline requirements that often cannot be realistically met by the clinicians or
parents (Worcel et al., 2007).
Due to the realities of these treatment and ASFA timeline conflicts, families with a
parental SUD are less likely to reunify (Brook et al., 2010). The intensive FCA used in family-
centered treatment aims to decrease the time needed to resolve these cases. These efforts also
ensure that the statutory requirements of ASFA are met. However, unlike the focus on adoption
planning mandated by the ASFA timeline (15 of 22 months), the FCA in family-centered
treatment emphasizes a reunification position of child permanency and treatment planning. These
opposing perspectives and practices are held by CW workers and SUD treatment providers
(clinicians and directors), respectively, and are further supported and entrenched by the
respective values system regarding the client being represented in the collaborative (Drabble,

38

2007, 2010; Green et al., 2008; Smith & Mogro-Wilson, 2008). Confronted with the ASFA
timeline, SUD treatment clinicians and directors have an increased burden of juggling these
challenging requirements, along with the heightened need for cohesive collaboration,
communication, and responsiveness with staff from the CW and CJC systems (Brodkin, 1997;
Smith & Mogro-Wilson, 2008).
Adverse Cross-System Collaboration Challenges and Barriers
Prior research on cross-system collaboration among the SUD treatment, CJC, and CW
systems has mainly focused on cross-system adoption, and no known research has explored the
adverse impact of the unintended consequences of current cross-system communication and
reporting on SUD treatment provision, the clinician-patient relationship, and treatment planning.
Further underscoring values regarding the client being represented, SUD treatment clinicians and
directors or CW workers may reject or not fully engage in collaborative communication that
conflicts with their values (Klien & Sorra, 1996). This is particularly relevant when the clinician-
patient relationship is perceived to be violated by breaches of patient confidentiality involved
with interagency collaborative communication requirements that may harm or obstruct the
treatment progress of the parent, such as when negative reports may justify the termination of
child custody rights or reincarceration of the parent to face prosecution. These negative reports
include but are not limited to (a) positive urine samples, (b) challenges with maintaining healthy
relationships, (c) not making required progress with comorbidities such as posttraumatic stress
disorder or depression, or (d) lack of stable housing, income, and employment.
From the SUD clinician perspective, the hope of regaining child custody rights or the
dismissal of criminal charges is an important motivational factor for parents in SUD treatment
and removing this hope may adversely affect the therapeutic clinician-patient relationship (e.g.,

39

confidentiality, trust, and openness) and the parent’s recovery. It should also be recognized that
continuous reporting or court appearances and CW family reunification status meetings can be
an anxiety-inducing or traumatic event for the parent, negatively influencing cross-system
collaborative communication and SUD treatment provision. These stressors may adversely affect
treatment planning and the clinician-patient relationship when positive urinalysis reports or
noncompliant adherence to mandated interagency treatment planning is revealed openly among
stakeholders and conveyed through the clinician or SUD treatment program.
Among people with SUDs, the role of stress in the activation of craving for alcohol and
drugs has been well documented. Increased craving due to exposure to heightened levels of
anxiety and stress is associated with relapse and treatment dropout (Daughters et al., 2009; Law
et al., 2016; Panlilio et al., 2019). These factors highlight the need to gain a better understanding
of the challenges facing SUD clinicians and directors when providing SUD treatment to patients
who may experience increased trauma, anxiety, and stress when their primary clinicians are
engaged in cross-system collaborative communication with the CJC and CW systems.
Dual Roles and the “Double Bind” of SUD Treatment Clinicians and Directors
Due to jurisdictional CJC and CW oversight and authority, treatment clinicians and
directors have dual roles and allegiances that place them in a “double bind,” meaning they are
accountable to the CJ or CW systems and the patient simultaneously (Burman, 2004). This can
interfere with developing the necessary clinical rapport and openness that is crucial to the clinical
relationship. When the clinician is required to engage or voluntarily cooperates in cross-system
communication and reporting of patient behavior to a CJC or CW worker, a client’s suspicion
that ulterior motives, such as a clinician’s commitment to the legal or CW system, could result in
the deterioration of trust, introducing an element of cynicism and resistance to the treatment

40

process and therapeutic clinician-patient relationship (Burman, 2004).
Moreover, the historically entrenched, values-driven, and siloed CJC, CW, and SUD
treatment practices, along with the myriad of current FCA and CJC cross-system implementation
challenges, requires understanding the insider’s (SUD treatment clinician and director)
viewpoint. These complexities call attention to the challenges and potential opportunities
involved in interagency treatment planning when clinicians and directors collaborate with
different stakeholders (CJC and CW) that have conflicting values when it comes to the clients
being served. Although there is increased confidence in cross-system collaboration, little is
known about the intra-agency contextual challenges that residential SUD treatment clinicians
and directors face when implementing these collaborative mechanisms in their programs (Rodi et
al., 2015; Smith & Mogro-Wilson, 2008).
Importantly, a paucity of research has examined SUD provider viewpoints on interagency
cross-system factors that inhibit essential SUD treatment provision, particularly regarding the
therapeutic clinician-patient relationship and treatment planning (Marsh et al., 2012; Smith &
Mogro-Wilson, 2008). These studies addressed key limitations and unanswered questions in the
current knowledge base related to cross-system collaboration among stakeholders tasked with
addressing the complex SUD treatment needs of parents and families that are mutual clients.
Increasing the knowledge base with a clearer understanding of cross-system collaborative
challenges and how they adversely affect treatment provision and the clinician-patient
therapeutic relationship will contribute to improving interagency collaborative relationships and
thus, improve treatment provision, outcomes, and rates of family reunification.
The current study uses a multisite qualitative research design that pursued three goals.
The first purpose of this study was to generate a deeper and richer understanding from SUD

41

treatment clinician and director experiences of (a) how interagency collaborative communication
barriers adversely affect SUD treatment provision and (b) challenges and barriers they
experience when interfacing with the CJC and CW systems. The second purpose was to gain a
clearer understanding of how current cross-system (SUD treatment, CJC, and CW) collaborative
communication and interaction levels (or lack thereof) adversely affect the SUD clinician-patient
relationship and treatment planning. The third purpose was to assess SUD clinician and director
viewpoints and recommendations regarding how to improve cross-system collaboration,
communication, and coordination among the different stakeholders (SUD treatment, CJC, and
CW). In addition, this research examined treatment provider recommendations on ways to
strengthen the clinician-patient relationship and SUD treatment planning with improved cross-
system communication and coordination between stakeholders.
Methodological Limitations of Past Research
This literature review found some limitations regarding the quality of prior work on CJC
and FCA programs. These include methodological limitations such as the rigor of study designs
(e.g., pre-experimental or quasiexperimental designs), small sample sizes, absence of comparison
groups, and the lack of appropriate statistical controls used when computing results. None of the
prior work cited in this study involved randomized controlled trials (Development Services
Group, Inc., 2016; Brook et al., 2015).
Many studies in these evaluations relied on administrative records and reports when
assessing outcomes. Although there is clinical validity in using administrative data, the reliability
of such measures remains murky (Ogbonnaya & Keeney, 2018). In other systematic reviews,
including multijurisdictional or multistate studies, the authors underscored the lack of propensity
score matching techniques used to build comparison groups to assess effectiveness of one

42

program or population versus another (Brook et al., 2015; Ogbonnaya & Keeney, 2018). Without
the use of propensity score matching, researchers could not control for predictive covariates
when making group comparisons. This is important because without controlling for comparison
group characteristics, the observed effects in the findings cannot be confidently attributed to the
intervention, whether CJC, family treatment court, or FCA (Lloyd, 2015; Van Wormer & Hsieh,
2016). Importantly, most of the existing literature on cross-system services provided by the SUD
treatment, CJC, and CW systems to women with SUDs who have children focused on a CJC and
CW research viewpoint, and no known qualitative (multisite) studies have been conducted from
the perspective and experiences of SUD treatment clinicians and directors from different gender-
specific treatment modalities. This research study addressed this limitation in the scientific
knowledge base.
Theoretical Frameworks
The theoretical frameworks that guided this qualitative study are the SEM
(Bronfenbrenner, 1979) and two organizational theories (Carman, 2011; Davis & Cobb, 2010;
Evan, 1965; Ferguson, 2018; Reitan, 1998). The SEM provides a theoretical framework critical
to understanding the multisystemic and intra-agency influences clinicians and directors
encounter when providing SUD treatment. As a theoretical framework, it provides an important
structure and lens to view the multilevel perspectives of SUD clinicians and directors regarding
the provision of treatment to parents referred through the CJCs (family treatment, reentry, or
drug courts). There are four nested, hierarchical levels of the SEM: the individual, interpersonal,
organizational, and policy levels (see Figure 1). This model provides a systemic framework and
lens for examining clinician and director experiences and perspectives, wherein providers are
nested in multiple systems that maintain a bidirectional influence on clinical practice and

43

treatment provision. The SEM allows the exploration of SUD providers’ experiences and
behaviors as embedded in multiple levels of influence, including (a) individual (treatment
provider); (b) interpersonal (treatment provider with CJC, CW workers, and patient or patient
with CJC, CW workers, and treatment provider); (c) organizational (treatment provider, CJC,
and CW); and (d) policy (legislative or legal).
Using the SEM framework, implications are that insights into interventions that target
SUD treatment determinants at multiple levels and that mutually reinforce each other are likely
to produce improved and more sustainable outcomes (e.g., parental SUD treatment recovery and
family reunification; Sussman et al., 2013; Weiner et al., 2012). The key for designing effective
multilevel interventions include combining interventions that work together in synergistic ways.
As outlined in studies conducted by Weiner et al. (2012) and Sussman et al. (2013), more
multilevel research that examines the “interdependence” of determinants or bidirectional
influences on interventions between the four SEM levels are needed (Sussman et al., 2013;
Weiner et al., 2012). Meaning that, interdependence of determinants should be explored as cross-
level interactions in multilevel models, which is suitable for qualitative research and complexity
analysis.
Organizational theories have been frequently used for conceptual guidance and
explanation regarding the formation of interagency collaborative relationships (Carman, 2011;
Davis & Cobb, 2010; Ferguson, 2018; Reitan, 1998). For example, resource dependence theory
suggests that an organization will engage in cross-system collaboration when the agency will
gain something from its participation in the collaborative partnership (Carman, 2011; Davis &
Cobb, 2010). Hence, SUD treatment agencies and CW agencies would be expected to engage in
collaboration with CJCs, because each rely on one another for either funding or referrals

44

Figure 1: SEM Framework: Multilevel Context of Cross-System SUD Treatment Challenges

(Carman, 2011; Davis & Cobb, 2010). From the perspective of interorganizational relations
theory, cross-system collaboration is more likely to develop among agencies that realize cross-
system partnerships can lead to a more comprehensive and proficient approach to tackling a
complex issue than what could be done by an individual agency (Evan, 1965; Ferguson, 2018;
Reitan, 1998). For instance, the interrelated and common goals among the SUD treatment, CJC,
and CW systems in addressing SUDs among parents include (a) providing an integrated FCA to
women and their families, (b) reducing the incarceration and recidivism rates of women, (c) the
reduction in time to treatment admission from different treatment system entry points, and (d)
reducing the rate of children entering the foster care system and increasing family reunification,
respectively.
Together, the SEM and these organizational theories provide a framework and structure
that guided the qualitative exploration of SUD treatment clinician and director viewpoints on
treating parents referred from the CJC and CW systems. Through the lens of these theoretical
Challenges and barriers: Adoption and Safe Families Act
(ASFA); CW and CJC legal requirements
Challenges and barriers: Cross-system relationship
between SUD treatment providers and the CJC and
CW systems
Challenges and barriers: Clinician-patient
relationship and treatment alliance; CJC or CW
worker relationship with patient
Challenges and barriers: Experiences and beliefs about
cross-system challenges that adversely impact residential
SUD treatment to patients/mothers
Policy
Organizationl
Interpersonal
Clinician
Director

45

frameworks, barriers and challenges to cross-system collaboration were highlighted at the
individual, interpersonal, organizational system, and policy levels. Contextualizing through these
conceptual frameworks and theoretical constructs, this multisite qualitative study yielded key
insights into (a) SUD provider (clinician and director) challenges and barriers that shape SUD
treatment provision; (b) the impact on the clinician-patient relationship and treatment planning of
women involved with the CJC and CW systems; and (c) key provider strategies for improving
these conditions.
Summary
This chapter reviewed and synthesized the current knowledge base and literature on
CJCs, CW, and the FCA for parents with a SUD that are in residential SUD treatment. In doing
so, this chapter highlighted the effectiveness of these cross-system intervention approaches while
underscoring important limitations and gaps in the current state of research. Despite increased
confidence in cross-system collaboration, little is known about challenges and barriers
encountered by residential SUD treatment providers (clinician and director) when collaborating
with the CJC and CW systems (Rodi et al., 2015; Smith & Mogro-Wilson, 2008). Further, most
current research on cross-system collaboration, particularly with the FCA, has been conducted
from the viewpoints of the CW and CJC systems (CFF & NADCP, 2019; CFF & NDCI, 2017;
Drabble, 2010; Drabble et al., 2013; Marlowe & Carey, 2012; Marlowe et al., 2016).
Given that SUD treatment clinicians and directors have residential SUD treatment
custody of the parent and are tasked with being the primary collaborative agent between the
mother and the CJC and CW systems, their experiences are crucial to understanding the
collaborative challenges that adversely affect SUD treatment provision, the therapeutic clinician-
patient relationship, and treatment planning. Clinician and director viewpoints also can provide

46

crucial insights into strategic ways to (a) improve cross-system collaboration, communication,
and coordination among stakeholders; and (b) strengthen the clinician-patient relationship and
treatment planning with improved communication and responsiveness among treatment
providers, the parent, and cross-system stakeholders (CJC and CW systems).
However, in Los Angeles County, California, the uptake and cross-system
implementation and collaboration regarding the nationally recognized FCA framework remain
unclear due to several barriers and challenges to implementation, including (a) poor
communication between agencies and their workers, (b) lack of coordination, (c) inadequate
resources, and (d) different value-oriented and philosophical approaches (Brook et al., 2016;
DiBella et al., 2016; Child Welfare Information Gateway, 2014). This is particularly salient
when factoring in the significant obstacles of the ASFA and its timeline requirements for the
parent and her family and the often-siloed perspective and values that obstruct interagency
collaboration among treatment providers and the CW and CJC systems (Drabble, 2010; Green et
al., 2009; He, 2015; Rockhill et al., 2008). Addressing gaps and limitations in this area of
research from the SUD provider viewpoint will inform important strategies for improving cross-
system collaboration among the SUD treatment, CJC, and CW systems. This study provides a
critically important contribution to the knowledge base on the FCA in women’s residential SUD
treatment, CJC, and CW cross-system collaboration.

47

CHAPTER THREE: METHODOLOGY
Restatement of Study Purpose
The aim of this study was to explore questions that would generate a deeper and richer
understanding from SUD treatment clinician and director viewpoints of how current cross-
system collaborative relationships create challenges or barriers in SUD treatment provision. The
second goal of this study was to provide a clearer understanding of how existing cross-system
(CJC and CW) reporting and monitoring requirements, along with communication and cross-
system responsiveness, affect the SUD clinician-patient relationship and treatment planning.
Further, an important aim was to identify and highlight key strategies, from the viewpoints of
SUD treatment providers, on ways to improve cross-system collaborative mechanisms that will
improve treatment provision, the clinician-patient relationship, and treatment planning.
Restatement of Research Questions
This study highlights qualitative data from SUD treatment clinicians and directors on
how cross-system jurisdictional oversight and monitoring, along with the lack of treatment
coordination and responsiveness by the CJC and CW systems create a challenging treatment
environment for providers and patients who are simultaneously involved with each system.
Importantly, this study sought to identify the multilevel challenges and strategies for improving
these conditions based on the four SEM level categories including (a) individual (clinician and
director); (b) interpersonal (clinician with CJC and CW workers or patient and patient with CJC
and CW workers or clinician); (c) organizational (SUD provider, CJC, and CW); and (d) policy
(legislative or legal). To achieve these aims, this multisite study investigated clinician and
director experiences and viewpoints based on the following research questions:
1. What cross-system collaborative mechanisms involving the SUD treatment, CJC, and

48

CW systems create SUD treatment provision challenges for clinicians and directors?
2. How do cross-system oversight and monitoring requirements, communication and
responsiveness, and ASFA requirements adversely affect the clinician-patient
relationship and treatment planning?
3. How can (a) cross-system collaboration and coordination among the different
stakeholders (SUD treatment, CJC, and CW) be improved and (b) the clinician-patient
relationship and SUD treatment planning be strengthened via improved cross-system
communication and coordination?
Theoretical and Conceptual Framework
Through the theoretical framework and lens of the SEM and organizational theories, this
qualitative study employed a phenomenological qualitative methodological approach to
analyzing and understanding the experiences and viewpoints of clinicians and directors who
provide SUD treatment to parents referred through the CJC and CW systems (Fereday & Muir-
Cochrane, 2006; Sandelowski & Barroso, 2003). Phenomenology was chosen based on its
qualitative approach that explores and helps to understand and describe the lived experiences of
an individual or group (Padgett, 2016). For this study, phenomenological analysis focused on
how SUD treatment clinicians and directors perceive, experience, and talked about providing
SUD treatment to women involved with several systems simultaneously (Pietkiewicz & Smith,
2014; Smith, 2004). These important viewpoints and experiences were related to the
multisystemic treatment environment clinicians and directors experience when providing SUD
treatment to their patients. More specifically, the qualitative phenomenological analysis of SUD
clinicians’ and directors’ experiences as they are related to treatment provision, the clinician-
patient relationship, SUD treatment planning, and their viewpoints on strategies or

49

recommendations for cross-system collaborative improvement were assessed.
Women’s Residential SUD Treatment Program Sample
Purposive sampling was employed to select four women’s residential SUD treatment
programs (number of sites = 6) in Los Angeles County (see Table 6). Each selected and recruited
SUD treatment program met a sampling strategy to achieve maximum variation (two SUD
treatment modalities and two types of participants that include clinicians and directors). Program
inclusion criteria included (a) SUD treatment agencies that provide residential treatment to
women involved with the CJC or CW system or both; and (b) women’s residential SUD
treatment that allows children to remain with the parent during the treatment episode or women-
only residential SUD treatment (child cannot be in treatment with mother). Programs meeting
these criteria were selected from the Los Angeles County Substance Use Disorder Organized
Delivery System, which is administered by the Department of Public Health’s Substance Abuse
Prevention and Control Unit.
Table 6: Sampling Strategy and Timeline
Note. The number of clinicians or directors at treatment facilities that did not or did allow
children to remain with the mother in treatment was 14 and 10, respectively (see Table 6); the
number of treatment programs was four and the number of sites was six.
From the complete directory of contracted SUD treatment programs (n = 212) serving
adults only across the levels of care SUD treatment continuum in Los Angeles County, a list
meeting the study’s sampling strategy and participant inclusion criteria was compiled. Of the

Sampling
strategy
Number of participants or treatment
programs
Start and end
date for data
collection

Clinicians and
directors
Purposive
sampling
Clinician (n=18)
directors (n = 6)
February to
April 2021

Treatment
programs
Purposive
sampling
Child can remain with mother in treatment
(allowed: n = 3 sites; not allowed: n = 3 sites)
February to
April 2021

50

adult residential treatment programs (n = 46) and residential perinatal programs (n = 7), a list of
six women’s residential treatment programs meeting the study’s sampling strategy and inclusion
criteria were compiled. For the six programs that met the study sampling strategy and inclusion
criteria, four agreed to participate and two declined (see Figure 2). For both programs that
declined, each cited staffing and coordination challenges related to the COVID-19 pandemic
environment for the inability to participate. Importantly, both programs that declined were
modalities of SUD residential treatment that allowed the child to remain in treatment with the
mother. Of the four programs that agreed to participate, two do allow children to remain with the
mother during treatment and two do not, thus the variation in the study sampling strategy and
representativeness of the sample was not affected by the programs that declined. Of the four
programs selected for this study, two were perinatal (i.e., allowed child to remain with the
mother in treatment) and two were not. Both perinatal programs represented two sites each and
the two non-perinatal programs represented one site each in the program modality sample (total
sites = 6).
For the two modalities of women’s residential SUD treatment recruited for this study,
each program type offered different levels of services that were in addition to SUD treatment
programming, groups, and curriculum. For example, the agencies that allowed the child to
remain with the mother during treatment offered a more comprehensive array of services and
programming as compared to the agencies that do not allow the child to remain with the mother.
Both treatment programs that allowed the child to remain with the mother during treatment
provided services that included (a) nursing care or health care support, (b) psychiatric services
(i.e., psychotropic medication management), (c) parenting and family education, (d)
childcare/daycare, (e) children’s services/Early Head Start programming, (f) vocational

51

Figure 2: Women’s Residential SUD Treatment Program Selection Diagram

Source: The Los Angeles County Department of Public Health, Substance Abuse Prevention and
Control (2016)

Sampling frame of Los Angeles
County SUD treatment agencies:
(all modalities and serving adults only)
(n = 212)

Residential treatment programs:
(serving adults only)
(n = 46)

Women’s residential treatment:
(serving women only)
(n = 7)

Women’s residential treatment:
(child allowed to remain with
mother in treatment (n = 4);
not allowed to be with mother (n = 2))

Women’s residential treatment sample:
(child allowed to remain with
mother in treatment (n = 2);
not allowed to be with mother (n = 2))

Did not meet residential
treatment inclusion
criteria:
(n = 166)
Did not meet women’s
residential treatment
inclusion criteria:
(n = 39)
Women’s residential
treatment programs
contacted for participation:
(n = 6)
Two programs declined to
participate:
(child allowed to remain
with mother in treatment
(n = 2)

52

training, (g) educational support, (h) housing services support, (i) social services and community
referrals. In addition to SUD treatment, both programs that do not allow the child to remain with
the mother offered services that included (a) parenting and family education, (b) housing services
support, and (c) social services and community referrals. Both SUD treatment modalities point to
the agency’s program size, funding level, and capacity of the program to address the
comprehensive needs of women and their families who are simultaneously involved with the
CJC and CW systems.
Clinician and Director Sample
This multisite research study employed an exploratory qualitative research design to
investigate SUD treatment director and clinician viewpoints at four women’s-only residential
SUD treatment programs (six sites) in Los Angeles County, California. A sample of SUD
treatment clinicians (n = 18) and directors (n = 6) involved in the administration and service
delivery of residential SUD treatment to women who are simultaneously involved with the CJC
and CW systems was recruited (see Table 6; Miles & Huberman, 1994). Of the six directors in
the study sample, there was one director representing each of the six sites of the four SUD
treatment programs. For clinicians (n = 18) in the study sample, two programs were represented
by four and two programs were represented by five clinicians, respectively. Uniform dispersion
of directors and clinicians across SUD treatment programs and sites further strengthened and
maximized treatment provider representativeness. Variability in treatment modality and provider
viewpoints was important because programmatic issues may differ among program types based
on the population served. For example, increased clinician, director, and parental involvement
with the CW system would be expected in residential perinatal treatment programs that allow the
child to remain with the mother during treatment compared to treatment programs that do not.

53

Agency CEOs or appropriate directors of SUD treatment programs that met program
inclusion criteria were contacted to obtain approval for agency to become a site for the
recruitment of clinicians and directors for this research study. Criteria for all directors and
clinicians to enroll in the study were as follows: (a) being directly or indirectly involved with the
provision of SUD treatment services to patients involved with the CJC or CW systems; (b)
serving as a director or program director; (c) serving as a clinician at the level of a licensed
clinical social worker or licensed marriage and family therapist, with a master’s degree in social
work or a related field, or as an associated clinical intern; (d) having clinical roles that include
being a therapist or certified SUD treatment counselor; and (e) providing permission for the
interview to be audio recorded. Exclusion criteria were: (a) directors or clinicians not directly or
indirectly involved with providing treatment to patients involved with the CJC or CW systems;
and (b) respondents who did not agree to be audiotaped during the interview.
The recruitment of SUD treatment clinicians and directors in the study’s agencies
followed a process whereby agency directors received a recruitment flyer (Appendix A)
describing the research study, highlighting its inclusion criteria, and providing the contact
information of the researcher for those who wanted to participate. Executive directors and
program directors facilitated recruitment by disseminating the recruitment flyer to SUD
treatment clinicians individually through emails or at staff meetings. Upon initial contact from a
potential participant, the researcher determined whether the inclusion criteria had been met.
Upon confirmation, interviews were scheduled and the information sheet for exempt research
(Appendix B) was emailed to the respondent. Each participant received a $100 gift card as
compensation for their involvement in the study. Following strict public health COVID-19
protocols, all interviews were conducted via Zoom. Data were collected between February and

54

April 2021.
Adequacy of the Protection Against Risks
The principal investigator has received training in human subjects protection, good
clinical practice, and the Health Insurance Portability and Accountability Act as provided by the
Collaborative Institutional Training Initiative. The researcher expected interviews with SUD
clinicians and directors would not pose a greater than minimal risk as defined by federal
regulations (45 CFR 46) and outlined by the Office for the Protection of Research Subjects at the
University of Southern California. Therefore, a human subjects application was submitted and
approved for an exempt review fitting Category 2, wherein recorded information would not
readily identify participants and any disclosure of responses would not reasonably place
participant at risk. All procedures were approved by the University of Southern California
Institutional Review Board (IRB).
Prior to participation, each respondent received an IRB information sheet for exempt
research that described (a) the purpose of the study; (b) the respondent’s rights; (c) a description
of the participant’s involvement in the study; (d) steps the researcher will take to protect
participants’ confidentiality; and (e) contact information for the investigator, faculty advisor, and
IRB contact information if the participant has any questions or concerns (Appendix B). Prior to
the interview, the investigator reviewed the information sheet for exempt research with the
participant to ensure understanding of its contents and to answer any questions the participant
may have had. All interviews began upon participants providing their verbal consent to
participate and agreeing to be audiotaped via Zoom.
Instrumentation
Data collection instruments consisted of beginning and ending each interview with the

55

use of an interview guide and script. All interviews were conducted one-on-one between the
researcher and the participant utilizing an interview guide with 14 open-ended questions that
were developed and compiled to qualitatively answer the study’s three research questions
Appendix C). All interviews were audio recorded, and reflective memos were written after each
interview. Prompts and probes were used to expand or narrow the focus based on participant
narratives (Jacob & Furgerson, 2012). After the interview, the use of a sociodemographic form
was used to collect sociodemographic, characteristic, and descriptive data from each individual
participant (Appendix D).
Data Collection
Semistructured interviews were conducted via Zoom with each participant and lasted
approximately 1.15 hours. All Zoom recordings and interview transcripts were saved and stored
on a password-secured server maintained by the University of Southern California. All
interviews were audio recorded with the permission of participants and professionally
transcribed verbatim. Prior to beginning participant interviews, the researcher (a) collected
information and documents from each agency that oriented and guided interviews in relation to
the protocols, requirements, and processes involved in their relationships with the CJC and CW
systems; and (b) started interviews with questions pertaining to the participant’s agency
alignments between clinicians and written protocols regarding interagency CJC and CW
relationships. Information and documents came from the respective agency’s or parent
company’s website in downloadable brochures describing the agency’s SUD treatment focus, the
population the SUD treatment agency engages and serves, all integrated treatment services that
are provided, and what cross-system oversight agencies (CJC, CW, probation, parole) are
simultaneously involved in the provision or funding of SUD treatment services for patients.

56

At the beginning of each interview, an interview guide was used to provide a brief
description and purpose of the study related to obtaining director and clinician perspectives on
(a) how interagency SUD treatment partnerships involving the CJC and CW systems create
challenges or barriers to SUD treatment provision by directors and clinicians; and (b) how
additional cross-system reporting, monitoring, and communication requirements affect the
clinician-patient relationship and treatment planning. This brief description and purpose also
highlighted questions related to clinician and director viewpoints on suggestions for ways to
improve (a) cross-system collaboration among providers, CW, and CJC stakeholders; and (b) the
clinician-patient relationship and treatment planning with improved collaboration and
communication. The interview included 14 open-ended questions (Appendix C), beginning with:
“In your view, how would you characterize your agency’s relationship with the courts and child
welfare agencies?” and “In what ways do you as a clinician [or director] communicate or
collaborate with child welfare workers or the courts?” Prompts and probes were used to
encourage continued narrative descriptions that provided more context regarding key factors that
explained the challenges or barriers to cross-system collaboration, their impact on the clinician-
patient relationship, and ways to improve these mechanisms (Saldaña, 2015).
After each interview, all participants completed a quantitative survey that collected
descriptive data, including (a) basic demographic data; (b) type of SUD treatment director or
clinician; (c) length of time in practice at the treatment agency; (d) treatment modality, services
provided in addition to SUD treatment, and population served; and (e) licensing and degree
information (Appendix D). At the end of each interview, the researcher completed interview
memos that provided a general impression of participants’ responses. The researcher then
evaluated and discussed these memos with an ATLAS.ti expert trainer and consultant to identify

57

initial common codes and emergent themes.
Data Analysis
The general means of analysis involved an ongoing, iterative, and cyclical process of
examining and reexamining data with code and concept development. This qualitative data
collection and analytic approach employed a SEM and phenomenological theoretical lens for
examining the micro, meso, and macro experiences and viewpoints of SUD treatment clinicians
and directors regarding their interactions with the CW and CJC systems. Guided by the SEM
framework (Bronfenbrenner, 1979) as a theoretical lens, data were analyzed inductively using
thematic analysis. The SEM is a congruent framework to analyze research that addresses the
individual (SUD treatment clinician and director) and their behaviors in multiple contexts and at
multiple levels: intrapersonal, interpersonal, organizational, and policy levels.
Using a phenomenological lens and methodological approach, the researcher repeatedly
referred to prior research during qualitative data collection and analysis, informing the process of
amendments to codes and guiding subsequent revisions to the codebook (Fereday & Muir-
Cochrane, 2006). This aided in the emergence and identification of what clinicians and directors
experienced with their interagency collaboration and interactions with the CJC and CW systems;
and how this affected treatment provision, their relationships with the patient, and SUD
treatment planning. It further enabled the identification of common elements among SUD
clinician and director experiences that are part of SUD treatment provision and practice with
patients referred by the CJC and CW systems. Components of both methodological approaches
(SEM and phenomenological) drove the thematic analysis, aiding in the identification, analysis,
and interpretation of patterns of themes in the qualitative data (Fereday & Muir-Cochrane, 2006).
This mix of methodological approaches ensured the sufficient proficiency and coordination of

58

managing the different tasks needed to answer the research questions, further strengthening the
rigor and trustworthiness of the findings (Fereday & Muir-Cochrane, 2006; Padgett, 2016;
Sandelowski & Barroso, 2003).
Data analysis began with the general assumption that cross-system collaboration and
communication challenges affect residential SUD treatment provision, the clinician-patient
relationship and treatment planning. Aside from the a priori theme of treatment provision,
clinician-patient relationship and treatment planning being affected, the coding structure
emerged organically from the qualitative data analysis. The goal of analysis was to identify the
depth and scope of those affects, along with their associations with the different categories of
SUD provider, patient, and cross-system relationship involvement (CJC and CW).
Descriptive statistics of the sociodemographic and SUD treatment program
characteristics in the study sample were calculated using STATA version 15.1. All qualitative
data were analyzed using ATLAS.ti 9.1.7 software. Data were analyzed wherein the first step
involved the review of interview transcripts and audio recordings to generate initial codes
(Creswell & Creswell, 2017; Saldaña, 2015). Transcripts were read and interview notes were
collated into segments of text that corresponded with the initial codes (Creswell & Creswell,
2017; Saldaña, 2015). The thematic development and generation of all coding of qualitative data
were conducted in two rounds comparing results between the researcher and an expert ATLAS.ti
consultant who met biweekly to discuss the application of codes to the data, the emergence of
new codes, and looking for similarities and differences (Boyatzis, 1998; Braun & Clarke, 2006;
Creswell & Creswell, 2017; Padgett, 2016). Independent coding of data was based on thematic
relationships among clinicians and directors related to the challenges in cross-system
collaboration as a barrier to SUD treatment provision and its effect on the clinician-patient

59

relationship and treatment planning (Boyatzis, 1998). The researcher served as the tiebreaker and
designed the final coding scheme strategy and categorization. To determine consistency among
raters, an interrater reliability analysis using Kappa statistics were performed for each of the
research questions independently. For research question one, the interrater reliability for raters
was found to be kappa = .89 (p < .001). For research question two, the interrater reliability for
raters was found to be kappa = .92 (p < .001). For research question three, the interrater
reliability for raters was found to be kappa = .96 (p < .001). Kappa statistics were based on the
range of main themes within each of the three research questions. Each of the three kappa
statistics represent an excellent strength of interrater reliability and agreement.
The analysis then focused on interpretive themes with detailed definitions. Themes were
based on features of treatment provider viewpoints characterized by participant experiences of
challenges in cross-system collaboration and treatment provision that captured core phenomenon
relevant for answering each of the research questions. Through repeated analysis and open
coding of the qualitative data, the researcher identified prominent themes and established a
taxonomy that represented thematic hierarchies. The salience of themes was assessed using two
criteria: (a) the frequency that themes recurred across the interview transcripts and (b) the
emphasis placed on a given theme by each participant (Buetow, 2010). The emphases were
determined by the relative proportion of data focused on a theme in the interview as related to
the importance of the study’s research questions (Buetow, 2010). For example, throughout the
interviews, a recurring theme involved the lack of responsiveness or communication of CW
workers toward both clinicians and patients, which had an impactful negative consequence on
treatment provision and the clinician-patient relationship. However, this lack of CW
responsiveness had related subthemes specific to either the treatment providers or patients. For

60

example, this lack of CW worker and CW system responsiveness was associated with the
following subthemes: (a) high caseloads, (b) CW workers’ negative perceptions of the patient,
and (c) CW priorities related to the child versus the mother’s SUD treatment and CW case.
Through this strategy, achievement of credible, dependable, and trustworthy findings can
be attributed to the theoretical and methodological framework underpinning the analytic design,
consisting of the SEM framework, organizational theories, and a phenomenological analytic
method. Further, the SEM framework and phenomenological lens to thematic analysis produced
several themes related to the study’s primary aims and research questions (Boyatzis, 1998; Braun
& Clarke, 2006; Creswell & Creswell, 2017). Overarching themes and associated subthemes are
discussed for each research question in the text and presented in two types of tables. The first
table type presents the overarching theme and associated subthemes for each research question.
The second table type presents the overarching themes and subthemes connected to a specific
level in the SEM hierarchy. Quotes from participants are provided for contextual meaning and
insight.

61

CHAPTER FOUR: RESULTS
Chapter 4 presents qualitative research data from SUD treatment clinicians and directors
regarding how cross-system jurisdictional oversight and monitoring, along with the lack of
treatment coordination, communication, and responsiveness by the CJC and CW systems, create
a challenging treatment environment for treatment providers and patients. The purpose of this
study was to explore how these integrated cross-system challenges adversely affect SUD
treatment provision, treatment planning, and the clinician-patient relationship, along with
treatment provider strategies for improving these conditions. This multisite study enabled an
investigation of clinician and director experiences and viewpoints based on the following three
research questions:
1. What cross-system collaborative mechanisms involving the SUD treatment, CJC, and
CW systems create SUD treatment provision challenges for clinicians and directors?
2. How do cross-system oversight, monitoring requirements, and communication
responsiveness adversely affect the clinician-patient relationship and treatment
planning?
3. How can (a) cross-system collaboration and coordination among the different
stakeholders (SUD treatment, CJC, and CW) be improved; and (b) the clinician-
patient relationship and SUD treatment planning be strengthened via improved
communication and coordination?
The focus of Research Question 1 was to identify and obtain, from clinicians and
directors, a contextual description of current cross-system collaborative mechanisms that create
SUD treatment provision challenges. The focus of Research Question 2 narrowed the focus to
identifying how these cross-system challenges adversely affect the clinician-patient relationship

62

and treatment planning, particularly as it pertained to cross-system communication and
responsiveness, oversight and monitoring requirements, and ASFA timeline mandates. Research
Question 3 concentrates on key strategies or recommendations from SUD treatment clinicians
and directors regarding ways to (a) improve cross-system collaboration and coordination among
the three primary stakeholders (SUD treatment, CJC, and CW); and (b) strengthen or improve
the clinician-patient relationship and SUD treatment planning.
Participant Characteristics
Table 7 provides a detailed categorization of participants’ sociodemographic and SUD
treatment program characteristics. Stakeholders who participated in the interviews were 18
clinicians and six directors (n = 24). Of the 24 participants, all were women with a mean age of
47.3 years. Thirteen participants (54.2%) identified as Hispanic, eight (33.3%) as White non-
Hispanic, and three (12.5%) as Black. The mean length of time participants were employed at
their respective treatment programs was 75.83 months (6.3 years), with a range of 6 to 325
months (or 27.1 years). Nine of the participants had a master’s degree, and five were either a
licensed clinical social worker or licensed marriage and family therapist. Each of the four
programs required patient progress reporting updates to the CW and CJC systems, in addition to
the probation or parole department. Most participants (66.67%) described their cross-system
collaboration with the CW and CJC systems as a “basic level of exchange,” and only five
(20.83%) described their collaboration as involving “active cross-system engagement planning.”
Research Question One
What cross-system collaborative mechanisms involving the SUD treatment, CJC, and CW
systems create SUD treatment provision challenges for clinicians and directors?
The focus of this research question was to identify and obtain from clinicians and

63

Table 7: Participant Sociodemographic and Treatment Provider Characteristics (n = 24)
Characteristics Clinicians Directors Total
No child in
tx
a

Child in
tx
a

Total

(n = 18) (n = 6) (n = 24)
(Clinician:
n = 11;
directors:
n = 3)
(Clinicians:
n =7;
directors:
n = 3)
(n = 24)
n (%) n (%) n (%) n (%) n (%) n (%)
Age (M, SD)
45.56
(11.91)
52.33
(11.34)
47.25
(11.90)
48.29
(12.77)
45.8
(11.094)
47.25
(11.90)
Age (range) 23-62 40-71 23-71 23-71 26-59 23-71
Sex (% female)
18
(100)
6
(100)
24
(100)
14
(100)
10
(100)
24
(100)
Race and ethnicity

Hispanic
11
(61.11)
2
(33.33)
13
(54.17)
8
(57.14)
5
(50)
13
(54.17)

White non-Hispanic
4
(22.22)
4
(66.67)
8
(33.33)
4
(28.57)
4
(40)
8
(33.33)

Black
3
(16.67)
0
3
(12.5)
2
(14.29)
1
(10)
3
(12.5)
Hispanic ethnicity

Central American
1
(5.60)
1
(16.67)
2
(8.33)
2
(14.29)
0
2
(8.33)

Cuban
1
(5.60)
0
1
(4.17)
1
(7.14)
0
1
(4.17)

Mexican, Chicana
8
(44.44)
1
(16.67)
9
(37.50)
5
(35.71)
4
(40)
9
(37.50)

South American
1
(5.60)
0
1
(4.17)
0
1
(10)
1
(4.17)
Time at agency (M, SD in months)
55.72
(72.36)
136.17
(89.69)
75.83
(82.98)
50.93
(50.06)
110.7
(107.98)
75.83
(82.98)
Time at agency (range in months) 6-325 24-286 6-325 6-181 23-325 6-325
Degree

SUD certification
7
(38.89)
0
7
(29.17)
4
(28.57)
3
(30)
7
(29.17)

Associate
4
(22.22)
1
(16.67)
5
(20.83)
2
(14.29)
3
(30)
5
(20.83)

Bachelor’s
1
(5.56)
2
(33.33)
3
(12.50)
2
(14.29)
1
(10)
3
(12.50)

Master’s
6
(33.33)
3
(50)
9
(37.50)
6
(42.86)
3
(30)
9
(37.50)
License type

Licensed clinical social worker
1
(5.56)
1
(2.78)
2
(8.34)
1
(7.14)
1
(10)
2
(8.34)

Licensed marriage and family
therapist
2
(11.11)
1
(9.71)
3
(20.82)
3
(20.82)
0
3
(20.82)

Other
5
(27.78)
1
(16.67)
6
(25)
3
(21.43)
3
(30)
6
(25)

None or not at this time
10
(55.56)
4
(66.67)
13
(54.16)
7
(50)
6
(60)
13
(54.16)
Child allowed to remain with
parent in treatment

Yes
7
(38.89)
3
(50)
10
(41.67)
0
10
(100)
10
(41.67)

No
11
(61.11)
3
(50)
14
(58.33)
14
(100)
0
14
(58.33)

64

Characteristics Clinicians Directors Total
No child in
tx
a

Child in
tx
a

Total
Progress reporting updates
required (%)

CW
18
(100)
6
(100)
24
(100)
14
(100)
10
(100)
24
(100)

CJC
18
(100)
6
(100)
24
(100)
14
(100)
10
(100)
24
(100)

Probation or parole
18
(100)
6
(100)
24
(100)
14
(100)
10
(100)
24
(100)
Collaboration level

Basic exchange
14
(77.78)
2
(33.33)
16
(66.67)
10
(71.43)
6
(60)
16
(66.67)

Developing or implementing
2
(11.11)
1
(16.67)
3
(12.50)
2
(14.29)
1
(10)
3
(12.50)

Active cross-system engagement and
planning
2
(11.11)
3
(50)
5
(20.83)
2
(14.29)
3
(30)
5
(20.83)
Note. Of the six treatment sites, three allowed and three did not allow children to remain with the mother while in treatment.
a
No child in tx refers to SUD treatment programs that do not allow child to remain with the mother while in residential treatment.
a
Child in tx

refers to SUD treatment programs that do allow child to remain with the mother while in residential treatment.

directors a contextual description of current cross-system collaborative mechanisms that create
SUD treatment provision challenges. The analysis found several themes and subthemes that
emerged and overlapped regarding current collaborative mechanisms that create treatment
provision challenges. Major overarching themes and associated subthemes were (a)
“communication as a challenge to treatment provision” (subthemes: “cross-system
responsiveness to clinicians and directors” and “CW communication and responsiveness to
patients”); (b) “lack of knowledge on SUD treatment approaches, values, and goals” (subthemes:
“differing views or values regarding SUD treatment approach,” “negative biases or perceptions,”
and “lack of training in SUD treatment and trauma-informed care”), (c) “large caseloads or
logistical concerns” (subthemes: “lack of cross-system logistics and resources” and “heavy
workload concerns”); and (d) “ASFA as a challenge to SUD treatment provision” (subthemes:
“ASFA timeline as a barrier to SUD treatment provision” and “child custody concerns and CW
requirements as a SUD treatment competitor”). Each theme and its associated subthemes are
presented in Table 8. Additionally, in Table 9, each theme and its associated subthemes are
described in detail with illustrative quotes categorized by SEM designation.

65

Table 8: Research Question 1 (Themes and Subthemes)

Theme One: Communication as a Challenge to Treatment Provision
Cross-system collaborative practices that emphasize the FCA in women’s residential
SUD treatment require ongoing interagency communication as a core function (Huebner et al.,
2017; Lloyd et al., 2021). All participants described good communication as a primary driver and
a necessary component in the cross-system collaborative process. Breakdowns in communication
among the SUD treatment provider and CJC and CW systems led to various challenges in
treatment provision.
Cross-System Responsiveness to Clinician and Directors
Communication issues were a consistently expressed barrier and challenge to treatment
provision experienced by all treatment providers. For example, clinicians and directors shared
experiences regarding the challenges of collaboration and coordination with CJC and CW
Theme 1:
Communication as
a challenge to
treatment
provision
Theme 2: Lack of
knowledge on SUD
treatment
approaches, values,
and goals
Theme 3: Large
caseloads or
logistical concerns
Theme 4: ASFA as
a challenge to SUD
treatment
provision
Subthemes

Cross-system
responsiveness with
clinicians and
directors
Differing views or
values on SUD
treatment approach
Lack of cross-
system logistical and
resource concerns
ASFA timeline as a
barrier to SUD
treatment provision

CW communication
and responsiveness
with patient
Negative biases or
perceptions
Heavy workload
concerns

Child custody
concerns and CW
requirements as a
SUD treatment
competitor

Lack of training on
SUD treatment and
trauma informed
care

66

workers on important FCA treatment planning and reunification objectives. One director noted:
A lot of times, we’re not able to get calls back within a reasonable timeframe. … It’ll
take us about a good three to four days for us to get a call back. I think that’s a huge
challenge, especially when we’re working with patients that are eager to start getting
those unmonitored visits or monitored visits or even calling their kids and they know
there’s restraining orders and that they need to get approval from the social [CW] worker.
(Director 302D)
CW Communication and Responsiveness to Patients
Other treatment providers shared how nonresponsive or disengaged CW workers
drastically affect clients and their SUD treatment engagement and potentially (unknowingly)
induce overwhelming psychological stress. These stressors are known risk factors that lead to
relapses or leaving treatment. The following quote typifies how the lack of patient coping
mechanisms often leads to treatment disengagement or relapse:
I think it affects the client drastically because when they can’t get a hold of their child
welfare workers or communicate … they don’t respond and things like that, the clients
tend to … they lose engagement, for one. For two, they lose hope on seeing the child, and
it brings more stress on them because when they’re trying to get information or just
receive some kind of response or visit and they’re not getting anything from the CW
worker, it stresses them out even more. Of course, as an addict, stress can cause a relapse.
(Clinician 306C)
Theme Two: Lack of Knowledge on SUD Treatment Approaches, Goals, and Values
The SUD treatment, CJC, and CW systems differed in their values, perspectives, and
approaches to providing services, including whether the parent, child, or legal requirements
should be the primary focus. With these differing values, perspectives, and approaches came
conflicting and entrenched professional training and experiences, along with the lack of SUD
treatment knowledge processes, particularly as they pertained to trauma-informed care, which
further challenged a family-centered treatment approach. The following subthemes encapsulate
this theme and the barriers they present to SUD treatment provision.

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Differing Views or Values Regarding SUD Treatment Approach
In the CJC and CW context, workers often mandate standard requirements to include in
treatment plans rather than identifying the individual treatment needs of the patient and family.
This can result in overlapping, duplicate, or inappropriate services being added to treatment
plans, further contributing to the already heavy caseloads of the CJC docket and CW
caseworkers (D’Andrade, 2019). Clinicians and directors noted that these cross-system
challenges adversely affect treatment planning and provision:
You know, they [CJC] do have a lot of demands that may not be consistent with the
clients’ unique treatment needs. Most of these women have extensive trauma histories.
You know, I’ve seen minute orders [CJC treatment mandates] that say, they need to do
six months of treatment with a mainly one-size-fits all approach with the same required
meetings and groups such as domestic violence and anger management, which does not
address the underlying issue of trauma the patient needs to address. Clients need to go out
and test [urinalysis testing] outside to CW facilities in order to meet CW requirements,
and they need to test in here to meet our program’s testing requirements. They also need
to have a certain amount of visits [child visitation], which when you’re in a residential
facility, sometimes that can be difficult to coordinate with CW workers. Visitations and
outside testing makes it difficult when there is again a lack of communication. That’s the
biggest hurdle that I think that we lack. (Clinician 101C)
They [CW workers] will call the counselor and say, “OK, well, she told me she
relapsed. She hasn’t told you yet, but she told me, and we’re letting you know. …
What can we do? OK, more groups are going to be necessary along with residential
… more one-on-one individual sessions, more random testing, and that kind of
gives a little accountability to the client … but that’s only if the social worker’s
willing to work for the client. There’s a lot of social workers that are like, “Oh, no,
sorry. You [the mother] failed.” And then they go and they terminate reunification,
and that also starts as an excuse for the client, gives them an excuse just to leave.
They have more fear tactics than they do empathy tactics. (Clinician 201C)
Negative Biases or Perceptions
Consistent with prior qualitative research, SUD treatment providers expressed how CW
workers were primarily concerned with the safety of the child and struggled with their biases
about the SUD treatment process, relapses, and the mother’s prior drug use history (Fusco,
2019). Further challenging treatment provision and aligned with prior studies, CW workers may

68

have little understanding of the chronic nature of SUDs and the treatment process due to the lack
of training or education prior to working with parents with a SUD and a CW case (DePasquale,
2017; Quinn, 2010; Senreich & Straussner, 2013). The following description by a treatment
provider encompasses these negative biases and perceptions:
Personally, I’ve seen and I’ve heard where a CW worker will say to the mother, “Well,
this is not the first time that you’re doing it [relapse], so why should I continue to help
you when you’re going to do it again and putting your child at further risk?” So, instead
of encouraging [them], … the verbiage that they use with these women sometimes,
they’re so demeaning to them. And that’s one of the things that I know personally, and I
talk to these residents, constantly. … I’ve seen it where [CW workers say], “Oh, well,
good job, I’m so proud of you, we’ll see how long that’s going to last.” One of the things
that really upsets me [is when they say], “Well, it doesn’t matter what you’re doing
because you’re still not going to get him back, the judge is not going to give you your
child back.” You don’t know that. … They don’t know that; they don’t know what the
judge is going to say or think, but they [CW workers] do that. (Director 402D)
Having a SUD is a chronic condition and treatment is often marked by substance use
relapses as an individual progresses in their treatment and recovery. Resultantly, some CW
workers may project a disengaged or even unsupportive relationship with treatment providers
and patients. This affects the implementation and provision of effective treatment planning. One
clinician described it this way:
Then there’s the other type of social worker [CW worker]. Aloof, they’ve been doing this
for a while, or they’ve become cynical. [They think] this case is going to be the same
song and dance [relapse or treatment dropout] or they bring their own biases: “Oh, I can
tell this is going to be somebody that’s not going to make it.” So, they’re not engaged,
they’re not projecting this supportiveness, or they’re lackadaisical in their responsiveness,
and this stuff affects how we timely work with this patient, because you can’t move along
in the treatment planning, or the patient becomes stressed out. (Clinician 402C)
Negative progress reports can often be misconstrued or not conveyed to the judge with
additional important information regarding the patient’s treatment progress. A CW worker’s
biases may be supported or informed by a basic or uniform one-size-fits-all progress report
provided by the clinician, which does not reflect a full accounting of the treatment progress made
by the patient. When a full or more accurate treatment update is not conveyed to the judge, court

69

rulings can have an adverse effect, halting the treatment and family reunification planning
process. One participant described it this way:
And some of the DCFS [CW] experiences that I’ve had is, “Well, I feel like she shouldn’t
have her child yet.” But oftentimes it is whatever the social worker feels should be
written in the report that’s going to determine whether the parent keeps the child or the
child goes up for adoption. And I find that so, so heartbreaking because it’s based on this
report, because it’s this social worker [CW] not getting what she wanted to hear, which
may not include important progress that has been made by the patient. (Clinician 202C)
Lack of Training in SUD Treatment and Trauma-Informed Care
Although trauma-informed services have been shown to improve the CW worker’s and
parent’s ability to meet CW goals of child safety, permanency, and family reunification, many
CW staff members lack necessary trauma-informed training and knowledge. Parents involved
with the SUD treatment, CW, and CJC systems often have extensive trauma histories that can
affect their ability to work effectively with SUD treatment and CW staffs and respond effectively
to CW requirements (National Child Traumatic Stress Network, 2011; SAMHSA, 2014). This
lack of training or education extends to SUD and addiction treatment processes:
If maybe there was, if the CW department goal really is to reunify families as they say it
is, if everybody could get some level of education on trauma-informed care … and I’m
not sure they get it at school, I’m just not sure what the requirements are to work there
[CW department], but some level of education on trauma and the consequences of trauma
and people’s behaviors and why some people have negative behaviors as a consequence
of trauma. It would be helpful because … it doesn’t seem like everybody is trauma
informed, or it doesn’t even seem like their goal is to reunify families as the [CW]
department says it is. (Clinician 307C)
Sometimes I don’t think they understand how treatment works at all, maybe on a scale of
one to 10, seriously maybe a three. I don’t think they understand the disease, and I wish
that, since they are working with mothers who have a substance use disorder, be at least
trained or have some knowledge of substance use. I’ve had some crazy comments where
they [CW workers] would just personalize and say, “She’s a bad mother.” No, she’s not a
bad mother, she’s working on her substance use disorder, which led to the behaviors and
the legal issues. So yeah, I’ve had a lot of challenges with some CW workers, but I feel
like they have really minimal training, what I’ve encountered, of anything related to
substance use understanding. (Clinician 301C)

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Theme Three: Large Caseloads and Logistical or Resource Concerns
The CJC and CW workers often applied a one-size-fits-all approach to manage
inadequate resources and large caseloads, such that cross-system family-centered treatment goals
were replaced with efficiency goals that sacrificed alignment with FCA objectives. Respondents
also commented on the lack of resources available to support the FCA in family treatment. SUD
treatment providers described challenges in treatment provision pertaining to supporting child
visitation coordination and reunification planning, which is an essential component of family-
centered treatment.
Lack of Cross-System Logistics and Resources
Participants commented on the lack of collaborative efforts, resources, and logistical
support, particularly given the complex treatment needs of parents and their families in SUD
treatment. For example, treatment providers discussed challenges with the CJC and CW systems
regarding the provision of child visitation planning and coordination:
The struggle has been where we create a case plan or they go to court and the judge [will]
order something and the social workers [CW] don’t follow through. That is our
challenge. The judge can say, “Oh, we’ll give referrals to the mother for housing.” Let’s
just say, those referrals never happened. They never happened for extra monitors for the
resident to have weekend visits [with children], to get her full four hours of visits …
because now we need a monitor. The judge says, “OK, make sure that the resident or the
mother gets a monitor.” We’ve seen it numerous times where we see it in paper, but yet
we’re advocating and we’re asking and it doesn’t happen because their response is,
“There’s not enough social workers [CW] or monitors.” (Director 402D)
Child visitation planning is an essential component of family-centered treatment. When a
family treatment court orders family visitation coordination between the CW system and the
parent, it is often accompanied by funding for independent monitors. But participants said these
court orders are often not met based on logistical and resource concerns. One director described
the challenges her program encounters regarding this essential family treatment planning
component:

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Visitation with children who are in foster care is a big issue. Usually, the clients here
have limited funds. If their child is not really close nearby or if they’re in a different
county, they don’t have the money to get themselves to a child visit. A lot of times, foster
parents are not able to bring the child to the program because they may have other kids in
the house [and] that doesn’t fit into their schedule. This is a big issue. A lot of times,
visits need to be on weekends, and if there needs to be a monitor, we are not monitors
[ordered through the courts and provided by the CW department] … [and] having one
provided for the residents is difficult, especially if they are expected to pay for it because
they don’t have any money. That’s a huge issue and one that also brings up barriers to a
successful treatment episode. That is another thing that will take somebody out the door
is if they don’t have a way to get to that visit or the child welfare worker cannot make
sure that the visit happens here, or at least in a park or a restaurant nearby … they will
leave treatment and find a way to get to wherever their kids are for a visit. … That’s very
discouraging. It really is. (Director 401D)
Heavy Workload Concerns
Creating additional collaborative implementation barriers, large caseloads can be viewed
as a burden for CW and court staff members (Gopalan et al., 2021). For example, SUD treatment
clinicians and providers often are unable to communicate with or reach CW workers in a timely
manner, affecting clinician-patient family treatment needs. The following comments describe
how heavy workloads are a central factor that challenges cross-system child visitation planning
and CW and CJC progress updates:
They [CJC and CW] just want them here [in treatment] a certain amount of time. It is
very difficult to get ahold of [CW] workers. Sometimes emails go back and forth for
days, phone calls go unanswered, and we appreciate that that has to do with their
workload, which is extreme. So, we understand that, but it does put things on hold,
especially if we have a resident who may be in crisis and struggling here, and we want
some support from the worker, maybe some encouragement, maybe an update on
visitation planning, “Hang in there, stay there, don’t get kicked out.” That sort of thing.
And it is difficult to get ahold of them. (Director 401D)
I get it, maybe their workload is too much, and they’re not so involved. I usually
hear from them the day before or the morning of the person’s court date. I have
some of our clientele that try to call their DCFS worker on a consistent basis, and
they’re like, “She’s not answering. What do I do?” Or they try to call the attorney,
and the attorney’s not answering. Like, “What do I do? I need help? Can you email
her? Can you call her?” And that’s usually when I get involved, and I find it’s a
little challenging, too. (Clinician 410C)

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Theme Four: ASFA as a Challenge to SUD Treatment Provision
Respondents described the significant challenge of adhering to the ASFA timeframe
(termination of parental rights after a child has been in temporary foster care settings for 15 of 22
months). Parents often enter treatment later in the ASFA timeline due to the inability to access
SUD treatment services in a timely manner. This impending adoption and permanency hearing
timeline affects treatment provision because patients become hyper-focused on meeting CW
requirements to not lose their children. The following subthemes encapsulate these challenges.
ASFA Timeline as a Barrier to SUD Treatment Provision
One clinician provided an estimated breakdown of women in residential SUD treatment
at her agency regarding their population percentage on the ASFA timeline:
I’m going to have to say the majority of the new parents, I’m going to give it maybe a
70%, right, are towards the end [of the ASFA timeline] of either losing the rights or at
adoption-70% probably there. The rest of the 30% are in the middle somewhere, whether
they can still do something. And very few, maybe like a 5%, are at the beginning.
(Clinician 307C)
SUD treatment providers are challenged by the incongruity of the ASFA timeline and its
adoption focus, and with the provider’s focus being on the parent’s treatment and family
reunification goals. This treatment incongruity often leads mothers to not engage in or receive
the intensive treatment necessary for family reunification:
It affects it [treatment provision] a lot. To me, I think that that’s one of the biggest things
that they have hanging over their heads [imminent child custody loss], and a lot of times
that contributes to clients not being ready [for treatment engagement]. When you have a
client that comes in … at the tail end [of the ASFA timeline], and they might come in and
this is their last chance to get their children back. You’ve got 90 days before you go back
to court and it’s going to be decided whether or not you get your child back. It takes the
focus away from the client’s actual treatment because now they are only focused on
getting the child back and what the DCFS [CW system] and courts are requiring from
them. Now, as a counselor, nine out of 10 times, you know these clients are not ready.
Especially when they truly didn’t focus on treatment. The client doesn’t know how to
deal with the stress of having their child back. A lot of these times, these families have
been separated for about six months, nine months, 12 months. They don’t know what it’s

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like to have a kid back in their life. They don’t know how to deal with that stress.
(Clinician 201C)
Well, I mean, once again, their focus is not going to be in taking care of finding
resolutions or why they’re here [residential SUD treatment] … addressing their trauma or
why they’re using or drinking. Their main goal is to avoid this adoption. So, in reality,
how much time do I have to work with this patient, to identify or have her gain
awareness-oh, why is she using? Why does she put herself and her child in jeopardy?
And now it’s like, depending on if it’s right away or if there’s still time [on the ASFA
timeline], how are we going to work together to prepare her to go to court by herself, to
see if they’re going to adopt her baby or not? And in their eyes, like, “I’m going to give
my baby away to somebody else because I have failed to meet these requirements”
[CW and CJC reunification requirements that can’t be met in addition to SUD treatment].
(Clinician 202C)
Child Custody Concerns and CW Requirements as a SUD Treatment Competitor
It is well documented how the ASFA timeline requirements create increased pressures
and challenges on SUD providers and patients (Drabble, 2010; Green et al., 2008; He, Traube, &
Young, 2014). For example, achieving substance use abstinence, along with meeting all
urinalysis testing, parenting, anger management, and domestic violence group requirements,
within the ASFA timeframe can be an unrealistic goal, particularly when conducted concurrently
with intensive residential SUD treatment. The following treatment provider responses reflect
contextual insights into the SUD treatment provision challenges that the ASFA-mandated
timeline and its associated CW and CJC requirements (e.g., urinalysis testing, domestic violence,
anger management, and parenting groups) create with clinicians and their patients:
I think the way it affects treatment planning is actually, of course you have to meet the
requirements of maintaining sobriety and whatnot. But what it does is, it does again
impede some of the participation here, engagement here, because they’re so focused on
the adoption hearing or the placement hearing, or the “I got to [complete the CW
requirements]. … What can I do? My child’s going to get adopted out. What can I do?
My mother-in-law is going to get custody of my child.” Of course it’s going to be on their
mind all the time. So, it does impede in them getting, I’m going to say, the most out of
treatment when it is that late in the game [regarding the ASFA timeline]. (Clinician
307C)
The ASFA expectations and requirements that patients need to meet are often perceived

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as unrealistic and may lead to feelings of hopelessness and a defeated attitude, creating a
competing psychological barrier to treatment provision. For example, one participant described
how this can lead patients to leave treatment:
Yes, it is definitely [a SUD treatment provision challenge] because should they get word
that the workers were going to recommend termination of permanent visits because
they’ll be informed prior to them going to court … a lot of times they get the information
of the department’s recommendation and it just creates this, again, detrimental thinking
of “What’s the point and why am I here? I’m going to lose my child anyways.” There’s
no point in treatment if that child’s going to get taken away. Sometimes it gets to the
point of abandoning treatment altogether. (Clinician 307C)
Similarly, participants described the disempowering impact of the ASFA timeline
requirements and expectations on patients.
We’ve seen mothers who kept thinking, “Well, it doesn’t matter what I’m going
to do. They’re going to take them anyway because I’ve only got four months to go
[before permanency or adoption proceedings]. They want me to do this, this, and
this [CJC and CW requirements], and there’s no way I can get it all done.” So,
they want to give up. They say, “Why even try?” We try to share with them
because we have seen all the way up until the very last day, until that document is
signed saying, “adoption permanent,” you still have a chance. So, don’t give up
because we’ve seen it happen. We try to let them know that, “Hey, even if you’re
making small, positive steps, keep moving forward.” I mean, if that 22 months is
next month and you’re in treatment and you’re working your program, you’re
learning new skills, you’re demonstrating new skills, you’re staying on top of
everything just as if you just had a little hiccup, because we’ve seen until the
official documents are signed that you still have a chance. (Clinician 307C)
Functions of Quality Cross-System Collaboration and Communication
Cross-system collaborative models, such as the FCA framework, include things such as
continuing collaborative case planning, monitoring, and support. For example, although
collaborative support is helpful in many ways, appropriate and timely communication and
responsiveness is particularly important in terms of providing a collaborative teamwork support
approach that involves the parent’s complex family treatment needs:
“Then you have the engaged social workers who literally will come onsite, visit,
and talk with the parent. The parents can easily get ahold of the worker. The
worker is in constant communication with the counselor or the clinician through

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emails or through phone calls. We could actually see that, "Hey, this worker
really is trying to help the parent see that it's not a loss." I've been doing this for
years. I've even been with with another agency; and the thing with the mothers is
when their children are removed from their care, it's an automatic DCFS (CW) is
the bad guys. Right? As counselors and clinicians, we try to help them see that
they're not the bad guys. They're giving you the opportunity to get yourself back
together while your kids are being cared for, because you can't do both at the
same time. It's difficult because as a mother, your focus has to be on the child. But
in recovery, new in recovery, your focus needs to be on you, not your child.
Right? So, DCFS (CW) is giving them that opportunity. “Hey, we're going to hold
your children. We're going to care for your children or child while you get
yourself some recovery.” (Clinician 304C)

Table 9: Cross-System Collaborative Mechanisms That Adversely Affects Treatment Provision
Overarching theme
(see Table 7)
Subtheme
(see Table 7)
SEM framework Participant quote
Communication as a
challenge to treatment
provision

Cross-system
responsiveness to
clinicians and directors
Organizational

A lot of times, we’re not able to get
calls back within a reasonable
timeframe. … It’ll take us about a good
three to four days for us to get a call
back. I think that’s a huge challenge,
especially when we’re working with
patients that are eager to start getting
those unmonitored visits or monitored
visits or even calling their kids and they
know there’s restraining orders and that
they need to get approval from the
social [CW] worker. (Director 302D)

CW communication
and responsiveness to
patient

Interpersonal
(CW or CJC with
patient)

I think it affects the client drastically
because when they can’t get a hold of
their child welfare workers or
communicate … they don’t respond
and things like that, the clients tend to
… they lose engagement, for one. For
two, they lose hope on seeing the child,
and it brings more stress on them
because when they’re trying to get
information or just receive some kind
of response or visit and they’re not
getting anything from the CW worker,
it stresses them out even more. Of
course, as an addict, stress can cause a
relapse. (Clinician 306C)

Lack of knowledge on
SUD treatment
approaches, values, and
goals
Differing views or
values regarding SUD
treatment approach

Organizational

You know, they [CJC] do have a lot of
demands that may not be consistent
with the clients’ unique treatment
needs. Most of these women have
extensive trauma histories. You know,
I’ve seen minute orders [CJC treatment
mandates] that say, they need to do six

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Overarching theme
(see Table 7)
Subtheme
(see Table 7)
SEM framework Participant quote
months of treatment with a mainly one-
size-fits all approach with the same
required meetings and groups such as
domestic violence and anger
management, which does not address
the underlying issue of trauma the
patient needs to address. Clients need
to go out and test [urinalysis testing]
outside to CW facilities in order to
meet CW requirements, and they need
to test in here to meet our program’s
testing requirements. They also need to
have a certain amount of visits [child
visitation], which when you’re in a
residential facility, sometimes that can
be difficult to coordinate with CW
workers. Visitations and outside testing
makes it difficult when there is again a
lack of communication. That’s the
biggest hurdle that I think that we lack.
(Clinician 101C)

Interpersonal
(CW or CJC with
patient)

They [CW workers] will call the
counselor and say, “OK, well, she told
me she relapsed. She hasn’t told you
yet, but she told me, and we’re letting
you know. … What can we do? OK,
more groups are going to be necessary
along with residential … more one-on-
one individual sessions, more random
testing, and that kind of gives a little
accountability to the client … but that’s
only if the social worker’s willing to
work for the client. There’s a lot of
social workers that are like, “Oh, no,
sorry. You [the mother] failed.” And
then they go and they terminate
reunification, and that also starts as an
excuse for the client, gives them an
excuse just to leave. They have more
fear tactics than they do empathy
tactics. (Clinician 201C)

Negative biases or
perceptions

Interpersonal
(CW or CJC with
patient)

Personally, I’ve seen and I’ve heard
where a CW worker will say to the
mother, “Well, this is not the first time
that you’re doing it [relapse], so why
should I continue to help you when
you’re going to do it again and putting
your child at further risk?” So, instead
of encouraging [them], … the verbiage
that they use with these women
sometimes, they’re so demeaning to
them. And that’s one of the things that I
know personally, and I talk to these

77

Overarching theme
(see Table 7)
Subtheme
(see Table 7)
SEM framework Participant quote
residents, constantly. … I’ve seen it
where [CW workers say], “Oh, well,
good job, I’m so proud of you, we’ll
see how long that’s going to last.” One
of the things that really upsets me [is
when they say], “Well, it doesn’t matter
what you’re doing because you’re still
not going to get him back, the judge is
not going to give you your child back.”
You don’t know that. … They don’t
know that; they don’t know what the
judge is going to say or think, but they
[CW workers] do that. (Director 402D)

Organizational Then there’s the other type of social
worker [CW worker]. Aloof, they’ve
been doing this for a while, or they’ve
become cynical. [They think] this case
is going to be the same song and dance
[relapse or treatment dropout] or they
bring their own biases: “Oh, I can tell
this is going to be somebody that’s not
going to make it.” So, they’re not
engaged, they’re not projecting this
supportiveness, or they’re lackadaisical
in their responsiveness, and this stuff
affects how we timely work with this
patient, because you can’t move along
in the treatment planning, or the patient
becomes stressed out. (Clinician 402C)

Organizational And some of the DCFS [CW]
experiences that I’ve had is, “Well, I
feel like she shouldn’t have her child
yet.” But oftentimes it is whatever the
social worker feels should be written in
the report that’s going to determine
whether the parent keeps the child or
the child goes up for adoption. And I
find that so, so heartbreaking because
it’s based on this report, because it’s
this social worker [CW] not getting
what she wanted to hear, which may
not include important progress that has
been made by the patient. (Clinician
202C)

Lack of training in
SUD treatment and
trauma-informed care

Intrapersonal If maybe there was, if the CW
department goal really is to reunify
families as they say it is, if everybody
could get some level of education on
trauma-informed care … and I’m not
sure they get it at school, I’m just not

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Overarching theme
(see Table 7)
Subtheme
(see Table 7)
SEM framework Participant quote
sure what the requirements are to work
there [CW department], but some level
of education on trauma and the
consequences of trauma and people’s
behaviors and why some people have
negative behaviors as a consequence of
trauma. It would be helpful because …
it doesn’t seem like everybody is
trauma informed, or it doesn’t even
seem like their goal is to reunify
families as the [CW] department says it
is. (Clinician 307C)

Intrapersonal Sometimes I don’t think they
understand how treatment works at all,
maybe on a scale of one to 10,
seriously maybe a three. I don’t think
they understand the disease, and I wish
that, since they are working with
mothers who have a substance use
disorder, be at least trained or have
some knowledge of substance use. I’ve
had some crazy comments where they
[CW workers] would just personalize
and say, “She’s a bad mother.” No,
she’s not a bad mother, she’s working
on her substance use disorder, which
led to the behaviors and the legal
issues. So yeah, I’ve had a lot of
challenges with some CW workers, but
I feel like they have really minimal
training, what I’ve encountered, of
anything related to substance use
understanding. (Clinician 301C)

Large caseloads and
logistical or resource
concerns

Lack of cross-system
logistical and resource

Organizational The struggle has been where we create
a case plan or they go to court and the
judge [will] order something and the
social workers [CW] don’t follow
through. That is our challenge. The
judge can say, “Oh, we’ll give referrals
to the mother for housing.” Let’s just
say, those referrals never happened.
They never happened for extra
monitors for the resident to have
weekend visits [with children], to get
her full four hours of visits … because
now we need a monitor. The judge
says, “OK, make sure that the resident
or the mother gets a monitor.” We’ve
seen it numerous times where we see it
in paper, but yet we’re advocating and
we’re asking and it doesn’t happen

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Overarching theme
(see Table 7)
Subtheme
(see Table 7)
SEM framework Participant quote
because their response is, “There’s not
enough social workers [CW] or
monitors.” (Director 402D)

Organizational Visitation with children who are in
foster care is a big issue. Usually, the
clients here have limited funds. If their
child is not really close nearby or if
they’re in a different county, they don’t
have the money to get themselves to a
child visit. A lot of times, foster parents
are not able to bring the child to the
program because they may have other
kids in the house [and] that doesn’t fit
into their schedule. This is a big issue.
A lot of times, visits need to be on
weekends, and if there needs to be a
monitor, we are not monitors [ordered
through the courts and provided by the
CW department] … [and] having one
provided for the residents is difficult,
especially if they are expected to pay
for it because they don’t have any
money. That’s a huge issue and one
that also brings up barriers to a
successful treatment episode. That is
another thing that will take somebody
out the door is if they don’t have a way
to get to that visit or the child welfare
worker cannot make sure that the visit
happens here, or at least in a park or a
restaurant nearby … they will leave
treatment and find a way to get to
wherever their kids are for a visit. …
That’s very discouraging. It really is.
(Director 401D)

Heavy workload
concerns

Organizational They [CJC and CW] just want them
here [in treatment] a certain amount of
time. It is very difficult to get ahold of
[CW] workers. Sometimes emails go
back and forth for days, phone calls go
unanswered, and we appreciate that that
has to do with their workload, which is
extreme. So, we understand that, but it
does put things on hold, especially if
we have a resident who may be in crisis
and struggling here, and we want some
support from the worker, maybe some
encouragement, maybe an update on
visitation planning, “Hang in there, stay
there, don’t get kicked out.” That sort

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Overarching theme
(see Table 7)
Subtheme
(see Table 7)
SEM framework Participant quote
of thing. And it is difficult to get ahold
of them. (Director 401D)

Interpersonal
(CW or CJC with
patient)
I get it, maybe their workload is too
much, and they’re not so involved. I
usually hear from them the day before
or the morning of the person’s court
date. I have some of our clientele that
try to call their DCFS worker on a
consistent basis, and they’re like,
“She’s not answering. What do I do?”
Or they try to call the attorney, and the
attorney’s not answering. Like, “What
do I do? I need help? Can you email
her? Can you call her?” And that’s
usually when I get involved, and I find
it’s a little challenging, too. (Clinician
401C)

ASFA as a challenge to
SUD treatment provision

ASFA timeline as a
barrier to SUD
treatment provision

Intrapersonal I’m going to have to say the majority of
the new parents, I’m going to give it
maybe a 70%, right, are towards the
end [of the ASFA timeline] of either
losing the rights or at adoption-70%
probably there. The rest of the 30% are
in the middle somewhere, whether they
can still do something. And very few,
maybe like a 5%, are at the beginning.
(Clinician 307C)

Policy It affects it [treatment provision] a lot.
To me, I think that that’s one of the
biggest things that they have hanging
over their heads [imminent child
custody loss], and a lot of times that
contributes to clients not being ready
[for treatment engagement]. When you
have a client that comes in … at the tail
end [of the ASFA timeline], and they
might come in and this is their last
chance to get their children back.
You’ve got 90 days before you go back
to court and it’s going to be decided
whether or not you get your child back.
It takes the focus away from the
client’s actual treatment because now
they are only focused on getting the
child back and what the DCFS [system]
and courts are requiring from them.
Now, as a counselor, nine out of 10
times, you know these clients are not
ready. Especially when they truly
didn’t focus on treatment. The client

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Overarching theme
(see Table 7)
Subtheme
(see Table 7)
SEM framework Participant quote
doesn’t know how to deal with the
stress of having their child back. A lot
of these times, these families have been
separated for about six months, nine
months, 12 months. They don’t know
what it’s like to have a kid back in their
life. They don’t know how to deal with
that stress. (Clinician 201C)

Interpersonal
(clinician or
director with
patient)
Well, I mean, once again, their focus is
not going to be in taking care of finding
resolutions or why they’re here
[residential SUD treatment] …
addressing their trauma or why they’re
using or drinking. Their main goal is to
avoid this adoption. So, in reality, how
much time do I have to work with this
patient, to identify or have her gain
awareness-oh, why is she using? Why
does she put herself and her child in
jeopardy? And now it’s like, depending
on if it’s right away or if there’s still
time [on the ASFA timeline], how are
we going to work together to prepare
her to go to court by herself, to see if
they’re going to adopt her baby or not?
And in their eyes, like, “I’m going to
give my baby away to somebody else
because I have failed to meet these
requirements” [CW and CJC
reunification requirements that can’t be
met in addition to SUD treatment].
(Clinician 202C)

Child custody
concerns and CW
requirements as a SUD
treatment competitor

Policy I think the way it affects treatment
planning is actually, of course you have
to meet the requirements of
maintaining sobriety and whatnot. But
what it does is, it does again impede
some of the participation here,
engagement here, because they’re so
focused on the adoption hearing or the
placement hearing, or the “I got to
[complete the CW requirements]. …
What can I do? My child’s going to get
adopted out. What can I do? My
mother-in-law is going to get custody
of my child.” Of course it’s going to be
on their mind all the time. So, it does
impede in them getting, I’m going to
say, the most out of treatment when it
is that late in the game [regarding the
ASFA timeline]. (Clinician 307C)

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Overarching theme
(see Table 7)
Subtheme
(see Table 7)
SEM framework Participant quote

Interpersonal
(clinician or
director with
patient)
Yes, it is definitely [a SUD treatment
provision challenge] because should
they get word that the workers were
going to recommend termination of
permanent visits because they’ll be
informed prior to them going to court
… a lot of times they get the
information of the department’s
recommendation and it just creates this,
again, detrimental thinking of “What’s
the point and why am I here? I’m going
to lose my child anyways.” There’s no
point in treatment if that child’s going
to get taken away. Sometimes it gets to
the point of abandoning treatment
altogether. (Clinician 307C)

Interpersonal
(clinician or
director with
patient)
We’ve seen mothers who kept thinking,
“Well, it doesn’t matter what I’m going
to do. They’re going to take them
anyway because I’ve only got four
months to go [before permanency or
adoption proceedings]. They want me
to do this, this, and this [CJC and CW
requirements], and there’s no way I can
get it all done.” So, they want to give
up. They say, “Why even try?” We try
to share with them because we have
seen all the way up until the very last
day, until that document is signed
saying, “Adoption permanent,” you still
have a chance. So, don’t give up
because we’ve seen it happen. We try
to let them know that, “Hey, even if
you’re making small, positive steps,
keep moving forward.” I mean, if that
22 months is next month and you’re in
treatment and you’re working your
program, you’re learning new skills,
you’re demonstrating new skills, you’re
staying on top of everything just as if
you just had a little hiccup, because
we’ve seen until the official documents
are signed that you still have a chance.
(Clinician 307C)

Research Question Two
How do cross-system oversight and monitoring requirements, communication and

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responsiveness, and ASFA requirements adversely affect the clinician-patient relationship and
treatment planning?
The focus of this research question and the accompanying treatment provider experiences
and viewpoints extends beyond the first research question, which focused on identifying SUD
treatment provision challenges related to Los Angeles County’s current cross-system
collaborative mechanisms (SUD treatment, CW, and CJC). Research Question 2 narrowed
Table 10: Research Question 2 (Themes and Subthemes)

this focus to identifying how these cross-system challenges adversely affect the clinician-patient
relationship and treatment planning, particularly regarding cross-system communication and
responsiveness, oversight and monitoring requirements, and ASFA timeline mandates. The
clinician-patient relationship refers to the primary treatment clinician or director engaging in the
therapeutic alliance-building process with the patient and family members to gain their trust and
confidence while taking responsibility for the SUD treatment care being provided. Treatment
planning refers to SUD treatment providers co-creating, with the patient, an outline of the

Theme 1: Adverse
impacts on the
clinician-patient
relationship
Theme 2: Adverse
impacts on SUD
family treatment
planning
Theme 3: Adverse
ASFA timeline
impacts on the
clinician-patient
relationship
Theme 4: Adverse
ASFA timeline
impacts on
treatment planning
Subthemes

Inadequate cross-
system
communication and
responsiveness
Inadequate cross-
system
communication and
responsiveness
Fear of CJC and CW
knowledge of
patient continuing
treatment needs
Unrealistic
expectations
Impacts of cross-
system mandated
reporting
Impacts of cross-
system mandated
reporting
Induced
psychological stress
and CW focus

Lack of CW
communication and
responsiveness
Impacts of cross-
system monitoring
requirements

Impacts of cross-
system monitoring
requirements
Lack of CW
communication and
responsiveness

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identified SUD and associated problems that contains explicit goals and objectives for beginning
and sustaining the treatment plan during the treatment episode. Major overarching themes were
“adverse impacts on the clinician-patient relationship,” “adverse impacts on SUD family
treatment planning,” “adverse ASFA timeline impacts on the clinician-patient relationship” and
“adverse ASFA timeline impacts on treatment planning.” Each theme and its associated
subthemes are presented in Table 10. In addition, Table 11 describes each theme and its
associated subthemes in detail with illustrative quotes categorized by SEM designation.
Theme One: Adverse Impacts on the Clinician-patient Relationship
A healthy therapeutic clinician-patient relationship has been shown to be a key factor in
the treatment and healing process (Martin et al., 2000; Wolfe et al., 2013). For example, prior
research has shown that the development of a healthy therapeutic clinician-patient relationship is
a predictor of commitment and retention in SUD treatment. However, the therapeutic
relationship between the clinician and patient is also known for being difficult to establish and
maintain during the treatment episode (Livingston et al., 2012). The following clinician and
director viewpoints and experiences highlight the adverse impact of the current collaborative
SUD treatment, CJC, and CW cross-system environment on the clinician-patient relationship and
SUD treatment planning.
Inadequate Cross-System Communication and Responsiveness
Participants described experiences of inadequate cross-system communication between
CW workers and clinician or director or patient that had an adverse impact on the clinician-
patient relationship. The following quote highlights how inadequate CW worker responsiveness
induces psychological stress and treatment disengagement, affecting the clinician-patient
therapeutic relationship.

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I think it affects the client drastically because when they can’t get ahold of their social
workers, the communication … they don’t respond and things like that, the clients tend to
… they lose engagement, for one. For two, they lose hope, and it brings more stress on
them because when they’re trying to get information or just receive some kind of
response or visit and they’re not getting anything from the social worker, it stresses them
out even more. Of course, as an addict, stress can cause relapse. … On top of all the
struggles they have already, they’re building up even more stress with the social workers
that don’t get involved, the social workers that don’t make contact after they’ve
attempted. Sometimes, as a counselor, I have to go beyond that social worker and go to a
supervisor because we’re getting no responses, and that, to me, is a social worker who
has given up on the patient. I don’t know their background with that patient, all I know is
when that person comes in to me, they want to do something and they want to improve
their relationship, but the social workers have already washed their hands. … They shut
down [the patient], and it’s also difficult for a clinician because we have to make sure
they’re following all court orders through DCFS. That could consist of having restraining
orders, that could consist of they can only call certain days to their child, things like that
… and without us getting responses from the social workers, then it prolongs any
communication they get with their children because we cannot risk them violating
because we don’t have information. … Yeah, because if we can’t get that stuff in a timely
manner, the client sometimes can spend a month not engaged whatsoever until, finally, a
social worker reaches out and begins to schedule the visitation, gives us the information
we need to know, and then they become engaged, but they’ve lost 30 days. They’re
closed during that time because of their frustrations. (Clinician 306C)
Participants described how one of their biggest challenges to retaining patients in
residential SUD treatment is related to the patient not knowing what is going on with their child
and feelings of powerlessness when the CW worker does not communicate or is unresponsive to
the patient’s inquiry about their child’s current status or visitation planning. The treatment
provider experiences underscore how insufficient cross-system communication and updates from
CW caseworkers adversely affects the clinician-patient relationship. One director stated:
That is absolutely so true because when they don’t hear from the [CW] worker, they do
start to panic. And every day, sometimes two, three times a day, they’ll be in the office
[of the clinician or director, asking], “Can I call my worker? Can I call my worker?” It
becomes obsessive. Women often leave if they don’t hear from them [CW worker]
because they feel powerless and they feel like they are so out of control with what’s
going on with their kids, that if they leave and go … that maybe they could do something
on the outside that they can’t get done here. It’s very frustrating. It feels like we’re just
kind of putting out fires … and also it would only take one conversation with a worker,
just for a little bit of reassurance: “Your child is fine. You’re doing what you’re supposed
to do, keep going.” That’s one of the biggest problems we have with retaining women
and children in treatment, is the lack of contact that they have with the outside when

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they’re so scared about what’s going on. And they already feel powerless because they’re
here, they can’t have their drugs to make them feel powerful or to make them not feel at
all. So, their emotions are running rampant, and they just have to sit there and wait. It’s
very difficult. (Director 401D)
SUD treatment providers noted the negative impacts on the clinician-patient relationship
when cross-system coordination among the CJC, CW, and treatment providers is incongruent or
lacks appropriate communication. Treatment providers described how this cross-system
treatment discontinuity affects the patient’s treatment motivation and the therapeutic provider-
patient relationship. For example, cross-system incongruity and lack of communication can lead
the patient to blame the clinician for not coming through on expected family planning goals
ordered by a CJC and coordinated between CW workers and treatment providers. For example,
one director shared:
I think the trouble is if the residents are already having the thoughts of the cravings of
using, because life is hard and they’re not getting what they’re expecting. So, once they
already have that in their head, and then they receive this call that the social worker is not
able to comply with what we’ve been working with during our one-on-ones [therapy] or
what we’ve been advocating for [with CJC and CW systems], they lose motivation.
Number one, they lose motivation, and now their disease is kicking in; by this time,
they’re already [thinking], “Well, why am I doing this?” They start questioning, “Well,
why am I doing this? There’s no point of me doing it if I’m not going to be seeing my
children.” But for them, they lose motivation, they do get upset with the counselor,
because it’s like, “You’re the one that’s supposed to be advocating for me, what
happened?” I’ve had situations where the residents accused me of being—“Well, you’re
not being assertive with them. You need to demand, I’ve been clean, you’re my
counselor, you see my progress.” We do everything that we can for this resident to be
able to even see her children, which is the main thing to stay clean … and so, they get
really discouraged. And then that’s where their thought process starts getting distorted.
And a lot of the times, they end up leaving, because they don’t get what is promised to
them. (Director 402D)
Impacts of Cross-System Mandated Reporting
Treatment providers are required to provide treatment progress updates and reports to
both the CJC and CW systems regarding mutual clients in their care. Because trust and
confidentiality are such an important factor in the therapeutic relationship, mandated cross-

87

system reporting has the potential to negatively affect the therapeutic provider-patient alliance.
For example, one provider shared how this cross-system mandated reporting requirement can
affect the therapeutic relationship with the patient:
It’s affected greatly, because the patient comes in and thinks that you’re in cahoots with
DCFS and the courts. They do not trust you. So, it’s really, really hard to build a rapport
with that population, because they’re thinking, “You know what, this counselor’s going
to report everything and anything because she’s connected with the courts. She has to
write a report.” So, they don’t want to tell you anything. They’re very, very guarded. It
takes a while before you can gain their trust. And the longer it takes to gain their trust, the
longer it takes to start the treatment. Because within the first month or two, you haven’t
really gone anywhere, because you’re working on very little basic stuff, just stabilization,
because you’re not able to gain their trust for them to say, “This is what I need to work
on” or “Can we explore this?” or “Can we explore that?” They don’t trust you, because
they think you’re with the court’s side. (Clinician 301C)
When trust in the therapeutic relationship has been broken, patient engagement in the
treatment plan and the reestablishment of the clinician-patient relationship become a struggle.
The therapeutic alliance between the treatment provider and patient often becomes irreparable
and can lead to a relapse or the patient leaving treatment. The following quote provides an
account of circumstances in which these conditions manifest when negative progress reports are
provided to the court or CW system.
The trust barrier is broken. They feel that the only person they probably thought that was
in their corner is failing them now, because here I am, I have to do my job. I have to
report that there was a negative UA [urinalysis] test for February. And then knowing that,
and now I have to have a session [counseling] because now she’s going to go to court and
help her understand that this is going to come out. … There’s a strain that develops; they
won’t be as open. And sometimes they don’t want to work on it [SUD and associated
issues] no more. There’s been situations—not just here, in other places that I’ve worked
at—[in which] they choose to leave the program. They choose to leave the program
because it’s like, “Forget it. I already messed up.” And trying to rebuild that self-
confidence of the patient, that’s harder on us because it’s like we have to go back and
start day one with them, because they lost confidence in themselves. They lost confidence
of us, because in true reality, why am I reporting that? (Clinician 202C)
Clinicians are placed in a “double-bind” position in which they are simultaneously
accountable for providing mandated progress reports to the CJC and CW system while

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negotiating confidentiality and ethical concerns involved with their therapeutic relationship with
patients. This double-bind situation can compromise the building or rebuilding of trust critical to
the clinician-patient treatment planning process. One clinician shared:
I mean, it brings strain to any clinician, any counselor, that we have to provide bad
reports to the court, because for me, and I can only speak for me, I’m an advocate for my
patient, although I have certain limitations of what I have to work with and reporting
mandates that I have to follow. All right! My patients are who I owe my services to. But
when we have the court involved, I feel like I can’t provide that advocacy for my patient,
because one, I want her to trust me but then when I write this negative report for her, that
trust is gone and now I have to find other ways to rebuild that and not have her hate me,
not have her see me as another person that’s attacking her or that’s traumatizing her,
because in a way I am, and she may relive another trauma in her life. (Clinician 202C)
Impacts of Cross-System Monitoring Requirements
SUD treatment providers shared their frustrations and described challenges regarding
how cross-system monitoring requirements affect the therapeutic relationship they are trying to
establish with patients in their care. One provider shared how her professional values can conflict
with cross-system CJC and CW monitoring requirements.
In the back of my head, I do have a thought that this letter, it might make her or break her
at the court. She might lose her child. But this is my job. This is what I’m hired for, to
write this letter and submit it to DCFS, because that’s what I need to report, what she did.
But they [CJC and CW] only see what’s in black and white, with DCFS; I see the woman
in front of me and the growth that she has made. And it’s bittersweet because you see the
growth and how excited she is to go to court but then she hasn’t been meeting some of
the requirements and then here I am sending this letter, but the difficulties of the process
of that is that the social worker [CW worker] is like, “I need this and is she attending, is
she this, and she’s that?” And it’s like sometimes they don’t want to hear, “They’re doing
OK.” That’s my experience. They want to hear that they’re not succeeding, not [doing]
what they’re supposed to do. (Clinician 202C)
Treatment clinician and directors shared their sense of frustrations and dissatisfaction
with CW workers who monitor with a disengaged “cookie-cutter” approach that does not
consider individual family treatment needs, particularly pertaining to SUD treatment support. For
example, one clinician shared:
With the social workers at DCFS, many look at it as their job is to make sure you

89

[patients] do their UAs [urinalysis testing] and there’s no positive signs of drugs or
alcohol in your system and did they do their parenting [classes or groups]—it’s kind of
like check, check, check, check, check. It’s not a lot of, “How could we help and get
creative and help the client understand that, you know what, I’m here to support you and
I’m all about you getting your kids back, not about taking them away.” (Clinician 101C)
To begin child visitation planning or forestall adoption hearings, CW monitoring
requirements entail meeting standardized benchmarks such as attending a certain number of
prescribed parenting and domestic violence groups along with urinalysis testing, in addition to
SUD treatment. These CW monitoring requirements and protocols challenge the clinician-patient
relationship because providers often find themselves attempting to refocus the patient on the
primacy and importance of SUD treatment. One clinician explained it this way:
It does [adversely affect the clinician-patient relationship]. They’re just either so
concerned or overwhelmed with meeting those goals [court or CW requirements] to get
their child back and to get the courts satisfied, that that’s all they want to do. And once
again, like I said, this is a part of the struggles in inpatient [residential treatment], but we
just keep redirecting and encouraging, and we’ll talk about the progress in other areas and
praise them for meeting those goals and other goals. But once again, it kind of does, yeah,
keep them hostage, because they’re just very focused on what DCFS wants as a top
priority. (Clinician 301C)
Theme Two: Adverse Impacts on SUD Family Treatment Planning
SUD treatment planning, particularly family-centered treatment planning, is a key
mechanism for improving parental recovery and family reunification outcomes. Given the
complex SUD treatment needs of the mother and her children, a comprehensive cross-system
treatment planning approach is vital, such as with the FCA. The CW and CJC systems have
historically emphasized value-oriented approaches to decision making regarding mutual clients,
focusing on siloed child or legal and public safety concerns, respectively. Despite progress
toward the cross-system implementation of the FCA with families with a SUD that are involved
with the CJ, CW, and SUD treatment systems, barriers to collaboration among systems persist.

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Inadequate Cross-System Communication and Responsiveness
Cross-system communication and responsiveness is a key element in a family-centered
treatment approach. The primary collaborative goal should be addressing the underlying SUD
condition that brings parents into involvement with the SUD treatment, CJC, and CW systems.
Treatment providers described how despite these systems sharing the goal of treating the
underlying SUD, cross-system collaborative communication, responsiveness, and CW treatment
demands persist as a barrier that adversely affects SUD treatment planning. For example, one
clinician shared the following:
I think one of the biggest issues that I’ve encountered sometimes is, again, the openness
of a social worker [CW worker]. Sometimes social workers are very closed off and they
don’t like to communicate with a treatment team, and that can become a bit difficult
because just like with the courts, a treatment plan is also done in collaboration with the
client. … When you call the social worker or you get a call from the social worker and
they say something to you like, “Well, I want them to go to domestic violence outside of
the treatment plan [at another agency].” And you’re telling them, “Well, they’re already
doing it here, and all of a sudden there’s a demand from there [CW].” It’s difficult. We
have a lot of demanding social workers, and again … when there is absolutely no
communication or there is a lot of restricted information that they want to keep, it makes
it extremely difficult for us to try to do our jobs. (Clinician 201C)
In a FCA, communication, responsiveness, and timeliness are crucial aspects of cross-
system family treatment planning, particularly as it pertains to child visitation planning which
leads to overnight visits and eventual full child custody reinstatement. Importantly, child
visitation planning is a highly motivational SUD treatment engagement and incentive mechanism
to the patient. The following clinician described how obstructions to this potent incentive and
motivational treatment mechanism is obstructed through inadequate communication and
responsiveness with the CW worker.
That's how we lose women in our program. Because social workers, and the visits, like I
said, it's my reward [mother’s incentive and motivation]. They see it as a reward. Those
are the main things [mother’s goal], "I'm here because I want this. I'm doing it, I know it's
not going to be instant, but I'm working towards it so I will have some sort of visit, or see
my kid, or have some type of contact with my son or my daughter." And it doesn't happen

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because of, sometimes, social workers don't answer. You try to contact them, and yes,
their focus [the patient’s] goes into, "Why am I doing this if I don't get anything back.”
(Clinician 403C)
The lack of responsiveness of CW workers regarding important SUD family treatment
needs that often arise is a challenge to parental treatment planning. One clinician described this
lack of responsiveness as one of their biggest challenges.
Their follow through. I mean, we’re all busy with our jobs. Sometimes the follow through
is super slow. Well, I might email and say, “Hey, can we talk, chat for a minute. I’ve got
an issue I wanted to go over with you [about a mutual client].” And their follow through
is usually very slow. Sometimes you have some that are good. But with the clients [when
the client calls], they’re very slow. So that’s one of the biggest challenges. (Clinician
101C)
Impact of Cross-System Mandated Reporting
One director shared her experience of how patients are hesitant to discuss or disclose
important treatment information for fear of the therapist reporting information that may
adversely affect their CJ or child custody case. This cross-system reporting can create a barrier in
the therapeutic treatment planning process:
I honestly think that most of the patients that have clinicians here and they have an open
case with DCFS are only going to open up enough but are not going to be open to full-
blown therapy just because they’re scared that something’s going to be misinterpreted or
something’s going to be reported to DCFS. That’s what I’ve noticed, from my own
experience, where if I find out something and I bring in the patient and I talk to the
patient and I tell them, “You need to talk to your therapist about this [positive drug test or
other issue].” They’ll tell me, “No, because I don’t want this to be reported.” And then I
go, “Well, we have to report it because we are mandated reporters, so your worker needs
to know about it.” And so, I let the patient know that I give them the opportunity to talk
to the therapist before I do. (Director 302D)
One clinician shared a strategy they use to negotiate the challenges of mandated progress
reporting while still preserving the treatment plan and not jeopardizing the clinician-patient
relationship. It involves getting buy-in from the patient that they are “writing their own progress
report” based on their behavior.
Because I know that it [a negative progress report to CJC or CW] could damage their

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treatment, … what I do is before, if I see a behavior that needs to be worked on, I could
say, “Hey, you have court in three weeks. What do you want that [report] to look like?” I
put it up front, so we don’t have to put that negative [behavior] on the report. Because …
once that negative report is submitted, they say, “You betrayed me, you’re jeopardizing
me getting my kid back,” … and the treatment can stop for them. They could just do their
time here, quote unquote, and leave and really not get anything out of it. You always
want to bring it up: “Hey, you have a progress report coming up, what do you want that
to look like? OK, we’re still working on this, so how do we fix this? We’ll focus more on
this than that.” So, they’ll say, “OK, my progress report’s coming up, I want it to look
like this, let me work towards it.” Because it can affect the whole report. (Clinician 301C)
Patients are aware that treatment providers write regular progress reports to the CJC and
CW systems related to their behaviors and progress in meeting CJC and CW benchmarks. One
treatment provider expressed how a patient’s knowledge that treatment progress reports are being
shared with the court and CW systems can hinder the therapeutic treatment planning process.
Trust issues. They’re untrusting. Sometimes they won’t divulge what they really need to
work on because they’re afraid that if I share this or start working on this [behavioral
issue], it’s something that DCFS is going to frown on. “It’s going to hinder me being able
to get my children back.” They might not divulge a lot of the things that they need to talk
about. They might not talk about their trauma. They might not talk about their domestic
violence history. They may not talk about, “Yeah, my child was having dinner. I was in
the bathroom using drugs.” They may not talk about inappropriate behavior with a child,
not necessarily sexual, but physical abuse or verbal abuse or being real hard on a child.
They may not talk about any of that because they know that they’re writing their progress
report. (Clinician 305C)
Impacts of Cross-System Monitoring Requirements
Participants described how patient monitoring issues related to confidentiality and the
lack of knowledge of alternative SUD treatment therapies can negatively affect coordinated
cross-system SUD family treatment planning. Although Alcoholics Anonymous and Narcotics
Anonymous are well-known recovery programs for those recovering from addiction, treatment
providers expressed their frustration with these programs being a focus of monitoring
requirements by the CW and CJC systems. Treatment providers attributed this focus to the lack
of knowledge of targeted residential SUD treatment group therapies for women. One counselor
expressed it this way:

93

I just had a really bad experience with the social worker wanting information over a
patient and wanting details of conversations. And I’m [thinking], “You’re a social
worker. You should know this is all confidential information. I could let you know she’s
participating in treatment.” Another thing, a barrier that I’ve experienced, is them being
so focused on AA or NA [Alcoholics Anonymous or Narcotics Anonymous]; that’s not
the only way to recovery. There’s Celebrate Recovery. There’s Refuge Recovery. There’s
other methods of rehabilitation versus, “What is step seven?” Putting those restrictions on
somebody that might not believe in a higher power, that might need to go through
psychology treatment or go through some other method of recovery [trauma therapy], and
they put hurdles and barriers on these ladies involved with DCFS and the courts. I believe
social workers should have a semester in alcohol and drug studies, so they could
understand what alcohol [and] drug studies programs consist of. (Clinician 202C)
Treatment providers discussed how progress letters required by the CJC and CW systems
are often not requested in a timely manner. Further, they described frustration with how duplicate
or overlapping urinalysis testing requirements adversely affect the efficiency of the treatment
planning process.
Before there was a standard of six months, nine months, but now it’s really up to the
patient how long this program is going to work for them. And working with DCFS is
challenging; they want the test results here, but then they want them to jump through
hoops, to go to test for them as well, at DCFS. They want progress reports the week of,
instead of sending a notice like, “Hey, she’s going to court soon. Can we work something
out?” Because they’ll email you a week prior or three, four days prior, “Oh, she’s going
to court this day. You think you can give me a report?” Like it’s [a] priority. We have
other things here going on as well, that a crisis might arise and I might not be able to get
that [progress report] and I have to get the other party involved, that’ll give me a letter
request and give me permission to write this letter for her, even though it was still DCFS,
because my concern is with the patient, not DCFS. My client is the patient, the mom.
(Clinician 202C)
Most clinicians and directors expressed that CJC- and CW-mandated group requirements
obstruct and compete with the treatment planning process. Providers described how patients
focus on these mandated group requirements rather than their therapeutic needs outlined in the
SUD treatment plan. One clinician described it this way:
Yes, because we’ve had girls that when we’re making the treatment plan, the initial
treatment plan, it has to be the drug addiction, obviously because that’s why they’re here.
Their main goal is, “Get my kids back, get my kids back, get my kids back.” And
sometimes they have court back-to-back-to-back, because again, if it’s the last end of
their court case, they have a lot of court, they have a lot of mediation, and that does take

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up their time while they’re here. Sometimes there’s no engagement in groups [SUD
treatment] other than the ones that are court ordered. They’re just worried about their
[court-ordered] parenting, domestic violence, anger management [programs]. Sometimes
there’s no engagement in any other kind of group, and that’s for us to work around, too, if
their main focus is parenting [groups]. … We have to work around that because their
main goal is just getting their children back … not being in treatment for the drug
addiction and alcoholism sometimes. So, it does take up a lot of time in the case or it’s a
lot of cleaning up … so it’s hard to move forward. … It does take up a lot of the time and
program. (Clinician 402C)
Theme Three: Impacts of the ASFA Timeline on the Clinician-patient Relationship
When discussing cross-system CJC and CW treatment mandates as potentially having
adverse effects on the clinician-patient relationship and treatment planning, participants
described the ASFA timeline and associated CJC group and CW requirements as a prevalent
overarching theme. These treatment mandates can include attending different CW and CJC
groups such as domestic violence, parenting, and anger management. These group attendance
mandates supersede and accompany the SUD treatment plan and treatment program curriculum.
Moreover, these CJC and CW mandates often commandeer the patient’s focus away from
addressing their underlying SUD condition and toward meeting these group requirements for fear
of losing custody of their children. These two focal points compete and contradict the overall
goal of addressing the underlying addiction that brought the parent and her family into contact
with the SUD treatment, CJC, and CW systems. The following sections express how these
challenges adversely affect the clinician-patient relationship and treatment planning.
Fear of CJC and CW Knowledge of the Patient’s Continuing Treatment Needs
Participants shared how patients frequently do not fully engage in addressing their
co-occurring mental health or trauma conditions for fear that it will reflect adversely on their
reunification and child custody case.
I don’t know. I feel sometimes they’re going through the motion. They know what the
mandate is, and they’re going through the motions. But part of the treatment is actually
pulling back those layers and being vulnerable. A lot of times they don’t, in order to heal.

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It’s a lot of trauma involved with the disease of addiction, with the mental health, and a
lot of that plays into it as well. Sometimes they need mental health, but they feel if they
go to mental health, this is going to be a strike against them in getting their kids back.
They don’t know, this is how they’re feeling, I’m getting what they’re telling me, what
they’re feeling, so they stonewall. They will stonewall. They won’t be open for getting a
mental health evaluation. (Clinician 204C)
Induced Psychological Stress and CW Focus
Participants expressed how women who come into SUD residential treatment and have
ongoing concurrent child custody cases become hyper-focused, psychologically stressed, and
worried about losing custody of their children. One director described how having an ongoing
CW case induces perpetual psychological stress, obstructing the clinical process of developing a
therapeutic alliance with the patient.
I have seen a lot of patients who, as long as the kid is going to grandma, grandpa, or an
aunt [via adoption], they’re OK and they’re like, “OK, well, that’s fine.” It’s the moms or
dads who don’t have that or they have family ruled out and told them “No,” that they’re
going to go to adoption or foster care. It’s like they’re in a constant state of fear and
survival, like, “What do I got to do next? What do I got to do? What do I got to do?” So,
it’s perpetual stress on them. Yeah, it’s really hard to do the actual recovery work with
them. On another side, we used to be able to keep patients for four to five months, and we
can’t do that now, and now it’s like we get them in, we put a Band-Aid on, “You’re going
to be OK; we’re going to get you in the outpatient,” and we’re not able to really do some
of the heavy work with recovery that they need [inpatient residential treatment]. (Director
303D)
Lack of CW Communication and Responsiveness
The following clinician expressed how the lack of CW cross-system communication
negatively affects mothers who enter residential SUD treatment later on the ASFA timeline. She
expressed how this affects the provider’s relationship with the patient.
I think that’s where you get the disengaged social workers. We can’t get information
because they are at that length of time [end of the ASFA timeline] where they’re shutting
it down. However, I keep it open and honest with the individuals [patients] I’m working
with, with that timeline. What can I do from this point? If this is what they want to do,
what can I do from this point? “Is your children going to a foster care closed adoption?” I
work out what they’re doing. What is the plan? Family, things like that. What do I do
with the client to move forward and still have this relationship with their child? Maybe
not as the legal guardian but a mother that’s still participating in their life. (Clinician

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306C)
Theme Four: Adverse ASFA Timeline Impacts on Treatment Planning
Unrealistic Expectations
A common adverse effect on SUD treatment planning that treatment providers
underscored is the ASFA timeline. A core treatment planning challenge is when the patient
focuses on forestalling adoption hearings by meeting CW- and CJC-mandated group
requirements. As additions to the patient’s treatment, treatment providers view these CW- and
CJC-mandated group requirements as unrealistic expectations that are overwhelming or cannot
be met.
Yeah, I would say they [patients] rush it [CW requirements]. They try to get everything
done as fast as possible, and it’s too much for them. And then that usually leads to maybe
relapsing if it’s too much. They try to do a bunch of parenting classes, they are trying to
enroll in domestic violence, they’re maybe trying to rekindle that, maybe the
communication with their kids. I have noticed when they first get here, it’s like, “Oh, I
have to do this. I have to this because my kids are in the system, and I have to do this to
get them.” So, usually it’s all about trying to get their kids and it’s not about the
treatment. They’re doing it for their kids, which is understandable, but they need to be
there for themselves in order to be there for their kids. That’s what I try to let them know,
but on the [ASFA] timeline, they’re not focused on that. (Clinician 303C)
Whatever their timeline is when we get them, the time’s ticking at that point. It’s
overwhelming coming into treatment in the first place, and then on top you’re having
systems tell you, “Look, you have this amount of time to complete this. You need to do
this in that time.” So, the thinking of, “I can’t get all this done. I’m never going to have
my children back.” It’s hopelessness at the end for them. Yes, definitely unreasonable
expectations. Also, the discouragement to even come into treatment or even do treatment.
When they’re at that point of pretty much where the adoption is going to happen …
they’re telling them “OK, go into treatment but most likely you’re going to lose your
kids. They’re going to be adopted out because it’s been this long.” Why would anyone
want to come into treatment and work on themselves after hearing that, hearing that
timeline, hearing that … you’re not going to reunite with your family? (Clinician 203C)
But if they could not have so much expectation on the patient when they can’t meet them
because they’re just working out their SUD, you see what I’m saying, and let them focus
on their recovery in order to have a clear mind to meet those goals. So, if the courts
would get onboard and DCFS would get onboard with being more involved with the
treatment first, and not these expectations that they can’t meet, because they’re not
getting treatment, can’t fix it. (Clinician 301C)

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Lack of CW Communication and Responsiveness
Treatment providers expressed another common cross-system collaborative
communication and responsiveness barrier that adversely affects family-centered treatment
planning. One treatment clinician described having to obtain crucial cross-system family
treatment planning information from the patient instead of the CW workers or CJC staff, which
would be more accurate and coordinated.
We’re at the back burner, we don’t know. I mean, we find out what’s going to happen next
because of the patients coming back from court, conveying information to us. At least my
experience, I’ve never had a social worker call me or email me to let me know what the
next process is with reestablishing visitation or reunification planning. I usually follow up
with my patient after court like, “Hey, how did the court go? What’s expected from you?”
And if they don’t know, I try to encourage them to advocate for themselves, to most of the
process of, “What’s next?” Planning or updates from the DCFS [worker] would help us
and the patients prepare for whatever is expected from them in their treatment that will
improve reunification with the child. (Clinician 202C)
Functions of Quality Cross-System Collaboration and Communication
Communication emerged as a core theme in understanding cross-system treatment
provision challenges that SUD providers and patients encounter. Improving cross-system
communication among the SUD treatment, CW, and CJC systems and the parents is a key factor
in implementing the FCA in parental SUD treatment. Participant responses related to the
importance of communication went beyond communication challenges and barriers. Treatment
providers also shared experiences of ideal responsiveness and collaborative communicative
practices. For example, one participant described exemplary interagency communication that
improves cross-system supports and outcomes:
You’ve got the ones that are engaged with their client or engaged with you [clinician].
They give proper responses, for instance, when visitations have been granted by the court
or when monitoring needs to start occurring. This responsiveness is important. It shows
supportiveness, and it really keeps the parent feeling engaged and not hyper-focused,
worried, and anxiety-ridden, and it can still be focused and really be focused on her
treatment and thus, the clinician and patient relationship. (Clinician 402C)

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Table 11: Cross-System Patient Monitoring, Inadequate Communication and Responsiveness
Adversely Affect the Clinician-patient Relationship and Treatment Planning
Overarching theme
(see Table 9)
Subtheme
(see Table 9)
SEM
framework
Participants quote
Adverse impacts on
the clinician-patient
relationship

Inadequate cross-system
communication and
responsiveness

Interpersonal
(CW or CJC
with patient)

I think it affects the client drastically
because when they can't get a hold of
their social workers [CW worker]...they
don't respond and things like that, the
clients tend to ... they lose engagement,
for one. For two, they lose hope, and it
brings more stress on them because
when they're trying to get information
or just receive some kind of response or
visit and they're not getting anything
from the social worker, it stresses them
out even more. Of course, as an addict,
stress can cause relapse. On top of all
the struggles they have already, they're
building up even more stress with the
social workers that don't get involved,
the social workers that don't make
contact after they've attempted. all I
know is when that person comes in to
me, they want to do something and they
want to improve their relationship, but
the social workers have already washed
their hands. … They shut down [the
patient], and it’s also difficult for a
clinician ... because if we can’t get that
stuff in a timely manner, the client
sometimes can spend a month not
engaged whatsoever until, finally, a
social worker reaches out and begins to
schedule the visitation, gives us the
information we need to know, and then
they become engaged, but they’ve lost
30 days. They’re closed during that time
because of their frustrations. (Clinician
306C)

Interpersonal
(clinician or
director with
patient)

“That is absolutely so true because
when they don't hear from the worker
[CW], they do start to panic…And
every day, sometimes two, three times a
day, they will be in the office, "Can I
call my worker? Can I call my worker?"
It becomes obsessive. Women often
leave if they don't hear from them [CW
worker] because they feel powerless
and they feel like they are so out of
control with what's going on with their
kids, that if they leave and go... That’s
one of the biggest problems we have
with retaining women and children in

99

Overarching theme
(see Table 9)
Subtheme
(see Table 9)
SEM
framework
Participants quote
treatment, is the lack of contact that
they have with the outside when they’re
so scared about what’s going on. And
they already feel powerless because
they’re here, they can’t have their drugs
to make them feel powerful or to make
them not feel at all. It’s very difficult.
(Director 401D)

Interpersonal
(clinician or
director with
patient)
I think the trouble is if the residents are
already having the thoughts of the
cravings of using ... once they already
have that in their head, and then they
receive this call that the social worker is
not able to comply with what we’ve
been working with during our one-on-
ones [therapy] or what we’ve been
advocating for, they lose motivation ...
and now their disease is kicking in; by
this time, they’re already [thinking],
“Well, why am I doing this?” They start
questioning, “Well, why am I doing
this? There’s no point of me doing it if
I’m not going to be seeing my
children.”... they do get upset with the
counselor, because it’s like, “You’re the
one that’s supposed to be advocating for
me, what happened?” I’ve had
situations where the residents accused
me of being—“Well, you’re not being
assertive with them. You need to
demand, I’ve been clean, you’re my
counselor, you see my progress.”...
that’s where their thought process starts
getting distorted. And a lot of the times,
they end up leaving. (Director 402D)

:

Impacts of cross-system
mandated reporting
Interpersonal
(clinician or
director with
patient)

It’s affected greatly, because the patient
comes in and thinks that you’re in
cahoots with DCFS and the courts.
They do not trust you. So, it’s really,
really hard to build a rapport with that
population, because they’re thinking,
“You know what, this counselor’s going
to report everything and anything
because she’s connected with the
courts. She has to write a report.” So,
they don’t want to tell you anything.
They’re very, very guarded. It takes a
while before you can gain their trust.
And the longer it takes to gain their
trust, the longer it takes to start the
treatment. ...you’re working on very

100

Overarching theme
(see Table 9)
Subtheme
(see Table 9)
SEM
framework
Participants quote
little basic stuff, just stabilization,
because you’re not able to gain their
trust for them to say, “This is what I
need to work on” or “Can we explore
this?” or “Can we explore that?” They
don’t trust you, because they think
you’re with the court’s side. (Clinician
301C)

Interpersonal
(clinician or
director with
patient)
The trust barrier is broken. They feel
that the only person they probably
thought that was in their corner is
failing them now, because here I am, I
have to do my job. I have to report that
there was a negative UA [urinalysis]
test for February. And then knowing
that, and now I have to have a session
because now she’s going to go to court
and help her understand that this is
going to come out. … There’s a strain
that develops; they won’t be as open.
And sometimes they don’t want to work
on it [SUD and associated issues] no
more. There’s been situations—not just
here, in other places that I’ve worked
at—[in which] they choose to leave the
program. They choose to leave the
program because it’s like, “Forget it. I
already messed up.” And trying to
rebuild that self-confidence of the
patient, that’s harder on us because it’s
like we have to go back and start day
one with them, because they lost
confidence in themselves. They lost
confidence of us, because in true reality,
why am I reporting that? (Clinician
202C)

Interpersonal
(clinician or
director with
patient)

I mean, it brings strain to any clinician,
any counselor, that we have to provide
bad reports to the court, because for me,
and I can only speak for me, I’m an
advocate for my patient, although I have
certain limitations of what I have to
work with and reporting mandates that I
have to follow. All right! My patients
are who I owe my services to. But when
we have the court involved, I feel like I
can’t provide that advocacy for my
patient, because one, I want her to trust
me but then when I write this negative
report for her, that trust is gone and now
I have to find other ways to rebuild that
and not have her hate me, not have her

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Overarching theme
(see Table 9)
Subtheme
(see Table 9)
SEM
framework
Participants quote
see me as another person that’s
attacking her or that’s traumatizing her,
because in a way I am, and she may
relive another trauma in her life.
(Clinician 202C)

Impacts of cross-system
monitoring requirements
Intrapersonal

In the back of my head, I do have a
thought that this letter, it might make
her or break her at the court. She might
lose her child. But this is my job. This is
what I’m hired for, to write this letter
and submit it to DCFS, because that’s
what I need to report, what she did. But
they [CJC and CW] only see what’s in
black and white, with DCFS; I see the
woman in front of me and the growth
that she has made. And it’s bittersweet
because you see the growth and how
excited she is to go to court but then she
hasn’t been meeting some of the
requirements and then here I am
sending this letter, but the difficulties of
the process of that is that the social
worker is like, “I need this and is she
attending, is she this, and she’s that?”
And it’s like sometimes they don’t want
to hear, “They’re doing OK.” That’s my
experience. They want to hear that
they’re not succeeding, not [doing]
what they’re supposed to do. (Clinician
202C)

Intrapersonal With the social workers at DCFS, many
look at it as their job is to make sure
you [patients] do their UAs [urinalysis
testing] and there’s no positive signs of
drugs or alcohol in your system and did
they do their parenting [classes or
groups]—it’s kind of like check, check,
check, check, check. It’s not a lot of,
“How could we help and get creative
and help the client understand that, you
know what, I’m here to support you and
I’m all about you getting your kids
back, not about taking them away.”
(Clinician 101C)

Interpersonal
(clinician or
director with
patient)

It does [adversely affect the clinician-
patient relationship]. They’re just either
so concerned or overwhelmed with
meeting those goals [court or CW
requirements] to get their child back
and to get the courts satisfied, that that’s

102

Overarching theme
(see Table 9)
Subtheme
(see Table 9)
SEM
framework
Participants quote
all they want to do. And once again,
like I said, this is a part of the struggles
in inpatient [residential treatment], but
we just keep redirecting and
encouraging, and we’ll talk about the
progress in other areas and praise them
for meeting those goals and other goals.
But once again, it kind of does, yeah,
keep them hostage, because they’re just
very focused on what DCFS wants as a
top priority. (Clinician 301C)

Adverse impacts on
SUD family treatment
planning
Inadequate cross-system
communication and
responsiveness

Organizational

I think one of the biggest issues that
I’ve encountered sometimes is, again,
the openness of a social worker.
Sometimes social workers are very
closed off and they don’t like to
communicate with a treatment team,
and that can become a bit difficult
because just like with the courts, a
treatment plan is also done in
collaboration with the client. … When
you call the social worker or you get a
call from the social worker and they say
something to you like, “Well, I want
them to go to domestic violence outside
of the treatment plan [at another
agency].” And you’re telling them,
“Well, they’re already doing it here, and
all of a sudden there’s a demand from
there [CW].” It’s difficult. We have a
lot of demanding social workers, and
again … when there is absolutely no
communication or there is a lot of
restricted information that they want to
keep, it makes it extremely difficult for
us to try to do our jobs. (Clinician
201C)

Interpersonal
(CW or CJC
with patient)

That's how we lose women in our
program. Because social workers, and
the visits, like I said, it's my reward
[mother’s incentive and motivation].
They see it as a reward. Those are the
main things [mother’s goal], "I'm here
because I want this. I'm doing it, I know
it's not going to be instant, but I'm
working towards it so I will have some
sort of visit, or see my kid, or have
some type of contact with my son or my
daughter." And it doesn't happen
because of, sometimes, social workers
don't answer. You try to contact them,

103

Overarching theme
(see Table 9)
Subtheme
(see Table 9)
SEM
framework
Participants quote
and yes, their focus [the patient’s] goes
into, "Why am I doing this if I don't get
anything back.” (Clinician 403C)

Organizational Their follow through. I mean, we’re all
busy with our jobs. Sometimes the
follow through is super slow. Well, I
might email and say, “Hey, can we talk,
chat for a minute. I’ve got an issue I
wanted to go over with you [about a
mutual client].” And their follow
through is usually very slow.
Sometimes you have some that are
good. But with the clients [when the
client calls], they’re very slow. So that’s
one of the biggest challenges. (Clinician
101C)

Impacts of cross-system
mandated reporting
Interpersonal
(clinician or
director with
patient)

I honestly think that most of the patients
that have clinicians here and they have
an open case with DCFS are only going
to open up enough but are not going to
be open to full-blown therapy just
because they’re scared that something’s
going to be misinterpreted or
something’s going to be reported to
DCFS. That’s what I’ve noticed, from
my own experience, where if I find out
something and I bring in the patient and
I talk to the patient and I tell them,
“You need to talk to your therapist
about this [positive drug test or other
issue].” They’ll tell me, “No, because I
don’t want this to be reported.” And
then I go, “Well, we have to report it
because we are mandated reporters, so
your worker needs to know about it.”
And so, I let the patient know that I give
them the opportunity to talk to the
therapist before I do. (Director 302D)

Interpersonal
(clinician or
director with
patient)

Because I know that it [a negative
progress report to CJC or CW] could
damage their treatment, … what I do is
before, if I see a behavior that needs to
be worked on, I could say, “Hey, you
have court in three weeks. What do you
want that [report] to look like?” I put it
up front, so we don’t have to put that
negative [behavior] on the report.
Because … once that negative report is
submitted, they say, “You betrayed me,
you’re jeopardizing me getting my kid

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Overarching theme
(see Table 9)
Subtheme
(see Table 9)
SEM
framework
Participants quote
back,” … and the treatment can stop for
them. They could just do their time
here, quote unquote, and leave and
really not get anything out of it. You
always want to bring it up: “Hey, you
have a progress report coming up, what
do you want that to look like? ...
Because it can affect the whole report.
(Clinician 301C)

Interpersonal
(clinician or
director with
patient)

Trust issues. They’re untrusting.
Sometimes they won’t divulge what
they really need to work on because
they’re afraid that if I share this or start
working on this [behavioral issue], it’s
something that DCFS is going to frown
on. “It’s going to hinder me being able
to get my children back.” They might
not divulge a lot of the things that they
need to talk about. They might not talk
about their trauma. They might not talk
about their domestic violence history.
They may not talk about, “Yeah, my
child was having dinner. I was in the
bathroom using drugs.” They may not
talk about inappropriate behavior with a
child, not necessarily sexual, but
physical abuse or verbal abuse or being
real hard on a child. They may not talk
about any of that because they know
that they’re writing their progress
report. (Clinician 305C)

Impacts of cross-system
monitoring requirements
Organizational

I just had a really bad experience with
the social worker wanting information
over a patient and wanting details of
conversations. And I’m [thinking],
“You’re a social worker. You should
know this is all confidential
information. I could let you know she’s
participating in treatment.” Another
thing, a barrier that I’ve experienced, is
them being so focused on AA or NA
[Alcoholics Anonymous or Narcotics
Anonymous]; that’s not the only way to
recovery. There’s Celebrate Recovery.
There’s Refuge Recovery. There’s other
methods of rehabilitation versus, “What
is step seven?” Putting those restrictions
on somebody that might not believe in a
higher power, that might need to go
through psychology treatment or go
through some other method of recovery

105

Overarching theme
(see Table 9)
Subtheme
(see Table 9)
SEM
framework
Participants quote
[trauma therapy], and they put hurdles
and barriers on these ladies involved
with DCFS and the courts. I believe
social workers should have a semester
in alcohol and drug studies, so they
could understand what alcohol [and]
drug studies programs consist of.
(Clinician 202C)

Organizational Before there was a standard of six
months, nine months, but now it’s really
up to the patient how long this program
is going to work for them. And working
with DCFS is challenging; they want
the test results here, but then they want
them to jump through hoops, to go to
test for them as well, at DCFS. They
want progress reports the week of,
instead of sending a notice like, “Hey,
she’s going to court soon. Can we work
something out?” Because they’ll email
you a week prior or three, four days
prior, “Oh, she’s going to court this day.
You think you can give me a report?”
Like it’s [a] priority. We have other
things here going on as well, that a
crisis might arise and I might not be
able to get that [progress report] and I
have to get the other party involved,
that’ll give me a letter request and give
me permission to write this letter for
her, even though it was still DCFS,
because my concern is with the patient,
not DCFS. My client is the patient, the
mom. (Clinician 202C)

Interpersonal
(clinician or
director with
patient)

Yes, because we’ve had girls that when
we’re making the treatment plan, the
initial treatment plan, it has to be the
drug addiction, obviously because that’s
why they’re here. Their main goal is,
“Get my kids back, get my kids back,
get my kids back.” And sometimes they
have court back-to-back-to-back,
because again, if it’s the last end of their
court case, they have a lot of court, they
have a lot of mediation, and that does
take up their time while they’re here.
Sometimes there’s no engagement in
groups [SUD treatment] other than the
ones that are court ordered. They’re just
worried about their [court-ordered]
parenting, domestic violence, anger
management [programs]. Sometimes

106

Overarching theme
(see Table 9)
Subtheme
(see Table 9)
SEM
framework
Participants quote
there’s no engagement in any other kind
of group, and that’s for us to work
around, too, if their main focus is
parenting [groups]. … We have to work
around that because their main goal is
just getting their children back … not
being in treatment for the drug
addiction and alcoholism sometimes.
So, it does take up a lot of time in the
case or it’s a lot of cleaning up … so
it’s hard to move forward. … It does
take up a lot of the time and program.
(Clinician 402C)

Adverse ASFA
timeline impacts on
the clinician-patient
relationship

Fear of CJC and CW
knowledge of the
patient’s continuing
treatment needs

Policy
and
interpersonal
(clinician or
director with
patient)

I don’t know. I feel sometimes they’re
going through the motion. They know
what the mandate is, and they’re going
through the motions. But part of the
treatment is actually pulling back those
layers and being vulnerable. A lot of
times they don’t, in order to heal. It’s a
lot of trauma involved with the disease
of addiction, with the mental health, and
a lot of that plays into it as well.
Sometimes they need mental health, but
they feel if they go to mental health, this
is going to be a strike against them in
getting their kids back. They don’t
know, this is how they’re feeling, I’m
getting what they’re telling me, what
they’re feeling, so they stonewall. They
will stonewall. They won’t be open for
getting a mental health evaluation.
(Clinician 204C)

Induced psychological
stress and CW focus

Policy
and
interpersonal
(clinician or
director with
patient)

I have seen a lot of patients who, as
long as the kid is going to grandma,
grandpa, or an aunt [via adoption],
they’re OK and they’re like, “OK, well,
that’s fine.” It’s the moms or dads who
don’t have that or they have family
ruled out and told them “No,” that
they’re going to go to adoption or foster
care. It’s like they’re in a constant state
of fear and survival, like, “What do I
got to do next? What do I got to do?
What do I got to do?” So, it’s perpetual
stress on them. Yeah, it’s really hard to
do the actual recovery work with them.
On another side, we used to be able to
keep patients for four to five months,
and we can’t do that now, and now it’s
like we get them in, we put a Band-Aid

107

Overarching theme
(see Table 9)
Subtheme
(see Table 9)
SEM
framework
Participants quote
on, “You’re going to be OK; we’re
going to get you in the outpatient,” and
we’re not able to really do some of the
heavy work with recovery that they
need [inpatient residential treatment].
(Director 303D)

Lack of CW
communication and
responsiveness

Policy
and
interpersonal
(clinician or
director with
patient)

I think that’s where you get the
disengaged social workers. We can’t get
information because they are at that
length of time [end of the ASFA
timeline] where they’re shutting it
down. However, I keep it open and
honest with the individuals [patients]
I’m working with, with that timeline.
What can I do from this point? If this is
what they want to do, what can I do
from this point? “Is your children going
to a foster care closed adoption?” I
work out what they’re doing. What is
the plan? Family, things like that. What
do I do with the client to move forward
and still have this relationship with their
child? Maybe not as the legal guardian
but a mother that’s still participating in
their life. (Clinician 306C)

Adverse ASFA
timeline impacts on
treatment planning

Unrealistic expectations

Policy
and
interpersonal
(Clinician or
director with
patient)
Yeah, I would say they [patients] rush it
[CW requirements]. They try to get
everything done as fast as possible, and
it’s too much for them. And then that
usually leads to maybe relapsing if it’s
too much. They try to do a bunch of
parenting classes, they are trying to
enroll in domestic violence, they’re
maybe trying to rekindle that, maybe
the communication with their kids. I
have noticed when they first get here,
it’s like, “Oh, I have to do this. I have to
this because my kids are in the system,
and I have to do this to get them.” So,
usually it’s all about trying to get their
kids and it’s not about the treatment.
They’re doing it for their kids, which is
understandable, but they need to be
there for themselves in order to be there
for their kids. That’s what I try to let
them know, but on the [ASFA]
timeline, they’re not focused on that.
(Clinician 303C)

Policy Whatever their timeline is when we get
them, the time’s ticking at that point.

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Overarching theme
(see Table 9)
Subtheme
(see Table 9)
SEM
framework
Participants quote

It’s overwhelming coming into
treatment in the first place, and then on
top you’re having systems tell you,
“Look, you have this amount of time to
complete this. You need to do this in
that time.” So, the thinking of, “I can’t
get all this done. I’m never going to
have my children back.” It’s
hopelessness at the end for them. Yes,
definitely unreasonable expectations.
Also, the discouragement to even come
into treatment or even do treatment.
When they’re at that point of pretty
much where the adoption is going to
happen … they’re telling them “OK, go
into treatment but most likely you’re
going to lose your kids. They’re going
to be adopted out because it’s been this
long.” Why would anyone want to come
into treatment and work on themselves
after hearing that, hearing that timeline,
hearing that … you’re not going to
reunite with your family? (Clinician
203C)

Organizational But if they could not have so much
expectation on the patient when they
can’t meet them because they’re just
working out their SUD, you see what
I’m saying, and let them focus on their
recovery in order to have a clear mind
to meet those goals. So, if the courts
would get onboard and DCFS would get
onboard with being more involved with
the treatment first, and not these
expectations that they can’t meet,
because they’re not getting treatment,
can’t fix it. (Clinician 301C)

Lack of CW
communication and
responsiveness

Organizational We’re at the back burner, we don’t
know. I mean, we find out what’s going
to happen next because of the patients
coming back from court, conveying
information to us. At least my
experience, I’ve never had a social
worker call me or email me to let me
know what the next process is with
reestablishing visitation or reunification
planning. I usually follow up with my
patient after court like, “Hey, how did
the court go? What’s expected from
you?” And if they don’t know, I try to
encourage them to advocate for

109

Overarching theme
(see Table 9)
Subtheme
(see Table 9)
SEM
framework
Participants quote
themselves, to most of the process of,
“What’s next?” Planning or updates
from the DCFS [worker] would help us
and the patients prepare for whatever is
expected from them in their treatment
that will improve reunification with the
child. (Clinician 202C)

Research Question Three
How can (a) cross-system collaboration and coordination among the different
stakeholders (SUD treatment, CJC, and CW) be improved; and (b) the clinician-patient
relationship and SUD treatment planning be strengthened via improved cross-system
communication and coordination?
With Research Question 1, contextual descriptions of current cross-system collaborative
mechanisms that create SUD treatment provision challenges were identified and obtained from
clinicians and directors. Research Question 2 narrowed the focus by describing subcategories of
treatment provision that are adversely affected by inadequate cross-system collaboration,
including the clinician-patient relationship and treatment planning. These challenges specifically
pertained to cross-system communication and responsiveness, oversight and monitoring
requirements, and ASFA timeline mandates. The focus of Research Question 3 concentrates on
key strategies or recommendations from SUD treatment clinicians and directors regarding ways
to (a) improve cross-system collaboration and coordination among the three primary
stakeholders (SUD treatment, CJC, and CW); and (b) strengthen or improve the clinician-patient
relationship and SUD treatment planning. Major overarching themes were “strategies or
recommendations for cross-system collaboration,” “strategies or recommendations for cross-
system coordination,” “strategies or recommendations for improving the clinician-patient

110

relationship” and “strategies or recommendations for improving SUD treatment planning.” Each
theme and its associated subthemes are presented in Table 12. In addition, Table 13 categorizes
each theme and its associated subthemes with illustrative quotes labeled by their SEM
designation.
Table 12: Research Question 3 (Themes and Subthemes)

Theme One: Strategies or Recommendations for Cross-System Collaboration
Advancing the capacity of cross-system collaboration to provide comprehensive family-
centered treatment requires an interagency individualized case-planning approach. In California,
the implementation and expansion of child and family team (CFT) meetings has emerged as a
crucial point of cross-system communication, support, and response for children and their
parents who are involved with the CW and SUD treatment systems. The purpose of CFT
meetings is to assemble cross-system stakeholders who are involved in the child’s and parents’
treatment and reunification planning. This assemblage can include the biological parents, child,
SUD treatment provider, CW caseworker, mental health representatives, temporary guardians,
and other key members that support the family’s well-being (Kim et al., 2020; Schreier et al.,

Theme 1:
Strategies or
recommendations
for cross-system
collaboration
Theme 2:
Strategies or
recommendations
for cross-system
coordination

Theme 3:
Strategies or
recommendations
for improving the
clinician-patient
relationship
Theme 4:
Strategies or
recommendations
for improving SUD
treatment planning
Subthemes

Cross-system
collaboration at the
treatment level

Cross-system
coordination at the
treatment level
Cross-system
treatment planning
with the patient
Cross-system
collaboration at the
treatment level
Cross-system
collaboration at the
systems level
Cross-system
coordination at the
systems level

Developing or
preserving the
patient alliance and
rapport

Cross-system
collaboration at the
systems level

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2021). This implementation in California and elsewhere is based on an increasing body of
evidence showing that services for children and their families are more effective when delivered
in the context of a single integrated team of professionals (Advokids, 2021). Because this
promising integrated treatment approach is still relatively new to both research and practice, little
is known about the degree of utility and importance of CFTs in the CJC, CW, and SUD
treatment systems context, particularly in Los Angeles County. In the framework of this study,
most participants identified this mechanism as a key function for treatment providers to improve
SUD treatment planning, along with their relationship with the patient.
Additionally, SUD treatment provider liaisons surfaced as an important mechanism for
strengthening and preserving the cross-system relationship of both the patient and treatment
providers and the CJC and CW systems. Treatment liaisons function as a crucial intermediary
between the treatment program and the CJC and CW system, providing progress reports or
facilitating communication and coordination among systems. CFTs and liaisons were frequently
suggested as strategies for improving treatment provision, the clinician-patient treatment
alliance, and SUD treatment planning. Other important strategies and recommendations are
highlighted and described in context by the participants.
Cross-System Collaboration at the Treatment Level
CFTs were noted by several participants as a key recommendation that should be further
expanded as an FCA practice with mothers in residential treatment. One participant expressed
the importance of having the SUD treatment team and parent at the table when discussing
treatment and family reunification planning. The participant emphasized how this collaborative
CFT process promotes encouragement and support for the parent, which is a crucial component
for cross-system treatment planning buy-in.

112

Well, in the past, there have been social workers that will come to the facility or set up a
meeting somewhere else where it is the counselor, the social worker, sometimes her
supervisor, and the client, and we go over flowcharts and whiteboard things about all the
goals and the plans from both sides of the table. … It’s really more with the social
workers that are engaged and supportive … because once the CFT happens, the social
worker shows she wants to encourage the resident to the next step. I have been involved
in a few of them, and they should happen more often for sure. (Director 401D)
In the following statement, a clinician expresses her viewpoint on the importance of
CFTs in cross-system, collaborative, family-centered treatment planning and support.
Once again, having collaboration with all parties involved—treatment, foster parent,
everybody that’s involved in the case—having a collaboration of what’s the best method
to, not just, “Yeah, she’s my patient, but we’re helping her get better, so she could be a
better mother.” So, how can we all collaborate to make this make sense … but I mean, I
would hope that DCFS’ primary goal is to reunify the family and have the child with the
mother, when the case permits. But once again, having that roundtable [cross-system
planning]. (Clinician 202C)
A residential SUD treatment liaison position was developed in one treatment program to
facilitate a more coordinated, collaborative relationship with the CJC and CW systems. A
participant described how liaisons help convey a more accurate treatment progress report
regarding a patient to the court, enabling the judge to make treatment-informed legal decisions
based on the patient’s progress or continuing treatment needs.
For me, because I think that how it [CJC and treatment center coordination] could have
been improved was with the liaison, and they [treatment agency] just started these
liaisons, so there could be more. Because before, the court was not communicating with
the treatment center that much. It’s just a court, they’re just waiting for a progress report.
And then they’re saying, “OK, the patient is better now. Now you go to RBH [temporary
housing for people in outpatient treatment], recovery bridge housing.” But now I think
the improvement they [treatment agency] made is the liaison part, where there’s a middle
person between the treatment center and the courts. (Clinician 301C)
Cross-System Collaboration at the Systems Level
The CJC, CW, and SUD treatment systems have historically siloed perspectives that
should be examined and discussed in a cross-system collaborative to achieve the common goal of
increasing rates of substance use recovery and family reunification. One clinician described this

113

challenge and her suggestions for improving these conditions.
Coming together on the board [a countywide cross-system stakeholder board] is
everything. I just feel like we don’t take in consideration each other’s perspective per se,
as a whole. They’re still defined. Each one is a separate entity, and I don’t think you can
really get a true assessment without it all being collaborated together. I think it’s a work
in progress, and I think it’s something that we need to take a closer look at, and its
success rate. My thing of it is, don’t knock it till you try it. They [stakeholders] haven’t
put a plan in effect in order to see how this will look like for the woman, how this will
look like for the family, how this will look like for the children as a whole. (Clinician
204C)
Similarly, another participant described the benefits of having a board of stakeholders
that collaborates, providing a venue for innovation and the implementation of more effective
collaborative cross-system models.
I think it should be a board of people representing the court, people that are representing
DCFS, and people that are representing substance abuse treatment. I think when you have
a collaboration and those people are in front of each other, it’s so important. I think it
creates a barrier when I’m talking to this person over the phone or I’m talking to a
probation officer. I think it’s so important that we have a community of people that have
that representation sitting at the same table, where they can cross their views with each
other, give their point of view, and ultimately understand what that looks like for each
entity, and then combine it together to bring a whole. … Sometimes you find out things
through that, sitting down through that process, you may never ever come across, just
being over the phone and just having those mandates [CJC or CW] handed there.
(Clinician 204C)
Another participant described an example of how this coordination and collaboration
might manifest at the system level:
So if we had a weekly, and it could even be a Zoom meeting, people don’t need to drive
to each other, but someone from the court system, someone from DCFS, the heads of all
the different treatment facilities, just all the modalities represented, we could work
together and a supervisor from SAPC [Los Angeles County Substance Abuse Prevention
and Control]. … I feel like if we had better collaboration … let’s discuss the macro issues
involved in this via Zoom, or everybody meet in downtown LA [Los Angeles] once a
month, then we’d have a couple hours where we would discuss these bigger treatment
issues, which involve multidimensional aspects and multiple agencies. And I think just
better discussion of that is what’s needed to address it adequately by professionals
who’ve been in the system a long time and who know, not like somebody who just
started the job and is really new to it, but people who’ve really lived it and done it.
(Clinician 102C)

114

Theme Two: Strategies or Recommendations for Cross-System Coordination
In drug courts, patients receive SUD treatment while the court monitors treatment
progress through status hearings, the patient is tested frequently for substance or alcohol use, and
sanctions are imposed for positive urinalysis tests or graduated rewards for accomplishments like
substance or alcohol use abstinence. In the National Report on Drug Courts and Other Problem-
Solving Courts in the United States, Marlowe et al. (2016) emphasized how family treatment
court, unlike adult drug court, emphasizes the importance of coordinating treatment and
monitoring services for parents who have concurrent cases with the CW system. Unlike drug
court, where treatment adherence is coercive in nature and motivated by the avoidance of a
criminal record or incarceration, family treatment court incentivizes and motivates through
graduated child visitation and family reunification and child custody rights (Marlowe et al.,
2016).
The FCA combines a more inclusive and coordinated SUD treatment provider process for
informing and updating the court on patient progress that extends beyond the current required
progress reporting protocols (i.e., one-size-fits-all formatted emails or letters). Importantly, the
importance of coordinating treatment and monitoring can be extended through scaling up the
implementation of CFTs, which are currently used in a limited capacity, across courts (drug,
reentry, and family treatment courts). Through the expansion of CFT meetings and a more
inclusive role of SUD treatment providers in providing progress reports to the CJC, which
extends beyond the current one-size-fits-all format of a progress report, judges will have a
clearer and more integrated progress update to inform rulings.
Cross-System Coordination at the Treatment Level
Judges in CJCs often rely on sanctioning or rewarding defendants based on a one-size-

115

fits-all formatted progress report that details only the basics of treatment information, such as
whether the patient has been testing clean (urinalysis testing), attending the required number and
type of groups, and remaining in the program. These reports do not highlight the individualized
and contextual progress that patients have made, of which the judge would otherwise be
unaware, without more clinical input that may inform a more accurate decision-making process
for the judge. Some participants provided recommendations or strategies for improving the
progress reporting and decision-making process with clinical input.
Having the court system where we’re realistically involved, not just in punishing but
actually rewarding the patient as well. And having the courts or the DAs [district
attorneys] know more about what treatment consists of, maybe even having the counselor
be able to go with them and share their experience on how the patient has developed and
grown within the last few months. She’s still here! There’s a reason why she’s still
here—because she wants this. She wants to learn new ways of living and coping with
life, so she doesn’t have to go back and use. Instead of focusing on just the negative [e.g.,
positive urinalysis test], let’s focus on the good, positive affirmations. Let’s focus on
what good is it that she’s doing in this last few months that she’s been in treatment.
(Clinician 202C)
Several treatment providers noted the importance of CFT meetings as a means of
coordinating cross-system treatment and family reunification planning. For example, one
clinician described how CFT meetings identify each stakeholder’s role in the coordination of the
SUD treatment and family reunification planning process.
Well, for us, one of the things that we are involved with the residents is called a CFT
meeting. That’s the meeting where the social worker, the social worker’s supervisor, and
any support that the resident has, which would include absolutely the counselor—if the
counselor is not available, then I am available and I will sit in, or the coordinator [will].
And the way we fit in the case plan with DCFS is that we’re letting the DCFS know
what’s our part. What we’re going to be doing for the resident [family-centered SUD
treatment]. My role as a program director is making sure that the staff or the counselor is
following through with the resident. (Clinician 402D)
Residential SUD treatment providers for parents and their children are tasked with
providing SUD treatment to mothers with different levels of biopsychosocial clinical complexity
and needs. Treatment providers understand the importance of individualized treatment planning

116

and that not all parents improve or progress in their treatment at the same rate. One clinician
shared her viewpoint on important next steps for increased coordination with the court that will
address unique individualized patient needs and CJC progress expectations:
It would be really nice if, let’s say, substance abuse programs had, like, not a one-size-
fits-all [approach], but a basic thing [court expectations] that we follow that takes into
account all the different types of addictions, all the different types of when there’s co-
occurring disorders, what [CJC] expectations should be realistic with certain cases. And
that if the court could become aware of that, then we will see a lot more success versus a
lot more people falling off and failing because they just can’t meet the minimum. So, if
there was more of a conversation between court orders, those who set the court orders,
and the actual treatment centers, so that they can come to an agreement of, if we have to
have a mold, what should be a minimum for different levels of care? (Clinician 103C)
Cross-System Coordination at the Systems Level
In CJCs, stakeholders contribute information to the judge from their perspectives about
participants’ progress in treatment. The information shared by SUD treatment providers
primarily comes in the form of progress reports that are further shared with the CW worker, who
adds it to their report and recommendations to the court. In doing so, the judge can consider all
relevant information that has been discussed by the stakeholders and review these concerns with
the participant during the hearing before making a ruling. One participant discussed how current
mechanisms of providing progress reports to CJCs and CW workers is limited in its descriptive
accuracy of the patient’s progress. To increase progress reporting coordination and accuracy
among systems, the participant shared:
I think having a roundtable with the court system or having substance abuse counselors in
the court systems, engaging with the patients and courts, then providing reports and
following up with each. Maybe a middle person … somebody that’s going to engage with
the courts and call the facility that, “Hey, how she doing? What’s her progress?” And
hearing those positive things that are going on, as her recovery grows, as she grows as a
woman. (Clinician 202C)
Another participant described how with the use of liaisons in their program, an improved
continuum of care treatment planning coordination is possible. For example, the participant

117

described how liaisons are part of case conferences in their treatment agency, where they can
convey and advocate on the patient’s behalf with the CJC and CW systems:
We have case conferences, which is where we talk about the progress of our patients and
the court liaison is on Zoom with us. That’s when we talk in more specific, if let’s just
say, they’re doing really good, and we recommend them to step down to our continuum
of care [outpatient treatment] because they’re going to all their groups, they’re meeting
with their therapist, primary counselor, all their drug tests are clean. So, we give them the
information, so in addition to the progress there, they also have that information, too, so
they can advocate for, let’s say, a faster step-down or just presenting good progress.
(Clinician 303C)
Heavy workloads are a well-established barrier to cross-system collaboration given the
growing demand for services, particularly with populations with complex psychosocial needs.
With heavy workloads, CW workers may not communicate or inform SUD treatment providers
of specific needs and requirements of women in their CW caseload. One clinician expressed the
following:
I think that DCFS can have more direct contact with us. I don’t know what their
caseloads look like, but we’ve had some workers that we never meet. We don’t have a
clue who this person is [CW worker]. We’ve had some workers where we have to reach
out and find out who they are or where they are, or ask them if they can come in or,
“Hey, we’d like to meet with you. What are your expectations?” I think that it would
work better if they were directly involved with the treatment team because they’re kind of
disconnected. (Clinician 305C)
Theme Three: Strategies or Recommendations for Improving Clinician-patient
Relationship
The clinician-patient relationship is significantly influenced by the patient’s trust in the
treatment provider (Gabay, 2020). Prior research has shown that when a patient trusts their
clinician or therapist more, the patient’s adherence to their SUD treatment plan increases, which
is associated with an improvement in the clinician-patient relationship and treatment outcomes.
Important barriers to fostering and maintaining trust underlie the clinician-patient relationship.
For example, ambiguous or conflicting treatment expectations from the CJC, CW, and SUD

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treatment systems is related to the lack of clear cross-system communication, which is confusing
and frustrating for all parties, particularly the patient. This is exacerbated when extraneous
requirements from other systems, such as the CJC and CW systems, necessitate a coordinated
interagency communication agenda and treatment planning process among patients, treatment
providers, CW workers, and CJC staff members. When there is a lack of awareness among the
clinician, associated stakeholders, and the patient regarding cross-system treatment expectations,
adverse impacts to the clinician-patient relationship are likely. SUD treatment provider strategies
or recommendations for improving the clinician-patient relationship as it relates to cross-system
(CJC and CW) and SUD treatment expectations is crucial to improving family-centered
treatment outcomes.
Cross-System Treatment Planning with the Patient
Due to prior cross-system treatment planning, coordination, and communication
challenges the following treatment agency created a liaison staff position whose task was to be
an intermediary between the treatment program and the CJC and CW systems. Limited funding
and the financial constraints by the treatment agency allowed for only a few liaison positions that
are operational. However, the following treatment provider quotes describe the benefits of this
position and its potential in promoting improved cross-system treatment planning that enhances
the clinician-patient relationship and alliance. Treatment providers described the cross-system
collaborative improvements this position yields, recommending liaison expansion and use across
Los Angeles County’s SUD treatment delivery system for women in SUD treatment.
[We need] a liaison or a caseworker that is not from the treatment, not from DCFS, in
order to be the middleman. You see what I’m saying? In order to say, “This is how the
treatment’s going,” advocate for them, and relay to DCFS. Because it’s really hard; you
have DCFS that’s meeting these requirements, and then you as counselor have to meet
those requirements, and so does the patient. So, you feel stuck between a rock and a hard
place. So, if there was just this middleman, maybe like a monitor, that was neutral, it

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would ease the patient and ease the whole thing up. (Clinician 301C)
The following clinician described an important strategy in cross-system treatment
planning that improves the clinician-patient relationship. In the providers description, she
emphasizes the importance of CFT meetings that clarify the responsibilities and roles of each
person thereby fostering a supportive and positive recovery experience for the patient.
I think that would look like having a CFT [child and family team meeting] within 30 days
of a patient’s treatment so all could be on the same page. They would come on-site and
there’d be the pages [large poster sheets] of everything right here [goals, needed services,
cross-system roles, etc.] that they get to visualize. They get a look at the concerns of the
whole team. They get a look at what we want for them, not just what they want for
themselves but what the team wants for this particular patient. I think it could be a very
positive experience for them. (Clinician 306C)
It is important that the relationship with the CW worker and the patient is one that
projects mutual respect and concern. This mutual respect for the recovery and family treatment
planning process is further strengthened with consistency and follow through by the CW worker
on important cross-system coordinated objectives. The following treatment provider described an
ideal condition that maintains and fosters the treatment provider relationship and alliance with
the patient and the CW worker.
I think that what it would look like is first, it would be the way that they respond to the
resident. It would be like you would not look down at the resident, regardless of the
reason why the resident had her children removed from them. It would look like you say
something, you’re going to make it happen. Not just continuously, “Oh, well, I’m going
to try, I’m going to try,” and here we are 90 days later, and we still haven’t had that visit
[child]. (Director 402D)
Treatment providers consistently described the cross-system treatment planning
challenges in meeting the ASFA timeline and associated CW and CJC requirements while
simultaneously providing SUD treatment. This frequently noted cross-system SUD treatment
challenge is consistently described as having an adverse effect on the clinician-patient
relationship. The following treatment provider describes the necessity for flexibility in these CW

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and CJC requirements and expectations to establish SUD treatment is a central goal in family
treatment planning.
But if they could not have so much expectation [CJC and CW requirements] on the
patient when they can’t meet them because they’re just working out their SUD, you see
what I’m saying, and let them focus on their recovery in order to have a clear mind to
meet those goals. So, if the courts would get onboard and DCFS would get onboard with
being more involved with the treatment first, and not these expectations that they can’t
meet, because they’re not getting treatment, can’t fix it. (Clinician 301C)
Developing or Preserving the Patient Alliance and Rapport
CFT meetings were described as an excellent mechanism for the clinician to provide
support to the patient. Discussing relapse or the prior substance use behaviors that led to CW and
CJ involvement is challenging for the patient, yet a necessary component in showing CFT
stakeholders acknowledgment and awareness on the patient’s part. The following treatment
provider described how this clinical support for the patient promotes a cross-system
stakeholders-patient alliance.
Like I said, in the social workers that I’ve seen who are supportive, when we do those
CFT meetings, we’re sitting down, the social worker has the whiteboard and they’re
writing down goals. And one of the biggest things that, and I always tell the residents
here, one of the biggest things is relapse. We have to talk about relapse because it would
be not realistic to not talk about relapse. We need to talk about [how] it can happen. We
need to talk about triggers. In the cases where the social workers are really supportive,
they’re very supportive when it comes to this part of the relapse. They ask, “OK, so what
might cause you to relapse?” And the resident is able to say what might cause the relapse.
Mind you, the counselor is sitting right next to the resident to provide the support. And
I’ve seen them be honest with the social worker and whoever’s involved in this CFT
meeting. (Director 402D)
Providing treatment progress reports to the CJC and CW system is a mandated reporting
requirement that can be a challenge to the fostering or maintaining of a clinician-patient
relationship. A strategy frequently described by clinicians to minimize the adverse effects on the
clinician and patient relationship is to go through the report with the patient and coordinate how
they are writing their own progress report with their behaviors (whether positive or negative).

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For example, the following clinician stated:
But like I said, once again, I always go through my progress report with my patient. That
way they know what they’re expecting, they know what’s on there, and they’re not
traumatized or angered or triggered or betrayed. I always share, “This is your progress.
This is what will be shared.” I could say, “Hey, you have court in three weeks,” What do
you want that to look like?” I put it up front, so we don’t have to put that negative on the
report. Because once they see that negative report, they say, “You betrayed me, you’re
jeopardizing me getting my kid back,” or anything goes, and the treatment can stop for
them. And if they feel like there’s something on there that they didn’t like, we’ll say,
“OK, how could we work on this,” and we’ll get the clinical team. (Clinician 301C)
Liaisons provide a key function of providing the required progress reports to the CJC,
instead of the clinician or therapist. With the liaison providing the progress reports to the CJC,
this helps to preserve the treatment provider and patient relationship because the clinician is not
the one informing the CJC on treatment progress or behaviors, thus the perceived confidentiality
remains intact. Moreover, as a mediator between SUD treatment and the CJC, the liaison is able
to provide an independent layer of accountability and perspective on SUD treatment expectations
from the CJC and the treatment programs perspective. For example, the following clinician
stated:
It does definitely preserve it [clinician-patient relationship]. So, for an example, we’ve
had a couple court-mandated patients. Both of them relapsed, the one I just mentioned
plus one previous. What we’ve done is we contacted the court liaison and had them come
out to the location and have a little chat with her instead of just saying, “Hey, you’ve got
to go. You can’t be here.” They come in. They talk to the patient. They let them know,
“Hey, this is what’s going on. Remember, this is what the court requires us to tell them.”
They share the court’s perspective. But they’re also [agency name] and a program
employee]. So, we can share things with the liaison like, “Hey, the patient’s really
struggling. Can you come talk to her before we have to do something drastic?” So, I
mean, we get it from our end that it’s a struggle, that we’re not perfect in recovery in the
beginning. So, we’d hate for her to have to go to jail or even go to prison because of a
bad decision that she made while she’s in treatment. (Clinician 304C)
Theme Four: Strategies or Recommendations to Improve SUD Treatment Planning
Implementation of the FCA depends on strong cross-system collaboration among
stakeholder agencies and systems. Collaborative strategies can be defined as how organizations

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align services across systems to meet mutual underlying goals. However, collaborative strategies
with the CJC and CW for improving SUD treatment planning remain unclear. Identifying
collaborative strategies for promoting collaboration that improves SUD treatment planning is
critical. Further, it is important to identify under what conditions these collaborative strategies
can be most effective in assisting treatment providers at the systems level. This can take the form
of independent cross-system liaisons who are tasked with facilitating communication and
coordination, thereby providing clarity on the roles, responsibilities, and expectations for each of
the different stakeholders.
Cross-System Collaboration at the Treatment Level
I think that’s one way that they could improve more, is where the liaison is more
involved with the patient and the treatment center, to say, “Hey, how’s it going? Are you
meeting the court’s requirements, expectations? What are you working on?” You see
what I’m saying? Because before, there wasn’t no middleman, and it was like, “OK, this
is what the patient’s doing. OK, they’re healed, go on.” No! So, now I think that that’s
how they’re getting better at things, is having a middleman … because the liaison will
advocate more for them because what they’re doing is keeping in contact with the
treatment center, so they know a little bit more about the patient’s treatment, to tell the
judge, “This is what’s going on with the patient and their treatment.” (Clinician 301C)
Having a dedicated independent cross-system court liaison is a way for promoting and
improving proficiency and clarity on expectations and family treatment goals among the
different stakeholders. One treatment provider described the liaison position they created for
their treatment agency provides this key function that improves cross-system treatment planning
for mutual stakeholder clients.
It helps the courts have a better understanding of what happens on our end, but the
liaisons also help us and the patient understand the court’s end. Because, I mean, when I
was going through the whole thing years ago, I’d come out of court and I had no idea
what was going on, what was being said. I didn’t understand it because I was so out of it.
If I had a liaison that could actually come back to me later when I’m not under pressure
of being in court and all this to help me to understand, I probably would not have viewed
the court as a bad thing in the beginning. So, definitely the liaison is helping educate both
sides, which I think is awesome. Awesome. (Clinician 304C)

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Cross-System Collaboration at the Systems Level
Despite heavy workloads and inadequate funding, several treatment providers
emphasized and recommended that CW collaboration and coordination with treatment providers
should be individualized on a case-by-case basis. The following participant expressed:
I think with DCFS that one really needs—and I know this is going to require a lot more
work and there’s not enough workers to do it, I get that—but there has to be an individual
case-based requirement for each person, because not every DCFS case is the same. Yes,
there’s child abuse. Yes, there’s neglect. Yes, there’s physical and the emotional, a bunch
of different things. But to also do a one-size-fits-all [approach] for all DCFS cases, that
doesn’t work, because you have a mom, let’s say, who stayed sober for 10 years and then
relapsed. But all of a sudden, none of those 10 years are considered anymore. Now she’s
just an addict again. So, if DCFS could work with treatment centers that are specific to
her needs, OK, where did this trauma come from? Where did the addiction come from?
We have to look at all the root causes of that main problem while they’re there. (Clinician
103C)
Treatment agency liaisons provide an important role in progress reporting and
communicating between the courts, the treatment program, and the patients. With liaisons
providing an intermediary role facilitating a crucial collaborative component, clinical input can
inform the CJC and CW systems that enables a more accurate decision-making process for the
judge. When a full or more accurate treatment progress update is conveyed to the judge, legal
rulings are more informed and conducive to FCA practices. The following director shared how
her treatment agency’s liaisons have helped to shape advancement of CJCs perspective on the
importance of cross-system collaboration and the SUD treatment process.
I’ve been here for about seven years, and for many years, we continued to encounter the
same issue where we would send the patient to court, and the patient would get
incarcerated or the public defender wouldn’t advocate for our patients, whereas now we
have a liaison in every court and we even have one at DCFS. With them being there, they
were able to open the channels of communication with supervisors and the public
defender and the DAs and the judges as well. Having the liaisons there has really helped
the communication between the courts and our program and our patients. Before the
liaisons at the court, the court didn’t really have a good understanding of what treatment
was. I think they were thinking they could do a whole year in treatment and when they
come out, they’re going to be really good and they’re going to be able to function and

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there was going to be low recidivism and they’re going to be able to go into the
community, get a job and be stable. But that wasn’t it. (Director 302D)
Treatment providers expressed the importance of treatment planning and progress
coordination across the SUD treatment, CJC, and CW systems. Considering the lack of current
cross-system treatment planning coordination, one clinician suggested the following:
I think, again, just more coordination. If we have a client who has DCFS and court
probation, whatever it is, why aren’t all aspects [stakeholders] coming together and
meeting not every month, but like a couple of weeks before that progress report is due.
Why aren’t we not meeting before so that we can see, what can we add to help this client
succeed? (Clinician 103C)
Table 13: Strategies and Recommendations on Ways to Improve Collaboration, Coordination,
the Clinician-patient Relationship and Treatment Planning
Overarching themes
(see Table 11)
Subthemes
(see Table 11)
SEM
framework
Participants quote
Strategies or
recommendations for cross-
system collaboration

Cross-system
collaboration at
the treatment
level
Organizational Well, in the past, there have been social
workers that will come to the facility or
set up a meeting somewhere else where
it is the counselor, the social worker,
sometimes her supervisor, and the client,
and we go over flowcharts and
whiteboard things about all the goals and
the plans from both sides of the table. …
It’s really more with the social workers
that are engaged and supportive …
because once the CFT happens, the
social worker shows she wants to
encourage the resident to the next step. I
have been involved in a few of them,
and they should happen more often for
sure. (Director 401D)

Organizational Once again, having collaboration with
all parties involved—treatment, foster
parent, everybody that’s involved in the
case—having a collaboration of what’s
the best method to, not just, “Yeah, she’s
my patient, but we’re helping her get
better, so she could be a better mother.”
So, how can we all collaborate to make
this make sense … but I mean, I would
hope that DCFS’ primary goal is to
reunify the family and have the child
with the mother, when the case permits.
But once again, having that roundtable
[cross-system planning]. (Clinician
202C)

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Overarching themes
(see Table 11)
Subthemes
(see Table 11)
SEM
framework
Participants quote
Organizational For me, because I think that how it [CJC
and treatment center coordination] could
have been improved was with the
liaison, and they [treatment agency] just
started these liaisons, so there could be
more. Because before, the court was not
communicating with the treatment center
that much. It’s just a court, they’re just
waiting for a progress report. And then
they’re saying, “OK, the patient is better
now. Now you go to RBH [temporary
housing for people in outpatient
treatment], recovery bridge housing.”
But now I think the improvement they
[treatment agency] made is the liaison
part, where there’s a middle person
between the treatment center and the
courts. (Clinician 301C)

Cross-system
collaboration at
the systems level
Organizational Coming together on the board [a
countywide cross-system stakeholder
board] is everything. I just feel like we
don’t take in consideration each other’s
perspective per se, as a whole. They’re
still defined. Each one is a separate
entity, and I don’t think you can really
get a true assessment without it all being
collaborated together. I think it’s a work
in progress, and I think it’s something
that we need to take a closer look at, and
its success rate. My thing of it is, don’t
knock it till you try it. They
[stakeholders] haven’t put a plan in
effect in order to see how this will look
like for the woman, how this will look
like for the family, how this will look
like for the children as a whole.
(Clinician 204C)

Organizational I think it should be a board of people
representing the court, people that are
representing DCFS, and people that are
representing substance abuse treatment. I
think when you have a collaboration and
those people are in front of each other,
it’s so important. I think it creates a
barrier when I’m talking to this person
over the phone or I’m talking to a
probation officer. I think it’s so
important that we have a community of
people that have that representation
sitting at the same table, where they can
cross their views with each other, give

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Overarching themes
(see Table 11)
Subthemes
(see Table 11)
SEM
framework
Participants quote
their point of view, and ultimately
understand what that looks like for each
entity, and then combine it together to
bring a whole. … Sometimes you find
out things through that, sitting down
through that process, you may never
ever come across, just being over the
phone and just having those mandates
[CJC or CW] handed there. (Clinician
204C)

Organizational So if we had a weekly, and it could even
be a Zoom meeting, people don’t need to
drive to each other, but someone from
the court system, someone from DCFS,
the heads of all the different treatment
facilities, just all the modalities
represented, we could work together and
a supervisor from SAPC [Los Angeles
County Substance Abuse Prevention and
Control]. … I feel like if we had better
collaboration … let’s discuss the macro
issues involved in this via Zoom, or
everybody meet in downtown LA [Los
Angeles] once a month, then we’d have
a couple hours where we would discuss
these bigger treatment issues, which
involve multidimensional aspects and
multiple agencies. And I think just better
discussion of that is what’s needed to
address it adequately by professionals
who’ve been in the system a long time
and who know, not like somebody who
just started the job and is really new to
it, but people who’ve really lived it and
done it. (Clinician 102C)

Strategies or
recommendations for cross-
system coordination

Cross-system
coordination at
the treatment
level
Organizational Having the court system where we’re
realistically involved, not just in
punishing but actually rewarding the
patient as well. And having the courts or
the DAs [district attorneys] know more
about what treatment consists of, maybe
even having the counselor be able to go
with them and share their experience on
how the patient has developed and
grown within the last few months. She’s
still here! There’s a reason why she’s
still here—because she wants this. She
wants to learn new ways of living and
coping with life, so she doesn’t have to
go back and use. Instead of focusing on
just the negative [e.g., positive urinalysis

127

Overarching themes
(see Table 11)
Subthemes
(see Table 11)
SEM
framework
Participants quote
test], let’s focus on the good, positive
affirmations. Let’s focus on what good is
it that she’s doing in this last few months
that she’s been in treatment. (Clinician
202C)

Interpersonal
(clinician or
director with
patient)
Well, for us, one of the things that we
are involved with the residents is called
a CFT meeting. That’s the meeting
where the social worker, the social
worker’s supervisor, and any support
that the resident has, which would
include absolutely the counselor—if the
counselor is not available, then I am
available and I will sit in, or the
coordinator [will]. And the way we fit in
the case plan with DCFS is that we’re
letting the DCFS know what’s our part.
What we’re going to be doing for the
resident [family-centered SUD
treatment]. My role as a program
director is making sure that the staff or
the counselor is following through with
the resident. (Clinician 402D)

Intra-personal It would be really nice if, let’s say,
substance abuse programs had, like, not
a one-size-fits-all [approach], but a basic
thing [court expectations] that we follow
that takes into account all the different
types of addictions, all the different
types of when there’s co-occurring
disorders, what [CJC] expectations
should be realistic with certain cases.
And that if the court could become
aware of that, then we will see a lot
more success versus a lot more people
falling off and failing because they just
can’t meet the minimum. So, if there
was more of a conversation between
court orders, those who set the court
orders, and the actual treatment centers,
so that they can come to an agreement
of, if we have to have a mold, what
should be a minimum for different levels
of care? (Clinician 103C)

Cross-system
coordination at
the systems level

Organizational I think having a roundtable with the
court system or having substance abuse
counselors in the court systems,
engaging with the patients and courts,
then providing reports and following up
with each. Maybe a middle person …

128

Overarching themes
(see Table 11)
Subthemes
(see Table 11)
SEM
framework
Participants quote
somebody that’s going to engage with
the courts and call the facility that, “Hey,
how she doing? What’s her progress?”
And hearing those positive things that
are going on, as her recovery grows, as
she grows as a woman. (Clinician 202C)

Organizational We have case conferences, which is
where we talk about the progress of our
patients and the court liaison is on Zoom
with us. That’s when we talk in more
specific, if let’s just say, they’re doing
really good, and we recommend them to
step down to our continuum of care
[outpatient treatment] because they’re
going to all their groups, they’re meeting
with their therapist, primary counselor,
all their drug tests are clean. So, we give
them the information, so in addition to
the progress there, they also have that
information, too, so they can advocate
for, let’s say, a faster step-down or just
presenting good progress. (Clinician
303C)

Organizational I think that DCFS can have more direct
contact with us. I don’t know what their
caseloads look like, but we’ve had some
workers that we never meet. We don’t
have a clue who this person is [CW
worker]. We’ve had some workers
where we have to reach out and find out
who they are or where they are, or ask
them if they can come in or, “Hey, we’d
like to meet with you. What are your
expectations?” I think that it would work
better if they were directly involved with
the treatment team because they’re kind
of disconnected. (Clinician 305C)

Strategies or
recommendations for
improving the clinician-
patient relationship
Cross-system
treatment
planning with
patient
Intra-personal [We need] a liaison or a caseworker that
is not from the treatment, not from
DCFS, in order to be the middleman.
You see what I’m saying? In order to
say, “This is how the treatment’s going,”
advocate for them, and relay to DCFS.
Because it’s really hard; you have DCFS
that’s meeting these requirements, and
then you as counselor have to meet those
requirements, and so does the patient.
So, you feel stuck between a rock and a
hard place. So, if there was just this
middleman, maybe like a monitor, that

129

Overarching themes
(see Table 11)
Subthemes
(see Table 11)
SEM
framework
Participants quote
was neutral, it would ease the patient
and ease the whole thing up. (Clinician
301C)

Organizational “I think that would look like having a
CFT [Child and Family Team] within 30
days of a patient's treatment so all could
be on the same page. They would come
on-site and there'd be the pages [large
Post-It sheets] of everything [goals,
needed services, cross-system roles, etc.]
right here that they get to visualize. They
get a look at the concerns of the whole
team. They get a look at what we want
for them, not just what they want for
themselves but what the team wants for
this particular patient. I think it could be
a very positive experience for them.”
(Clinician 306C)

Interpersonal
(CW or CJC
with patient)
I think that would look like having a
CFT within 30 days of a patient’s
treatment so all could be on the same
page. They would come on-site and
there’d be the pages [large poster sheets]
of everything right here [goals, needed
services, cross-system roles, etc.] that
they get to visualize. They get a look at
the concerns of the whole team. They
get a look at what we want for them, not
just what they want for themselves but
what the team wants for this particular
patient. I think it could be a very positive
experience for them. (Clinician 306C)

Interpersonal
(CW or CJC
with patient)
But if they could not have so much
expectation on the patient when they
can’t meet them because they’re just
working out their SUD, you see what
I’m saying, and let them focus on their
recovery in order to have a clear mind to
meet those goals. So, if the courts would
get onboard and DCFS would get
onboard with being more involved with
the treatment first, and not these
expectations that they can’t meet,
because they’re not getting treatment,
can’t fix it. (Clinician 301C)

Developing or
preserving the
patient alliance
and rapport
Interpersonal
(CW or CJC
with patient)
Like I said, in the social workers that
I’ve seen who are supportive, when we
do those CFT meetings, we’re sitting
down, the social worker has the

130

Overarching themes
(see Table 11)
Subthemes
(see Table 11)
SEM
framework
Participants quote

whiteboard and they’re writing down
goals. And one of the biggest things that,
and I always tell the residents here, one
of the biggest things is relapse. We have
to talk about relapse because it would be
not realistic to not talk about relapse. We
need to talk about [how] it can happen.
We need to talk about triggers. In the
cases where the social workers are really
supportive, they’re very supportive when
it comes to this part of the relapse. They
ask, “OK, so what might cause you to
relapse?” And the resident is able to say
what might cause the relapse. Mind you,
the counselor is sitting right next to the
resident to provide the support. And I’ve
seen them be honest with the social
worker and whoever’s involved in this
CFT meeting. (Director 402D)

Interpersonal
(clinician or
director with
patient)
But like I said, once again, I always go
through my progress report with my
patient. That way they know what
they’re expecting, they know what’s on
there, and they’re not traumatized or
angered or triggered or betrayed. I
always share, “This is your progress.
This is what will be shared.” I could say,
“Hey, you have court in three weeks,”
What do you want that to look like?” I
put it up front, so we don’t have to put
that negative on the report. Because once
they see that negative report, they say,
“You betrayed me, you’re jeopardizing
me getting my kid back,” or anything
goes, and the treatment can stop for
them. And if they feel like there’s
something on there that they didn’t like,
we’ll say, “OK, how could we work on
this,” and we’ll get the clinical team.
(Clinician 301C)

Interpersonal
(clinician or
director with
patient)
It does definitely preserve it. So, for an
example, we’ve had a couple court-
mandated patients. Both of them
relapsed, the one I just mentioned plus
one previous. What we’ve done is we
contacted the court liaison and had them
come out to the location and have a little
chat with her instead of just saying,
“Hey, you’ve got to go. You can’t be
here.” They come in. They talk to the
patient. They let them know, “Hey, this

131

Overarching themes
(see Table 11)
Subthemes
(see Table 11)
SEM
framework
Participants quote
is what’s going on. Remember, this is
what the court requires us to tell them.”
They share the court’s perspective. But
they’re also [agency name]. So, we can
share things with the liaison like, “Hey,
the patient’s really struggling. Can you
come talk to her before we have to do
something drastic?” So, I mean, we get it
from our end that it’s a struggle, that
we’re not perfect in recovery in the
beginning. So, we’d hate for her to have
to go to jail or even go to prison because
of a bad decision that she made while
she’s in treatment. (Clinician 304C)

Strategies or
recommendations for
improving SUD treatment
planning
Cross-system
collaboration at
the treatment
level
Organizational I think that’s one way that they could
improve more, is where the liaison is
more involved with the patient and the
treatment center, to say, “Hey, how’s it
going? Are you meeting the court’s
requirements, expectations? What are
you working on?” You see what I’m
saying? Because before, there wasn’t no
middleman, and it was like, “OK, this is
what the patient’s doing. OK, they’re
healed, go on.” No! So, now I think that
that’s how they’re getting better at
things, is having a middleman …
because the liaison will advocate more
for them because what they’re doing is
keeping in contact with the treatment
center, so they know a little bit more
about the patient’s treatment, to tell the
judge, “This is what’s going on with the
patient and their treatment.” (Clinician
301C)

Interpersonal
(clinician or
director with
patient)
It helps the courts have a better
understanding of what happens on our
end, but the liaisons also help us and the
patient understand the court’s end.
Because, I mean, when I was going
through the whole thing years ago, I’d
come out of court and I had no idea what
was going on, what was being said. I
didn’t understand it because I was so out
of it. If I had a liaison that could actually
come back to me later when I’m not
under pressure of being in court and all
this to help me to understand, I probably
would not have viewed the court as a
bad thing in the beginning. So, definitely
the liaison is helping educate both sides,

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Overarching themes
(see Table 11)
Subthemes
(see Table 11)
SEM
framework
Participants quote
which I think is awesome. Awesome.
(Clinician 304C)

Cross-system
collaboration at
the system level
Organizational I think with DCFS that one really
needs—and I know this is going to
require a lot more work and there’s not
enough workers to do it, I get that—but
there has to be an individual case-based
requirement for each person, because not
every DCFS case is the same. Yes,
there’s child abuse. Yes, there’s neglect.
Yes, there’s physical and the emotional,
a bunch of different things. But to also
do a one-size-fits-all [approach] for all
DCFS cases, that doesn’t work, because
you have a mom, let’s say, who stayed
sober for 10 years and then relapsed. But
all of a sudden, none of those 10 years
are considered anymore. Now she’s just
an addict again. So, if DCFS could work
with treatment centers that are specific
to her needs, OK, where did this trauma
come from? Where did the addiction
come from? We have to look at all the
root causes of that main problem while
they’re there. (Clinician 103C)

Organizational I’ve been here for about seven years, and
for many years, we continued to
encounter the same issue where we
would send the patient to court, and the
patient would get incarcerated or the
public defender wouldn’t advocate for
our patients, whereas now we have a
liaison in every court and we even have
one at DCFS. With them being there,
they were able to open the channels of
communication with supervisors and the
public defender and the DAs and the
judges as well. Having the liaisons there
has really helped the communication
between the courts and our program and
our patients. Before the liaisons at the
court, the court didn’t really have a good
understanding of what treatment was. I
think they were thinking they could do a
whole year in treatment and when they
come out, they’re going to be really
good and they’re going to be able to
function and there was going to be low
recidivism and they’re going to be able
to go into the community, get a job and

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Overarching themes
(see Table 11)
Subthemes
(see Table 11)
SEM
framework
Participants quote
be stable. But that wasn’t it. (Director
302D)

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CHAPTER FIVE: DISCUSSION
Chapter 5 begins by briefly summarizing the background of the study, the study’s
purpose, research questions, and the methodology that was employed. Next, a summary of the
findings is outlined and how they are viewed in the context of the SEM cross-level framework.
Then, a discussion of findings is provided by highlighting major themes and subthemes for each
research question. Following the discussion of findings, their implications for parental SUD
residential treatment are examined, along with important future research that is needed in cross-
system collaboration and FCA implementation and uptake among the SUD treatment, CJC, and
CW systems. The conclusions section then provides reflections and insights into the significance
of this research for improving women’s residential SUD treatment, along with its societal and
family reunification benefits.
Restatement of Background, Purpose of this Study, Research Questions, and Methodology
SUD treatment providers and their CJC and CW cross-system partners struggle to meet
the comprehensive family treatment needs of mothers and their children in residential SUD
treatment. This is often due to inadequate collaboration, communication, and coordination that
create treatment challenges or barriers for SUD treatment providers and their patients with the
CJC and CW systems (Brook et al., 2016; Clary et al., 2020; Lloyd et al., 2021). Despite the
importance of cross-system collaboration and FCA principles being recognized by SUD
treatment, CJC, and CW professionals, prior research has shown SUD treatment providers and
their patients frequently experience fragmented, disempowering, and even counterproductive
cross-system collaboration, communication, and responsiveness (Brook et al., 2015; Lietz, 2011;
Lloyd, 2015).
The purpose of this study was to explore questions that would generate a deep and rich

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understanding from SUD treatment clinician and director experiences and viewpoints of how
current cross-system collaborative relationships create challenges or barriers in SUD treatment
provision. An additional aim of this study was to provide a previously unknown understanding of
how existing cross-system (CJC and CW) reporting and monitoring requirements, along with
communication and cross-system responsiveness, affect the SUD clinician-patient relationships
and treatment planning. Further, an important goal was to identify and highlight key strategies,
from the viewpoints of SUD treatment providers, to improve cross-system collaborative
mechanisms that will improve treatment provision, the clinician-patient relationship, and SUD
treatment planning.
To achieve these aims, this study highlighted current qualitative data from SUD treatment
clinicians and directors (n = 24) on how cross-system oversight and monitoring, along with the
lack of treatment coordination and responsiveness by the CJC and CW systems, create a
challenging treatment environment for providers and patients who are simultaneously involved
with each system. Using the SEM as a theorizing lens for analysis and presentation of themes
and subthemes, this multisite study investigated clinician and director viewpoints to answer the
following research questions:
1. What cross-system collaborative mechanisms involving the SUD treatment, CJC, and
CW systems create SUD treatment provision challenges for clinicians and directors?
2. How do cross-system oversight and monitoring requirements, communication
responsiveness, and ASFA requirements adversely affect the clinician-patient
relationship and treatment planning?
3. How can (a) cross-system collaboration and coordination among the different
stakeholders (SUD treatment, CJC, and CW) be improved and (b) the clinician-patient

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relationship and SUD treatment planning be strengthened via improved communication?
Introduction to Discussion
Residential SUD treatment clinicians and directors identified a plethora of themes and
subthemes related to cross-system collaborative challenges that adversely affect the provision of
treatment, the providers’ relationships with their patients, and their SUD treatment planning.
Important themes and subthemes also emerged that highlighted key strategies and
recommendations for improving or strengthening cross-system collaboration, coordination, and
communication. The SEM provided a theorizing cross-level lens for analysis and presentation of
themes and subthemes identified in the data (see Figure 1 and Tables 8, 10, and 12;
Bronfenbrenner, 1977). The overlapping and interconnected levels demonstrate how themes and
subthemes, along with their associated concepts, influence one another at one level and across
the other levels of the SEM model. In addition to clarifying the interconnectedness among levels
of the SEM model, this study’s findings demonstrate that stakeholders from each system should
be aware of each cross-level influence in the SEM framework. This will foster effective cross-
system collaboration to operate at multiple levels at the same time to achieve a more holistic
FCA approach to parental SUD treatment. However, it is important to highlight that cross-system
FCA collaboration, implementation, and uptake may be affected by the lack of resources, large
workloads, opposing value-oriented perspectives, and the lack of communication and
responsiveness (Akin et al., 2016; Green et al., 2008).
The individual level (clinician and director) of the SEM framework features SUD
treatment clinician and director viewpoints on the cross-system collaborative challenges they
experience that adversely affect SUD treatment and their patients referred by the CJC and CW
systems (see Figure 1). The interpersonal level of the SEM framework encompasses both the

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clinician-patient relationship and the CJC or CW worker relationship with the patient. At the
organizational level, clinicians and directors highlighted specific cross-system challenges they
experience in their relationships with the CJC and CW system and workers. Notably,
communication and responsiveness were prominent cross-system collaborative barriers that
affected their ability to provide effective family-centered treatment, treatment planning, and the
development of healthy relationships with their patients. At the policy level, treatment providers
described how the effects of policy (ASFA) and mandated CJC and CW legal requirements
adversely affect treatment provision, the clinician-patient alliance, and SUD treatment planning.
Notably, in the findings that emerged, the cross-level (SEM) overlapping of themes and
subthemes highlight the bidirectional interconnectedness and influences the four levels of the
SEM have on one another.
Summary of Findings
For Research Question 1, several themes and subthemes emerged and overlapped,
supporting the theory that current collaborative mechanisms create SUD treatment provision
challenges. Major themes that indicate support are (a) “communication as a challenge to
treatment provision,” (b) “lack of knowledge on SUD treatment approaches, values, and goals,”
(c) “large caseloads or logistical concerns,” and (d) “ASFA as a challenge to SUD treatment
provision.” For Research Question 2, several themes and subthemes emerged and overlapped,
suggesting that CJC and CW oversight and monitoring requirements, communication
responsiveness, and ASFA requirements adversely affect the clinician-patient relationship and
treatment planning. Major themes consisted of “adverse impacts on the clinician-patient
relationship,” “adverse impacts on SUD family treatment planning,” “adverse ASFA timeline
impacts on the clinician-patient relationship,” and “adverse ASFA timeline impacts on treatment

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planning.” For Research Question 3, key themes and subthemes emerged regarding how cross-
system collaborative practices among the different stakeholders (SUD treatment, CJC, and CW)
can be improved and the clinician-patient relationship and SUD treatment planning can be
strengthened via improved communication. Major themes supporting key recommendations were
“strategies or recommendations for cross-system collaboration,” “strategies or recommendations
for cross-system coordination,” “strategies or recommendations for improving the clinician-
patient relationship,” and “strategies or recommendations for improving SUD treatment
planning.”
Discussion of Research Question One
Theme One: Communication as a Challenge to Treatment Provision
The lack of CW worker communication and responsiveness with treatment providers and
patients was a consistently expressed challenge that adversely affected SUD treatment provision.
For treatment providers, findings indicated that uncommunicative or unresponsive CW workers
negatively affected the coordination of child visitation FCA practices. This finding aligns with
previous work suggesting that communication problems are one of the biggest barriers in cross-
system collaboration and coordination of FCA practices among stakeholders (Child Welfare
Information Gateway, 2014; Drabble, 2010).
Participants stressed how the lack of CW worker communication and responsiveness with
the patient and their concerns induce acute psychological stress that fosters a self-defeating
attitude wherein they lose hope in child reunification and the benefits of remaining in treatment.
A possible explanation for this may be that a primary reason for women entering or engaging in
residential SUD treatment is to regain child custody rights. Child visitation, family reunification,
and regaining child custody rights is a key motivational factor that when removed, induces

139

parental stress and perceived powerlessness while contradicting the stated goals and objectives of
the SUD treatment, CJC, and CW systems. Supported by prior research, these findings suggest
that improved communication and responsiveness, with the clinical team and the patient, may
improve treatment provision in these areas (Akin et al., 2016).
Theme Two: Lack of Knowledge on SUD Treatment Approaches, Values, and Goals
Clinicians and directors emphasized how the CJC and CW systems use a mainly one-
size-fits-all approach to treatment expectations with their cross-system mutual clients (i.e.,
number of parenting, domestic violence, and anger management groups), in addition to SUD
treatment. Participants stressed how this approach does not address the underlying issue of
trauma histories of the patients and the need for trauma-informed care as a component of
parental mandated SUD treatment (Drabble et al., 2013; Weber et al., 2021). Aligned with prior
research, one-size-fits-all mandated requirements that are not individualized to the patient or
family may be inadequate or inappropriate given the prevalence of extensive trauma histories
among patients with SUDs (D’Andrade, 2019). These findings contribute to a FCA by
suggesting individualized patient screening and assessment of trauma histories be considered for
implementation and practice as a key component of CJC and CW requirements (Drabble et al.,
2013; Weber et al., 2021).
Clinicians and directors reported how CW workers were primarily concerned with the
safety of the child and struggled with personal biases regarding the SUD treatment process,
relapses, and the mother’s prior substance use history. Treatment providers emphasized how
these value-oriented biases were reflected in their lack of responsiveness or supportiveness to the
collaborative family-centered treatment planning process. These results match observations in
earlier studies where, despite the shared goal of SUD treatment and family reunification,

140

differing values led to clashes or tension in agency missions, the direction of family-centered
treatment, or disagreements on important child visitation and reunification decision-making
(CFF & NADCP, 2019; CFF & NDCI, 2017). Further supported by prior research, these findings
may reflect the CJC and CW systems’ lack of knowledge or understanding of the chronic nature
of SUDs in the treatment process due to the lack of training or education prior to working with
parents with SUDs who have a CW case (DePasquale, 2017; Lloyd et al., 2021; Quinn, 2010;
Senreich & Straussner, 2013).
Many participants stressed the importance of CW worker and CJC staff training or
education in working with parents and families with SUDs. Some providers felt that cross-
system stakeholders should have some level of training on trauma-informed care, whereas others
considered required education on SUDs and SUD treatment as necessary training that is key
when working with parents that are on their caseload or court docket and in residential SUD
treatment. Clinician and director concerns are in line with prior research that emphasized and
suggested that trauma-informed care (Bartlett & Steber, 2019; Bowen & Irish, 2020; Lloyd et al.,
2021; Middleton et al., 2019) and knowledge on SUDs and SUD treatment among parents (Lloyd
et al., 2021; Quinn, 2010; Senreich & Straussner, 2013) improve the patient’s ability to work
effectively with treatment providers.
Theme Three: Large Caseloads or Logistical Concerns
Treatment providers echoed the common challenge that heavy child welfare in CJC
caseloads have on cross-system FCA collaboration and coordination. Cross-system collaboration
and coordination challenges associated with heavy workloads included the lack of
communication and the unresponsiveness of CW workers, particularly as it pertained to child
visitation planning and important CW and CJC progress updates. These findings are in accord

141

with recent studies indicating increased caseloads may include the CJC and CW systems’
implementing efficiency goals versus practicing in alignment with evidence-based cross-system
FCA objectives to manage heavy caseloads (D’Andrade, 2019; Gopalan et al., 2021; He et al.,
2021; Kim et al., 2019). These findings suggest that heavy workloads can lead to SUD treatment
provision challenges for clinicians and directors, inefficiency in family-centered treatment
coordination, and the lack of FCA implementation, uptake, or cross-system practices.
SUD treatment directors and clinicians underscored their frustrations regarding how
court-ordered family-centered treatment planning (i.e., child visitation coordination and
implementation) is left unmet by the logistical and resource constraints of the CW system. This
was reflected in child visitation monitors often not being retained, through coordination with the
CW workers and treatment providers, for the required weekly hours of child visitation ordered
by the court and in accordance with family reunification planning. These findings further support
the idea that inadequate cross-system FCA funding can have adverse effects on treatment
provision for parents receiving SUD and behavioral health treatment (D’Andrade, 2019; Gopalan
et al., 2021).
Theme Four: ASFA as a Challenge to SUD Treatment Provision
Directors and clinicians stressed the significant challenge of providing SUD treatment
while simultaneously attempting to adhere to the ASFA timeframe (termination of parental rights
after a child has been in temporary foster care settings for 15 of 22 months). Mothers mostly
enter treatment later on the ASFA timeline. The impending adoption and permanency hearing
timelines affect treatment provision because patients become hyper-focused on meeting CW
requirements and forestalling custody loss of their children. The ASFA timeline creates
significant obstacles for the SUD treatment of the mother and her children, along with the

142

interagency collaboration of SUD treatment providers (clinicians and directors) and the CW and
CJC systems. These treatment provision challenges are in line with prior work suggesting CW
services reduce many barriers for families, although (a) combined oversight from the CW
workers and the CJC staff negatively affect the patient’s psychological condition in terms of
increasing the stress experienced by parents (e.g., lack of responsiveness, poor child visitation
scheduling and follow through, and treatment progress reporting/legal ruling and decision-
making inadequacies) and (b) the burden of the numerous other requirements mandated by the
CW and court systems in addition to SUD treatment. Findings from this study further suggest
how the ASFA timeline and its impending adoption focus may compete with residential SUD
treatment provision and the patient’s attention and focus. These findings are consistent with
Rockhill et al. (2008), suggesting how the overwhelming challenges of juggling the numerous
mandated CW family reunification requirements (additional CW groups, appointments and
hearings, urinalysis testing for both CW and CJC systems, etc.) compound and compete with the
mother’s SUD treatment engagement and treatment planning.
The first question in this research was to identify cross-system (CW and CJC)
collaborative mechanisms which create SUD treatment provision challenges for clinicians and
directors. The findings for this question substantiated prior work in this area; however, there is
one important limitation of prior work that this research addressed and contributed to the field.
Prior research on cross-system collaboration for families involved with the CJ and CW systems
has been primarily conducted at the system level and largely from the viewpoints of the CJC and
CW systems (Lloyd et al., 2014, 2021). This research contributed an individual-, interpersonal-,
organizational-, and systems-level perspective from residential SUD treatment provider
viewpoints, providing new contextual insights into the challenges of SUD treatment provision

143

experienced by providers when collaborating with the CW and CJC systems. To further clarify
findings from this multilevel perspective, the SEM, as a theoretical framework, provided an
important structure and lens for examining the multilevel perspectives that SUD clinicians and
directors encounter when providing treatment to parents referred through CJCs (family
treatment, reentry, or drug courts). Additionally, the SEM framework allowed for clarity and
investigation into the adverse bidirectional influences that have a cross-level cascading effect on
treatment provision, the clinician-patient relationship, and treatment planning.
Discussion of Research Question Two
Extending beyond Research Question 1, the aim of Research Question 2 was achieved by
narrowing the focus from (a) how cross-system collaborative mechanisms challenge or obstruct
treatment provision to (b) a contextual understanding of how oversight and monitoring
requirements, the lack of communication and responsiveness, and ASFA timeline mandates
adversely affect the clinician-patient relationship and treatment planning. The clinician-patient
relationship is defined as the treatment clinician or director engaging in the therapeutic alliance-
building process with the patient and family members to gain their trust and confidence while
taking responsibility for the SUD treatment care being provided. Treatment planning is defined
as SUD treatment providers co-creating, with the patient, an outline of the SUD and related
problems that contains explicit goals and objectives for starting and sustaining the treatment plan
during the treatment episode. Identified overarching themes were “adverse impacts on the
clinician-patient relationship,” “adverse impacts on SUD family treatment planning,” “adverse
ASFA timeline impacts on the clinician-patient relationship,” and “adverse ASFA timeline
impacts on treatment planning.”
Theme One: Adverse Impacts on the Clinician-patient Relationship

144

A common view among treatment providers was that inadequate cross-system
communication and responsiveness between CW workers and SUD treatment providers or the
patient had an adverse effect on the clinician-patient relationship. A significant concern
expressed was that unsatisfactory CW worker responsiveness to family treatment planning goals
induces psychological stress and treatment disengagement for the patient, which has a
detrimental effect on the patient’s treatment alliance with the provider. These conditions are
supported by prior research showing that attending court hearings produces a great deal of
anxiety for mothers, particularly when they face the potential loss of parental custodial rights,
incarceration, or both (Rockhill et al., 2008). These findings suggest that unresponsive CW
workers can contribute to an already overwhelming, acutely stressful, and often retraumatizing
experience for mothers (Rockhill et al., 2008), particularly when court-ordered or coordinated
child visitation planning objectives are not met. These findings highlight the frustrations
treatment providers experience with the patients when cross-system coordinated family-centered
treatment planning objectives fall through or are not consistently followed.
A common viewpoint among clinician and directors was the challenge or position of
being placed in a “double bind.” Treatment providers are placed in a position where they are
simultaneously accountable for providing mandated progress reports to the CJC and CW systems
while negotiating the confidentiality and ethical concerns involved with their therapeutic
relationship with patients. This finding emerged as particularly relevant when the clinician-
patient relationship was perceived to be violated by breaches of patient confidentiality when
negative provider reporting may justify the termination of custody rights, child visitation
planning, or reincarceration or prosecution. These negative reports to the CW and CJC systems
include but are not limited to (a) positive urinalysis tests, (b) problems with maintaining healthy

145

relationships, (c) not making required progress with psychiatric comorbidities, or (d) lack of
stable housing, income, and employment. Prior research supported this view that these cross-
system conditions (double bind) become an impediment and obstruction to the trust necessary in
the therapeutic clinician-patient relationship (Burman, 2004). These findings support the clinical
perspective the hope of regaining child custody rights or the dismissal of criminal charges is an
important motivational factor for parents and removing this hope may adversely affect the
therapeutic clinician-patient relationship (e.g., confidentiality, trust, and openness; Burman,
2004).
Two important concerns were expressed by treatment providers related to CW
monitoring having an adverse effect on the clinician-patient relationship. First, clinicians and
directors shared their frustrations regarding how some CW workers monitor with a disengaged
“cookie-cutter” or one-size-fits-all approach that does not consider the unique individual family
treatment needs. These findings are in accord with other recent studies showing that CW or CJC
one-size-fits-all approaches that are not tailored to the individual needs of the family often make
matters worse for the treatment provider and the patient (Baughman et al., 2021; D’Andrade &
Chambers, 2012). These studies corroborated how “cookie-cutter” approaches can disrupt the
clinician-patient relationship and alliance, making services less effective and increasing
reactance or resistance from parents (D'Andrade & Chambers, 2012; Mirick, 2012).
Second, SUD treatment providers emphasized how intensive CW monitoring and
looming child custody and reunification legal requirements (ASFA) impede on the clinician-
patient rapport-building process because providers often find themselves attempting to refocus
the patient on the primacy and importance of SUD treatment. This suggests that patients become
so concerned or overwhelmed with meeting ASFA, CW, or CJC requirements to forestall

146

adoption proceedings that treatment providers and the patient’s treatment is held “hostage.”
These findings contributing to research, practice, and policy are supported by prior work
indicating that ASFA and CW or CJC timeframe mandates related to child custody are
incongruent with residential SUD treatment timeframe needs (Brook et al., 2010; Rockhill et al.,
2008; Worcel et al., 2008). Importantly, the findings contribute two new insights. First, findings
from prior research primarily came from the perspective and viewpoint of the CW and CJ
systems and staff. Second, this study provided unique and in-depth contextual viewpoints from
the experiences of residential SUD treatment directors and clinicians on how ASFA, CW, and
CJC timeline incongruities related to adoption and child permanency legal requirements
adversely affect the clinician-patient relationship.
Theme Two: Adverse Impacts on SUD Family Treatment Planning
Despite progress and recognition of the importance of using an FCA in the
implementation and uptake of cross-system collaboration between the SUD treatment, CJC, and
CW systems, restricted communication and unresponsiveness issues persist that adversely affect
treatment planning. SUD treatment clinicians and directors stressed how CW unresponsiveness,
lack of timeliness, and inadequate collaborative communication, particularly as it pertains to
child visitation coordination, obstruct SUD treatment planning for providers and their patients.
These adverse treatment planning affects were reflected in the loss of the mothers’ incentive and
motivation to continue participating in treatment when the primary goal and reward of seeing or
visiting with their children is not occurring or is inconsistent. These findings are supported by
prior research that has demonstrated the effectiveness of contingency management principles
(NIDA, 2018) that are used in the treatment of parents with SUDs (Saldana et al., 2021; Weiss,
2021). Incentives or rewards that accompany treatment engagement and goal attainment of

147

patients are an effective clinical and motivational tool (Prendergast et al., 2006; Saldana et al.,
2021). These findings suggest that losing the powerful contingency management aspect of cross-
system child visitation planning, due to the lack of adequate communication or responsive
coordination from the CW worker, removes an important motivational treatment engagement
feature that affects family-centered treatment planning.
Clinicians and directors expressed concerns about how adverse effects of cross-system
mandated reporting for women with an open CW case affects treatment planning. Treatment
providers discussed concerns regarding how the patient’s knowledge that treatment progress
reports are being shared with the CJC and CW systems can hinder the therapeutic treatment
planning process, creating (a) challenges with developing the essential trust necessary in a
therapeutic treatment alliance or (b) hesitancy of the patient to divulge prior trauma-related
experiences, substance use, or child endangerment events for fear it will reflect negatively with
the CJC and CW systems on their child custody case or child reunification planning. These
findings are supported by prior work showing that stigma and fear, particularly related to women
with children, prevent parents from seeking treatment for fear of openly discussing their SUD
and domestic violence or trauma histories. These findings contribute to and further extend these
challenges to the family treatment planning processes of this population while they are in SUD
treatment for fear and stigma that is related to CJC and CW judgment of their child custody and
criminal justice cases (Adams et al., 2021; Frazer et al., 2019; Hammarlund et al., 2018).
Most treatment providers emphasized that CJC- and CW-mandated group requirements
that supersede, are in addition to, and are legally followed by treatment providers can obstruct
and compete with the treatment planning process. These concerns were reflected in how patients
focus on CJC- and CW-mandated group requirements (i.e., parenting, domestic violence, and

148

anger management) rather than their individualized SUD treatment plan (i.e., trauma-informed
therapy, relapse prevention, etc.) to forestall loss of child custody and reunification rights. These
findings are consistent with prior research that suggested third-party system-mandated
requirements can result in overlapping and duplicate (i.e., treatment or psychoeducational groups
and multisystem urinalysis drug testing), or inappropriate services (cookie-cutter, one-size-fits-
all, or not individualized) being mandated to treatment plans by the CW and CJC systems
(D’Andrade, 2019).
Theme Three: Adverse ASFA Timeline Effects on the Clinician-patient Relationship
The ASFA timeline was identified as a major challenge that negatively affects the
clinician-patient relationship. These adverse effects emerged because of the lack of
communication and responsiveness by CW workers, particularly for women who enter SUD
treatment later on the 15- to 22-month timeline (most women). Treatment providers emphasized
that CW workers are more disengaged because mothers are at the end of the ASFA timeline
where the CJC and CW systems are moving toward the recommendation of adoption, and family
reunification planning is coming to an end. This CW worker disengagement becomes a major
impediment to the clinical relationship and continued SUD treatment engagement of the parent.
This finding was reflected and emerged when parents lose the primary reason for being in
treatment that is associated with SUD and CW family treatment planning and child visitation
coordination. With the sobering reality and fear of losing of child custody, induced stress
(Daughters et al., 2009), and inadequate coping mechanisms (Monti, 2002; Noone et al., 1999),
the therapeutic relationship with the patient can be adversely affected. These findings are
supported by prior research that emphasized the competing and incongruent paradigms
associated with child welfare policy and practice as they relate to SUD treatment (Bosk et al.,

149

2017; Drabble, 2010; Green et al., 2008; Lloyd, 2015).
Common treatment provider concerns included how having an ongoing CW case induces
perpetual psychological stress, obstructing the clinical process of developing a therapeutic
relationship and alliance with the patient. Directors and clinicians stressed how women who
come into residential treatment and have an ongoing concurrent child custody case become
hyper-focused and worried about child visitation and losing custody of their children. Although
the underlying SUD condition is a primary reason for their involvement in the CJC and CW
systems, SUD treatment takes a backseat or is a secondary concern to the overwhelming and
unrealistic CJC and CW group requirements in addition to their SUD treatment. This induced
stress and its adverse effect on the clinical alliance and relationship with the patient is supported
by prior work on (a) the incongruency of the ASFA and its associated CW and CJC timeline
(Bosk et al., 2017; Drabble, 2010; Green et al., 2008; Lloyd, 2015) and (b) the role of stress in
maladaptive coping responses, substance use craving, and relapse (Bunce et al., 2015; Jaremko et
al., 2015; Law et al., 2016; Panlilio et al., 2019). The adverse effects of induced stress on the
clinical relationship with the patient, which is linked to the SUD treatment incongruity of the
ASFA timeline, is particularly relevant to the treatment engagement and trust vulnerability of
this population of women who are early in treatment.
Theme Four: Adverse ASFA Timeline Effects on Treatment Planning
Treatment providers underscored a core treatment planning challenge that frequently
occurs when patients forgo important clinical treatment for their SUD and instead, focus their
residential time in treatment on forestalling child adoption and permanency hearings by
attempting to meet the ASFA timeline and CW-mandated group requirements. Treatment
providers stressed how they view these ASFA and CW-mandated group requirements as

150

unrealistic expectations that are overwhelming to the patient or cannot be met, particularly when
they are in addition to residential SUD treatment. The participants emphasized the importance of
the CJC and CW systems being onboard with treatment first, to address the underlying SUD,
while being more flexible on the ASFA timeline (15 to 22 months), especially when treatment
progress is being made despite the chronic nature of the disorder that can include relapses. This
is in line with prior research that showed family treatment courts to be more effective for (a)
improving SUD treatment completion and family reunification outcomes compared to other
CJCs (i.e., drug and reentry courts) and (b) reduction in the amount of time children spend in
out-of-home placements (Huddleston & Marlowe, 2011; Lloyd et al., 2014; Marlowe & Carey,
2012; Marlowe et al., 2016; NIDA, 2020).
The lack of communication and responsiveness was a recurring theme that SUD
treatment clinicians and directors underscored as a factor that translated into adverse challenges
that affected SUD treatment planning. Treatment providers often had to rely on getting crucial
information from patients related to their CJC court appearances or meetings with the CW
worker. This suggests that treatment providers are left with incomplete, inaccurate, or inadequate
information to make important family-centered treatment planning decisions. Coupled with
disengaged or noncollaborative CW workers who may be unresponsive, overburdened, or even
biased, this does the SUD treatment provider and patient a disservice that affects the whole
family. Well-established prior research in this area has underscored the importance of
communication and responsiveness as a core feature in the FCA approach to providing SUD
treatment to mothers who are concurrently involved with the CJC and CW systems (CFF, 2011;
Seibert et al., 2019; Willauer & Coe, 2019).

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Discussion of Research Question Three
Research Question 3 concentrated on key strategies and recommendations from SUD
treatment clinicians and directors regarding ways to (a) improve cross-system collaboration and
coordination among the three primary stakeholders (SUD treatment, CJC, and CW); and (b)
strengthen or improve the clinician-patient relationship and SUD treatment planning. Major
overarching themes that emerged were “strategies or recommendations for cross-system
collaboration,” “strategies or recommendations for cross-system coordination,” “strategies or
recommendations for improving the clinician-patient relationship,” and “strategies or
recommendations for improving SUD treatment planning.”
Theme One: Strategies or Recommendations for Cross-System Collaboration
Several treatment providers highlighted the importance of child and family team (CFT)
meetings as a key recommendation that should be further expanded as an FCA practice with
mothers in residential treatment. Participants emphasized how this early collaborative CFT
process would promote encouragement and support for the parent, which is a crucial component
of cross-system treatment planning buy-in, particularly at the treatment level. These findings are
consistent with other FCA research showing CFTs that include the biological parents, child,
SUD treatment provider, CW caseworker, mental health representatives, temporary guardians,
and other key members support the family’s well-being and reunification potential by improving
cross-system coordination, communication, and collaboration (Advokids, 2021; Kim et al., 2020;
Schreier et al., 2021).
Participants suggested strategies that would include the implementation and
standardization of residential SUD treatment liaisons and how their tasks and function would be
as an intermediary (cross-system coordinator and information sharing) between the treatment

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program and the CJC and CW systems to facilitate a more coordinated, collaborative, and
informed relationships among the SUD treatment, CJC, and CW systems. Providers emphasized
how a treatment liaison position would strategically enhance cross-system collaboration at the
treatment level by helping convey a more accurate treatment progress report regarding a patient
to the court and CW worker, enabling the CJC judge to make treatment-informed legal decisions
based on the patient’s progress or continuing treatment needs, instead of relying on cookie-cutter
or partially informed reports (not individualized) that have key missing patient progress not
available. This strategy and recommendation is supported by prior research that found successful
collaborative efforts require liaisons with access to CJC committees (court panels) and decision
makers while also being able to provide and obtain timely cross-system responses necessary in a
FCA to SUD treatment planning (Bruns et al., 2012; Drabble, 2010).
Consistent recommendations were stressed as strategies for strengthening a cross-system
collaborative approach at the systems level. Strategies centered on recurring county, judicial, and
agency stakeholder meetings that would include recognizing historically siloed perspectives on
policy and practice while unifying around the common commitment and goal (policy- and
practice-wise) of increasing an FCA to substance use recovery and family reunification in the
SUD treatment, CJC, and CW framework. These findings are supported by recent studies that
highlighted the need to upscale implementation and practice, along with the improvements
established by systems-level stakeholder meetings that improve cross-system collaboration and
outcomes for women and their families in residential SUD treatment (Akin et al., 2016; Hedberg
et al., 2019; Middleton et al., 2019; Pryce et al., 2019; Testa & Kelly, 2020).
Theme Two: Strategies or Recommendations for Cross-System Coordination
Although collaborative progress has been slowly occurring, CJCs generally adhere and

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practice a black-and-white sanctioning or reward system of legal rulings (Logan & Link, 2019;
Marlowe et al., 2016) wherein positive urinalysis tests or negative reporting are met with
sanctions, often without the knowledge of additional pertinent clinical and individualized patient
information that may suggest treatment progress is improving. In accord with prior research,
clinicians and directors underscored important recommendations or strategies for improving
progress reporting and the cross-system decision-making process with more inclusive clinical
input. More inclusive clinical input would involve supporting the client by attending court in
person, via Zoom, or by teleconference to inform a more nuanced clinical progress statement to
the court that may provide the judge a more clinically informed report on which to base rulings.
This is particularly relevant for advocacy and education among CJCs that having a SUD is a
chronic health condition (Chandler et al., 2009) for which (a) relapses are likely and should not
be a determining factor on whether child adoption or permanency hearings ensue or a violation
of court order and prosecution and incarceration occurs and (b) relapses be considered in the
larger context of the SUD treatment progress that has been made by the mother (Marlowe et al.,
2012; Marlowe et al., 2014; Marlowe & Meyer, 2011; Warren et al., 2019).
SUD treatment providers are tasked with providing treatment to mothers and their
children with varying levels of biopsychosocial clinical complexity and needs. Participants
recommended the importance of moving beyond the historically entrenched one-size-fits-all
approach to defendant or patient treatment expectations. Although CJC progress has been made
on understanding SUD levels of care, many jurisdictions, courts, or judges mandate defendants
to a predetermined fixed period of time in residential treatment (too much or too little), which is
often incongruent with patient-assessed level-of-care funding available from Los Angeles
County. Level-of-care funding for different SUD modalities (i.e., residential, outpatient, etc.) is

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based on clinically assessed need, typically 60 to 90 days of residential treatment, followed by a
step down to outpatient treatment funding based on progress and not based on judicially
mandated fixed terms of residential SUD treatment.
Participants underscored the recommendation of improving cross-system coordination
with a standardized level of care assessment tool each system (CJC, CW, and SUD treatment)
would recognize to not overtreat or undertreat at a particular level of care. These findings are
supported by previous research that emphasized the importance of assigning the appropriate level
of care to clients who are mutual to different systems (Matusow et al., 2013; Neighbors et al.,
2021; Williams et al., 2019). It is further supported by research recommending that standardized
tools be used to reduce CJC incongruency that is misaligned with the patient and their treatment
needs, while ensuring appropriate level of care is based on a comprehensive set of validated
criteria (Coleman et al., 2005; Galanter et al., 2000). These clinically assessed level of care SUD
treatment needs are fluid, and patients may be assessed for a step down or step up in care based
on treatment progress or challenges, respectively.
Theme Three: Strategies or Recommendations for Improving the Clinician-patient
Relationship
Use of SUD treatment liaisons as CJC and CW intermediaries was found to be a strategy
for improving the clinician-patient relationship. As SUD treatment, CJC, and CW intermediaries,
liaisons coordinate and support the processing (keeping stakeholders, including patients, abreast
and informed) of complex cross-system communication decisions and treatment planning
objectives of treatment providers, CW workers, CJC staff members, and patients. The use of
liaisons alleviates the often ambiguous and conflicting treatment expectations that occur among
the CJC, CW, and SUD treatment systems that are related to the lack of clear cross-system

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communication, which is confusing and frustrating for all stakeholders, particularly the patient.
These findings are consistent with prior research showing that liaisons for individuals with co-
occurring SUDs promote effective care through advocating, linking, and brokering among
stakeholders (SUD treatment, CJC, and CW; Davidson et al., 2016). These findings suggest that
the use of liaisons can reduce ambiguous or conflicting treatment expectations between
stakeholders and the patient, thereby enhancing the clinician-patient relationship.
CFT meetings were consistently recommended as a key strategy for clarifying the
responsibilities and roles of stakeholders, including the patient. Having a clear understanding of
each stakeholder’s responsibility and role in the patient’s care fosters a supportive and positive
recovery experience. This is aligned with recent research suggesting that CFTs with clearly
defined responsibilities and goals increased a supportive atmosphere, reducing patient strain and
improving caregiver engagement in cross-system SUD treatment with a FCA (Kim et al., 2020;
Schreier et al., 2021; Snyder et al., 2012). These findings indicate that as a strength-based cross-
system collaborative approach, CFTs provide an inclusive voice to the treatment provider and
patient, empowering the patient to actively engage with the clinician in their FCA SUD family
treatment planning.
In the CFT context, participants underscored the importance of CW workers and other
stakeholders projecting a mutual respect for the parents’ recovery and family reunification
process, particularly as it relates to the language or way patients are responded to among
stakeholder groups in CFT meetings. This is aligned with a plethora of research showing stigma
and biases related to historically entrenched societal stigmatization of mothers with SUDs that
are experienced in the courts, CW systems, and workers (Hammarlund et al., 2018; McGinty &
Barry, 2020; Weber et al., 2021). These entrenched stigmas and biases influence how parents

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with SUDs are treated with respect to decision-making processes across the CJC and CW
systems, affecting their criminal justice and child custody outcomes (McGinty & Barry, 2020;
Weber et al., 2021). This emphasizes the importance of cross-system CFT stakeholders being
aware of their potential biases related to mothers with a SUD and not using stigmatizing
language in group or individual interactions with the patient or basing any decisions on these
biases (Hammarlund et al., 2018). These findings indicate an important way to improve the
clinician-patient relationship as the parent and treatment provider collaboratively work with CJC
and CW stakeholders.
Findings suggest the necessity for CJC and CW flexibility in mandated group obligations
associated with the ASFA timeline requirements, provided clinically meaningful treatment
progress is being made by the patient. Current ASFA timeline requirements, along with current
conditions wherein most parents entering treatment are at the end of the ASFA timeline, induces
patients being overwhelmed, psychologically stressed, and hyper-focused on attempting to meet
unrealistic CW- and CJC-mandated group requirements within the ASFA timeframe. These
findings are consistent with prior work suggesting the ASFA and CW or CJC timeframe
mandates related to child custody are not congruent with the patient’s residential SUD treatment
needs (Brook et al., 2010; Rockhill et al., 2008; Worcel et al., 2008). With the impending fear of
losing child custody, induced stress (Daughters et al., 2009) and inadequate coping mechanisms
(Monti, 2002; Noone et al., 1999) adversely affect the therapeutic relationship with the patient.
These findings suggest the need for policymakers, cross-system stakeholders, SUD practitioners,
and researchers to collaboratively develop and implement a more conducive and flexible FCA to
SUD parental treatment, instead of the current competing paradigm that is constrained by the
ASFA timeline.

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Theme Four: Strategies or Recommendations for Improving SUD Treatment Planning
Findings suggest that SUD treatment liaisons would provide an essential mechanism for
improving SUD treatment planning with their patients through promoting and improving
proficiency and clarity on expectations and family treatment goals among the different
stakeholders. Findings further indicate that effective cross-system collaboration requires the
expanded implementation and use of SUD treatment liaisons who have access to and can inform
decision makers (Drabble, 2010), particularly as it relates to clinically informed decision making,
which extends beyond the standard one-size-fits-all or cookie-cutter progress reporting format.
SUD treatment liaisons serve as essential intermediaries among the SUD treatment, CJC, and
CW systems, providing more timely and accurate progress reports or facilitating treatment
related communication, coordination, and updates among systems (Davidson et al., 2016; Scott
et al., 2013). These findings are in line with prior research showing the use of liaisons is a crucial
element in SUD treatment and jurisdictional collaboration for individuals involved with the CJC
system while performing a key public health function and enhancing CJC and treatment
processes (Davidson et al., 2016; Drabble, 2010; Scott et al., 2013). These findings indicate the
key role of liaisons as advocates, communicators, coordinators, and intermediaries among
systems (SUD treatment, CJC, and CW), thereby reducing treatment planning challenges and
enhancing the clinician’s proficiency in meeting treatment planning goals at the SUD agency
level. At the systems level, liaisons provide an intermediary role, facilitating a crucial
collaborative component with clinical input that can inform the CJC and CW systems and
enabling a more accurate decision-making process for the judge and CW worker. When a full or
more accurate treatment progress update is conveyed to the judge and CW worker, legal rulings
and child reunification planning decisions are more informed and conducive to FCA practices.

158

With the current inadequacies of cross-system treatment planning, communication, and
responsiveness with the CJC and CW systems, a consistently expressed recommendation was to
increase or improve cross-system treatment planning and coordination that focused on meeting
the patient’s family-centered SUD treatment needs. This is consistent with prior research
showing cross-system collaboration is an essential element of family-centered treatment and
meeting the complex family treatment needs requires coordination across systems (Werner et al.,
2007).
Implications
Findings from this research study, conducted in Los Angeles County, California, provide
several implications for cross-system collaboration among the SUD treatment, CJC, and CW
systems at the systems level and for SUD treatment providers at the treatment level. Importantly,
prior research on cross-system collaboration for families involved with the CJC, CW, and SUD
treatment systems has been primarily conducted at the system level and largely from the
perspectives of the CJC and CW systems (Lloyd et al., 2014, 2021). This research contributes to
the existing knowledge base by highlighting the viewpoints of SUD treatment clinicians and
directors who are tasked with managing many cross-system collaborative challenges while
simultaneously providing treatment to patients involved with the CJC and CW systems. This
research further contributes previously unknown SUD treatment provider viewpoints by
narrowing and identifying how cross-system challenges adversely affect the clinician-patient
relationship and treatment planning, particularly regarding cross-system communication,
responsiveness, monitoring requirements, and ASFA timeline mandates. Additionally, key
strategies and recommendations were emphasized by treatment providers for improving cross-
system collaboration among the three stakeholders, along with ways to improve the clinician-

159

patient relationship and treatment planning. Theoretical implications include the utility and
application of integrated theoretical frameworks (SEM and organizational theories) that can be
applied to future research or model development.
Advancing the capacity of cross-system collaboration to provide a comprehensive FCA
to SUD treatment necessitates a patient- and family-centered case planning approach. Active
cross-system communication and timely responsiveness are key drivers of effective collaboration
that will help treatment providers to (a) support improved cross-system decision-making about
patient cases and (b) improve progress reporting and CJC and CW case monitoring. Effective
cross-system communication is also described as crucial for (a) ensuring CJC- and CW-
mandated group requirements are not overwhelming, holding the patient hostage (their focus), or
competing with, and instead complementing, the patient’s SUD treatment planning; and (b)
keeping all stakeholders, including the patient, abreast and informed of decisions related to
changes and disposition of a patient’s CJC and CW case (Green et al., 2008; Rockhill et al.,
2008). Importantly, this research identified essential contributions that CFT meetings and SUD
treatment liaisons can provide for enhancement of cross-system collaboration and
communication among the SUD treatment, CJC, and CW systems, thereby strengthening SUD
treatment provision, the clinician-patient relationship, and treatment planning.
In Los Angeles County, California, the recommended implementation and expanded use
of CFT meetings emerged as a key patient- and family-centered communication, support, and
response for parents and children who are involved with the SUD treatment, CJC and CW
systems. The goal of CFT meetings is to assemble relevant cross-system stakeholders who are
involved in the child’s and parent’s treatment and reunification planning. This assemblage can
include the biological parents, their children, SUD treatment providers, CW caseworkers, mental

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health specialists, temporary guardians, and other key members who can support the family’s
reunification planning (Kim et al., 2020; Rockhill, 2021; Schreier et al., 2021). The
implementation and scaling-up process of CFTs in California and elsewhere is based on an
increasing body of evidence showing that services for mothers and their families are more
effective when delivered in the context of an integrated team of key stakeholders (Advokids,
2021; Rockhill, 2021). This CFT stakeholder assemblage facilitates communication and
coordination, thereby providing clarity on the roles, responsibilities, and expectations of each
stakeholder. Because this promising cross-system collaborative stakeholder approach is still
relatively new to both research and practice, little is known about the degree of utility of CFTs in
the CJC, CW, and SUD treatment systems context, particularly in Los Angeles County. This
research indicates this mechanism is a key function for SUD treatment providers to improve
SUD provision, treatment planning, along with the clinical relationship with the patient in the
context of the CJC and CW systems (Rockhill, 2021).
SUD treatment provider liaisons surfaced as an important mechanism for strengthening
and preserving the cross-system relationship of both the patient and treatment providers, along
with collaborative partnerships with the CJC and CW systems. Treatment liaisons function as a
crucial intermediary between the treatment program and CJC and CW systems, providing
progress reports or facilitating communication and coordination among systems (Davidson et al.,
2016; Drabble, 2007; Scott et al., 2013). Findings indicate liaisons play a key function of
providing required progress reporting to the CJC and CW systems, instead of treatment
providers. With the liaison furnishing progress reports to the CJC and CW systems, the
preservation of the clinician-patient relationship is enhanced because the clinician is not the one
informing the CJC or CW systems on treatment progress or behaviors; thus, perceived patient

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confidentiality remains intact. Moreover, as a mediator between SUD treatment and the CJC, the
liaison can provide an independent layer of accountability and perspective on SUD treatment
expectations from the CJC and the treatment program’s perspective. Findings support the view
that the SUD liaison position can enhance cross-system collaboration at the treatment level by
helping communicate more accurate treatment progress reports regarding a patient to the CJC
and CW worker (Davidson et al., 2016; Drabble, 2007; Scott et al., 2013). This assists the CJC
judge and CW worker in making treatment-informed legal or family reunification planning
decisions, respectively, based on the patient’s progress or continuing treatment needs, instead of
relying on cookie-cutter or partially informed reports that may be missing important information
on treatment progress the patient has made.
Despite the increasing acceptance that having a SUD is a chronic medical condition,
institutionalized stigma against parents who use drugs remains entrenched in the values and
practices of CW and CJC staffs, which are supported by policies and federal laws (ASFA) in
which institutionalized stigma is rooted (McGinty et al., 2020; NCSACW, 2015; Weber et al.,
2021). As SUD treatment, CJC, and CW systems become more attuned to the adverse impact of
trauma, this study’s findings have important implications for how to better understand and
respond to cross-system collaborative practices that will minimize systemic trauma-related
triggers (NCSACW, 2015). At the systems level, findings from this research will aid cross-
system practices that can reduce institutional stigmatization and traumatization where
collaboration is family centered, focusing on empowerment, acceptance, and compassion, which
is associated with increased patient engagement and retention (McGinty et al., 2020; NCSACW,
2015; Weber et al., 2021). Seeing parental SUD treatment through a trauma lens instead of
through historical CW and CJC value-oriented perspectives will aid in understanding how stigma

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and retraumatization play out in cross-system communication, responsiveness, and SUD
treatment monitoring.
Given the prevalence of extensive trauma histories among women with a SUD,
incorporating trauma-informed practices into a broad-based SUD treatment, CJC, and CW cross-
system framework can help reduce the historically entrenched institutional stigmatization of
parental substance use that is associated with the retraumatization of the patient (McGinty et al.,
2020; Weber et al., 2021). Although creating and implementing FCA cross-system informed
practices is outside the scope of this study, findings from this research allow for identification of
key cross-level (SEM) indicators of stigma and trauma experienced by the patient that can
inform targeted CW and CJC staff training and education that will minimize the impact on the
patient and their treatment (McGinty et al., 2020; Weber et al., 2021).
Along with the findings and implications from this research, there are additional policy
and cross-system collaborative implications to consider for the uptake and implementation of
FCA practices within the parental SUD treatment, CJC, and CW systems. At its core are
increased and flexible funding mechanisms that will support and promote implementation efforts
by SUD treatment providers and their collaborative partners as they engage state and county
leaders to identify funds that will support families affected by SUDs who are involved with the
CW and CJC systems. Two recent pieces of legislation have been enacted to further support
states and counties to integrate FCAs, including the Family First Prevention Services Act
(FFPSA; signed into law in 2018) and the Child Abuse Prevention and Treatment Act (CAPTA;
expanded in 2016). These two pieces of legislation offer a historic opportunity for CW agencies,
CJCs, and their SUD treatment collaborative partners to expand and enhance family-centered
interventions (NCSACW, 2021). To support states, counties, the courts, and the SUD treatment

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and CW agencies move toward family-centered care, the NCSACW has developed a series of
training modules on implementing an FCA (NCSACW, 2021). Importantly, informed by
findings from this research will provide crucial multilevel insights of treatment provider
challenges of collaborating with the CW and CJC systems, which adversely affect treatment
provision, their relationship with the patient, and SUD treatment planning. Coupled with the
recent funding mechanisms associated with the FFPSA and CAPTA, implications from this
study provide important treatment provider strategies and insights into key parts of the six
essential components of the FCA (see Table 5) to implement and integrate within the SUD
treatment, CJC and CW systems that will improve family SUD treatment outcomes in Los
Angeles County, California (NCSACW, 2021).
Theoretical implications of this research include the successful testing of the
effectiveness of applying a SEM theoretical framework for identification of major themes and
subthemes that highlight treatment provider experiences and behaviors as embedded in multiple
levels of bidirectional influence, including (a) individual (clinician and director); (b)
interpersonal (clinician with patient or CJC and CW system with patient); (c) organizational
(SUD provider, CJC, and CW); and (d) policy (legislative or legal). Extending the SEM
framework and application in this qualitative research, identification of SEM cross-level overlap
of themes and subthemes is achievable and apparent through the SEM cross-level framework.
Identification of SEM cross-level overlap of themes and subthemes can be viewed as
synonymous with identification of bidirectional SEM cross-level influences espoused in the
SEM conceptual framework. This SEM cross-level overlap, or thematic bleed-over, of themes
and subthemes allowed for the identification and examination of important cross-level thematic
influences that challenge and shape SUD treatment provision, treatment planning, and treatment

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providers relationships with the patient and CW or CJC staff. Further theoretical implications of
this research include enhancement to the SEM framework application using integration of
theories, where the SEM (dominant theory) and organizational theories (subtheories) are used in
combination as a guiding lens for identification of themes and subthemes to answer important
research questions. Organizational theories (resource dependence theory and interorganizational
relations theory) support the SEM with conceptual guidance and explanation regarding
mechanisms of how cross-system collaborative relationships develop and function (Carman,
2011; Davis & Cobb, 2010; Ferguson, 2018; Reitan, 1998). Implications of this research show
the utility of the integration of theories (SEM and organizational theories) for future research,
application, and model development in this area of cross-system collaborative research.
Limitations
As with any research, there are some limitations to this study. First, potential limitations
of this research include a nonrandomized sample drawn from only one county in California.
Second, this research relied on self-report data that was drawn from residential SUD treatment
providers and was not triangulated with data or viewpoints from patients, CW, and CJC staff.
Third, this research is based on purposive sampling of clinicians and directors from two
residential treatment modalities, therefore limits its transferability beyond the women’s
residential SUD treatment program modalities that participated in this study (children allowed to
remain with the parent during the treatment episode or child cannot be in treatment with mother).
Fourth, this research occurred in a large urban city limiting the study’s transferability to rural
settings. Fifth, the study’s analysis inevitably reflects the perspective and bias of the researcher;
and participant responses reflect the viewpoints and potential bias of SUD treatment providers
within this study’s cross-system context. Nonetheless, SUD treatment provider views on the

165

current state of SUD treatment challenges, and recommendations or strategies thereof, can
greatly inform cross-system collaboration within the CJC and CW context. In sum, findings from
this research should be regarded as preliminary evidence of current SUD treatment, CJC, and
CW cross-system collaborative challenges, along with recommended strategies to address the
adverse effects on parental SUD treatment provision, the clinician-patient relationship, and
treatment planning.
Conclusion
This study aimed to explore viewpoints of residential SUD treatment providers
(clinicians and directors) in a large urban city to determine the cross-system challenges they
experience in interagency relationships with the CJC and CW systems and staff; and, how these
challenges adversely affect treatment provision, the clinician-patient relationship and treatment
planning. A secondary aim was to identify SUD treatment provider strategies and
recommendations for improving the current cross-system collaborative environment, along with
strengthening clinical relationships with patients and improving the treatment planning
conditions that are affected by CJC and CW mandates, monitoring, and legal oversight. This
study achieved these research aims with findings that indicate cross-system collaborative
challenges adversely affect SUD treatment provision, the clinician-patient relationship and
treatment planning, particularly as they are related to cross-system communication,
responsiveness, monitoring requirements, and ASFA timeline mandates. Key strategies and
recommendations pointed to the importance of implementation and expanded use of CFT
meetings and SUD treatment provider liaisons as vital cross-system patient- and family-centered
communication and response mechanisms for providers treating parents who are involved with
the CJC, CW, and SUD treatment systems.

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Most of the prior research in cross-system collaboration among the SUD treatment, CJC,
and CW systems comes from the viewpoints and perspectives of CJC staff and CW workers.
While this study contributes the viewpoints of SUD treatment clinicians and directors, additional
research is needed that examines the patient’s perspective and experience to better understand
how these cross-system collaborative challenges adversely affect the clinician-patient
relationship and treatment planning from the viewpoint of the parent. This research provides an
important starting point for additional inquiry by underscoring key features that challenge
residential SUD treatment provision for women involved with the CJC and CW systems in one
county in an urban setting. Further research should be undertaken to investigate treatment
provider challenges, within this collaborative context (CJC, CW, and SUD treatment), among
multiple urban counties or within rural jurisdictions to better understand the sociogeographic
variability of cross-system collaborative SUD treatment provision challenges. Additionally, to
develop a fuller picture of these treatment provision challenges, additional studies will be needed
that examine outpatient treatment provider viewpoints on cross-system challenges that adversely
affect clinicians, directors, and parents in outpatient SUD treatment. This would paint a clearer
picture on the transferability of findings from residential treatment, as they would be related to
the commonalities or differences with the modality of outpatient SUD treatment. Importantly,
future research is needed that is conducted using more sophisticated methodologies, including
mixed methods or quasiexperimental studies. When conducting studies using more sophisticated
methodologies and analysis, findings from this research suggest isolating and examining
variables that are associated with the major themes and subthemes in this study. This study
points to important future research that can advance the body of knowledge on cross-system
collaborative approaches for improving parental SUD treatment and family-centered treatment

167

outcomes.
SUD treatment providers and the CJC and CW systems across state and county
jurisdictions recognize the need to shift toward an integrated FCA model driven by cross-system
collaboration while balancing the well-being of the child, the treatment needs of parents
struggling with a SUD, and family reunification goals. This study represents a preliminary effort
to gain a robust understanding of previously known and unknown challenges SUD treatment
providers experience in the current cross-system collaborative environment with the CJC and
CW systems when providing care to parents in residential SUD treatment. While there are
jurisdictionally unique challenges to broad-based SUD treatment, CJC, and CW cross-system
collaboration, informing the process at multiple levels from the viewpoints of residential SUD
clinicians and directors is fundamental and key.

168

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Appendices
Appendix A: Research Instrument: Recruitment Flyer
Appendix B: Research Instrument: Information Sheet (Exempt Form)
Appendix C: Research Instrument: Interview Guide
Appendix D: Research Instrument: Participant Demographic Form

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Appendix A: Recruitment Flyer

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Appendix B: Information Sheet (Exempt Form)
INFORMATION SHEET FOR EXEMPT RESEARCH

STUDY TITLE: SUD treatment clinician and director challenges working with collaborative
justice courts: A qualitative study

PRINCIPAL INVESTIGATOR: Dean Rivera, MSW, PhD Student
FACULTY ADVISOR: Benjamin Henwood, PhD

You are invited to participate in a research study. Your participation is voluntary. This document
explains information about this study. You should ask questions about anything that is unclear to
you.

PURPOSE
The purpose of this study is to gain a clearer understanding of (a) how SUD treatment clinician
or director engagement with child welfare workers and collaborative courts challenges or
facilitates the provision of SUD treatment; and (b) how SUD treatment clinician or director
reporting and monitoring requirements (e.g., urinalysis testing, progress reports, etc.) to child
welfare workers and collaborative courts affect the clinician-patient relationship and treatment
planning.

We hope to learn, from the perspective and experiences of SUD treatment clinicians and
directors, specific challenges and facilitators of collaboratively working with court and child
welfare representatives when providing treatment to mothers referred from different
collaborative justice courts (e.g., re-entry, family treatment, or criminal justice courts).
Understanding the intra-agency clinical framework from the director and clinician perspectives,
when interfacing with different systems and the patient simultaneously, can provide an informed
contribution to improving parental SUD treatment and family reunification.

You are invited as a possible participant because you are a SUD treatment director or clinician
who provides treatment services to patients referred through collaborative justice courts as a
result of child welfare or criminal justice issues. To be eligible for this study, you must be a
clinician or director who interacts, directly or indirectly, with the child welfare or collaborative
court system on behalf of the clients on your caseload or at your program.

PARTICIPANT INVOLVEMENT
If you decide to take part, you will be asked to participate in a 1.25- to 1.5-hour interview with
the principal investigator. After the interview, the researcher will collect information on
demographic characteristics, SUD treatment practice experience, licensing and degree
information, treatment modalities offered, and whether mental health or medication-assisted
treatment is also provided. Additionally, the interview will include 16 open-ended questions that
will explore your perspectives on (a) how working with the child welfare and collaborative court
systems challenges or facilitates SUD treatment and planning; and (b) why this can hinder or
strengthen the clinician-patient relationship. Due to the COVID-19 pandemic, all interviews will
be conducted via phone or internet videoconferencing. Upon your consent, open-ended questions

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and answers will be audio recorded using a deidentified code number, although you can choose
to decline and still participate.

PAYMENT OR COMPENSATION FOR PARTICIPATION
You will receive a $100 Amazon.com gift card for your time. You do not have to answer all of
the questions to receive the gift card. The card will be emailed to you upon completion of the
interview.

CONFIDENTIALITY
The principal investigator and the University of Southern California (USC) Institutional Review
Board (IRB) may access the data. The IRB reviews and monitors research studies to protect the
rights and welfare of research subjects.

When the results of the research are published or discussed in conferences or project meetings,
no identifiable information will be used. Your responses will not be associated with your name.
The researcher will assign a random code to your demographic questionnaire and the interview
transcript instead of your name. This information will be stored indefinitely in the principal
investigator’s office in a locked file cabinet. No names or other identifying information will be
used when discussing or reporting data. In addition, information will be saved and stored in a
secure password-encrypted cloud server managed by USC and SharePoint (Microsoft). The
signed consent form and any identifiable information will be stored separately from your
responses and will be destroyed 3 years after study completion.

The researcher cannot guarantee complete confidentiality. A breach of confidentiality is defined
as any disclosure of protected information to a third party without the consent of the participant.
There is the small chance this can occur through oral, written, or electronic means (e.g., email or
fax) or the loss of a laptop. In the event this occurs, a report will immediately be made to the
USC IRB. Further, the researcher may not be able to keep confidential any disclosure of harm to
oneself or to others (42 CFR 2.51; 45 CFR 164.512(j)(4); (42 CFR 2.51; 45 CFR 164.512(j)(4)).
In such a case, it may be necessary to disclose this information to ensure the safety of the
participant or others.

The researcher will store audio recordings and any electronic or printed transcripts in encrypted
files or in a locked, secure location for 5 years after the publication of this research, after which
all files will be destroyed. A transcriber will have access to the deidentified recordings for
transcription purposes. The USC IRB may inspect and review your information to ensure
appropriate safeguards were made to protect your information. You have the right to review or
have your recording or transcript edited. Please contact the principal investigator describing the
reasons of the review or edit so arrangements can be made.

INVESTIGATOR CONTACT INFORMATION
If you have any questions about this study, please contact Dean Rivera, MSW, at the USC
Suzanne Dworak-Peck School of Social Work: (213) 821-6449 or drrivera@usc.edu
or
Benjamin Henwood, PhD, faculty advisor at the USC Suzanne Dworak-Peck School of Social
Work: (213) 821-6449 or bhenwood@usc.edu

194

IRB CONTACT INFORMATION
If you have any questions about your rights as a research participant, please contact the USC IRB
at (323) 442-0114 or email irb@usc.edu. You may also contact the IRB by mail at the following
address:
USC Institutional Review Board
1640 Marengo St., Suite 700
Los Angeles, CA 90033

195

Appendix C: Interview Guide
SUD Treatment Clinician and Administrator Challenges Working with Collaborative
Justice Courts: A Qualitative Study
INTERVIEW GUIDE FOR CLINICIANS AND ADMINISTRATORS
Hello, my name is Dean Rivera. I am a doctoral student at the USC School of Social Work.
Thank you for agreeing to meet with me. I am interested in learning from you about your
experiences working with clients mandated to your treatment program through the family
treatment court, reentry court, or drug court [changed to appropriate court].
[ASK PARTICIPANT IF THEY HAVE REVIEWED STUDY INFORMATION SHEET AND IF THEY
UNDERSTAND ITS CONTENTS OR IF THERE ARE QUESTIONS. IF SO, ANSWER ANY QUESTIONS. IF
PARTICIPANT VERBALLY AGREES TO PARTICIPATE, PROCEED]
I would like to audio record our discussion today to make sure I don’t miss anything, although I
will need your verbal permission. Do I have your permission to start audio recording?
I. BACKGROUND
The collaborative courts and the DCFS systems each have their own client monitoring
and treatment expectations about what treatment is supposed to look like for clients mandated
into your program. This can include court mandates such as reporting urinalysis results,
attendance at court hearings, providing treatment progress updates, and completing treatment to
regain child custody rights or avoid prosecution or violations of parole or probation. Given these
monitoring and reporting requirements, clinicians [administrators] face challenges that include
(a) clinician-patient confidentiality concerns such as providing treatment progress reports and
reporting results on urinalysis tests; and (b) conflicting values on where the priority of focus
should be whether the child, the parent, or criminal justice requirements. Each of these factors
have the potential of affecting the client’s treatment plans or the clinician-patient relationship.
For example, this can manifest when negative progress reports, such as with continued treatment
noncompliance or positive urinalysis tests, trigger readjudication of child custody plans or court
sanctions.
An important purpose of this study is to gain a fuller understanding of how clinicians like you
manage the different cross-system monitoring and treatment requirements and to learn about
your opinions on how this work affects treatment plans and the clinician-patient relationship.
II. QUESTIONS
1. How would you describe the ways in which collaborative courts monitor the treatment of the
clients in your program?
2. How would you describe the ways in which the DCFS monitor the treatment of the clients in
your program?

196

[This question is asked of clinicians and directors]
3. As a clinician [program director], how would you describe the way you provide treatment
progress reports or updates to the courts?
3a. How would you describe the ways that the clinician-client relationship is affected with
their knowledge that negative progress reports are being shared with the courts?

3b. How would you describe the ways clinicians [program directors] are challenged when
treatment planning with the courts?

3c. How would you describe the ways that the clinician-client relationship is affected when
engaged in treatment planning with the courts?

3d. In your view as a clinician, what are some of the challenges of working with the courts
when providing treatment with a patient?

4. As a clinician [program director], how would you describe the process of providing treatment
progress reports to DCFS?
4a. How would you describe the ways that the clinician-client relationship is affected with
their knowledge that negative progress reports are being shared with the DCFS and their
workers?

4b. How would you describe the ways that the clinician-client relationship is affected when
engaged in treatment planning with DCFS workers?

4c. In your view as a clinician, what are some of the challenges of working with the child
welfare system and child welfare workers when providing treatment with a client?

4d. What are ways or how would you describe the ways cross-system treatment planning
with the DCFS could be improved for your program and its clinicians?

5. In your view, how does the ASFA permanency law timeline requirements affect the SUD
treatment planning for parents trying to regain child custody?
6. Thinking about what we have discussed, what ideas or suggestions do you have about how the
SUD treatment, CW, and CJC systems work together more effectively?
That completes all of the questions I had. Is there anything else you want to add?
For clarification purposes, may I recontact you if I need clarification on responses you have
given?

197

[CLOSING STATEMENT – STOP RECORDING]
Thank you again for your time and thoughtful responses. The experiences and thoughts you
shared make an important contribution to this study. I hope that the findings of all the interviews
will help us to develop ideas and strategies to strengthen and improve the collaboration between
courts, child welfare and substance use treatment so as to achieve the best outcomes possible for
clients. As a token of our appreciation an Amazon.com egift card will now be sent to you in an
email. Have a good day!

198

Appendix D: Participant Demographic Form
Participant Demographic Form
Date:
Participant ID:
Site ID:

Instructions: Please check the box to answer each of the following questions.

1. What is your age?
__________

2. What is your gender?
 Female
 Male
 LBGTQ
 I prefer not to answer
 Self-describe ______________________

3. Are you Hispanic or Latina?
 Yes
 No
 Don’t know
 Decline to answer
3a. If Hispanic or Latina, what is your ethnicity?
 Central American
 Cuban
 Dominican
 Mexican, Mexican American, Chicana
 Puerto Rican
 South American
 Other
 Please specify ________________________

4. With which racial category or group do you identify?
 White
 Black or African American
 American Indian or Alaskan Native
 Asian or Pacific Islander
 Other
 Please specify __________________
 I prefer not to answer

5. How long have you been with [name of agency]?
Years _____ Months _____

199

6. What is your highest educational degree attained?
 Intern
 SUD certification
 Bachelor’s
 Master’s
 Doctorate
6a. What type of clinical license do you possess?
 LCSW
 LMFT
 Another license type: ____________________

7. What modalities of SUD treatment services are provided for women at [name of agency]?
 Residential
 Residential perinatal
 Residential and outpatient treatment
 Residential, outpatient, and aftercare sober living
 Opioid treatment
 Medication-assisted treatment
 Withdrawal management

8. Are children able to remain with the parent during residential treatment?
 Yes
 No
 Only in aftercare sober living
 Only visitations

9. Which of the following services are provided in-house as part of SUD treatment?
 Nursing care or health care
 Psychiatric services (i.e., psychotropic medication management)
 Medication-assisted treatment
 Parenting or family education
 Childcare or daycare
 Child services or Early Head Start
 Vocational training
 Educational support
 Housing services
 Social services and community referrals or integration

10. As part of your work in this agency, which of the following agencies require treatment
progress reporting or status updates?
 Child welfare
 Collaborative justice courts (family treatment court, reentry court, drug court, etc.)
 Probation or parole departments
 All of the above

Question Emailed to Newly Scheduled Participant

200

Consider your agency’s interactions with collaborative justice courts (family treatment court,
reentry court, or drug court), DCFS agencies, and the criminal justice system (traditional
criminal justice court, parole, or probation). There are variations in the level of collaborative
engagement among agencies. Please select the level you believe reflects your agency’s current
collaboration with mandating agency partners (i.e., collaborative justice courts, DCFS, family
treatment court, criminal justice courts, and probation or parole).

Our agency level of cross-system collaboration is:
 Basic exchange of information between organizations on organizational procedures for
client status (e.g., treatment progress, child welfare, or criminal justice planning and
monitoring).
 In the process of developing and implementing a more formal cross-system
collaborative partnership with the child welfare, collaborative justice court, or
criminal justice systems (traditional criminal justice court or probation or parole).
 Actively engaged in formal joint cross-system planning related to client SUD
treatment, child welfare planning, and criminal justice cases.

Abstract (if available)

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Asset Metadata

Creator Rivera, Dean Ramon (author)

Core Title Substance use disorder treatment clinician and director challenges working with collaborative justice court and child welfare systems: A multisite qualitative study

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Philosophy

Degree Program Social Work

Degree Conferral Date 2022-08

Publication Date 07/22/2022

Defense Date 07/22/2022

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag clinician-patient relationship,cross-system collaboration,family-centered treatment,OAI-PMH Harvest,substance use disorder,treatment planning

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Henwood, Benjamin (committee chair), Amaro, Hortensia (committee member), Sussman, Steven (committee member), Wenzel, Suzanne (committee member)

Creator Email deanideal@yahoo.com,drrivera@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC111373918

Unique identifier UC111373918

Legacy Identifier etd-RiveraDean-10914

Document Type Dissertation

Format application/pdf (imt)

Rights Rivera, Dean Ramon

Type texts

Source 20220722-usctheses-batch-961 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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