Reflections on clinical reentry programs behind the walls

DBT and ACT in a Correctional Facility

My team has taken great strides in the past five years and I am continuously impressed and motivated by both my colleagues and the complexity of our pursuit; reducing recidivism by enhancing our client’s capacities to attain, make stronger, and generalize the skills they need in-order to pursue their workable-value-driven goals.

To do this we have done our best to adhere to an evidenced based model of assessment to determine the course of treatment.  We utilize some version of clinical assessment (there have been a few iterations of biopsychosocial assessments during my time at the FCSO) and the LS/RNR to determine how clinically/programmatically to respond to each individual client.  We have worked hard to adapt DBT and ACT treatment to address both the behaviors and contextual variables that act as cues to ineffective behavior.  In practice, more often than not, the majority of our clients receive the same course of clinical treatment; which at times I struggle with. I wonder if part of this is due to the seemingly endless flow of clients in need of intensive levels of care (with 75% of all clients falling into recidivism risk levels of “very high” or “high”).  But also to the reality that few clinical treatment modalities effectively target “reducing recidivism by reducing criminogenic risk” as the functional goal and so we get “stuck” with the urge to address all behaviors during the current bid.

We are in seemingly uncharted territory, informed by up-to-date evidence and fueled by a lot of ambition; we have certainly developed a more sophisticated program at FCSO than simply a menu of generic correctional programs offered to those clients who choose to participate.

The following paragraphs propose a reexamining of the overall goals, stages and targets of treatment/reentry through the lens’ of DBT & ACT.  Some of these we have directly addressed already, some need some more work.  I think it would be good to have a conversation about valid clinical targets inside a correctional facility; ultimately this is where I feel I can lose my footing.  It is the place where the uniqueness and context of our treatment environment is most at play.  I would argue that we need to keep our focus on targets related to criminogenic risk/need, choosing to ignore work on some other possible targets, or to defer the work to outpatient treatment.  For example, it might unrealistic to target the large number of serious quality-of-life interfering behaviors while an individual’s liberty is being withheld – and a level of physical safety is being imposed; instead focusing on the quality of life interfering behaviors or behaviors that will destroy therapy while the individual is incarcerated.  We have a finite number of resources and it is always preferential to address problem behaviors in the natural life context.

Goal of FCSO treatment: Reducing recidivism by enhancing our client’s capacities to attain, make stronger, and generalize the skills they need to pursue their workable-value-driven goals post incarceration.

Stages of FCSO treatment:

1) Steps of treatment that focuses on developing progressive levels of motivation and skills acquisition.

2) Phase-Up process where clients progress through phases, demonstrating a willingness and commitment to develop new knowledge and new skills.

Targets of treatment:

  • Target 1: Decrease life-threatening behaviors
  • Target 2: Decrease Therapy-interfering behaviors of client
  • Target 3: Decrease quality of life interfering behaviors
  • Target 4: Increase Behavioral Skills
  • Target 5: Reduce Suffering
  • Target 6: Increase self-respect
  • Target 7:  Decrease individual problems in living
  • Target 8: Increase freedom

One hope is that we may be able to come up with a way to better determine the target of treatment for each client in a more individualistic level.  The hope is that we develop a “deep structure” for our program as we continue to experience changes in our institutional environment and that will help us make decisions that will maintain the essence/philosophy of our clinical reentry program.

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