How do you give a sense of choice – with mandated treatment?

Consensus continues to develop among researchers, practitioners and lawmakers concerning the need to provide evidence based rehabilitative interventions to the incarcerated population.  By using validated assessment tools to determine risk and need areas, as well as delivering adequate dosage of evidence based treatment and reentry supports, correctional facilities may be able to significantly contribute to the safety and overall public health of our communities. The blog post focuses on the way in which our program has fused existing correctional systems with best practices of reentry, including screening and assessment, modern scientific evidence on behaviorism and treatment technologies, case management & post release reentry services.

This section focuses on the implementation of a validated criminogenic risk need responsivity assessment tool that identifies risk areas in client’s lives that if addressed have been shown to reduce future criminal actions.  In this post, I discuss a comprehensive clinical assessments and how to offer a sense of choice in a choice-less environment.

 Screening and assessment

Responding to the complexity of need for the incarcerated requires a comprehensive, multi-systems approach that fundamentally shifts the paradigm of corrections – moving it toward a public safety/public health goal:

“To reduce recidivism by enhancing an inmate’s capacities to attain, make stronger, and generalize the skills needed in-order to pursue and make committed actions toward adaptive-value-driven goals upon reentry.”

The program is informed by evidenced based assessments to determine the scope, sequence and unique reentry needs for each individual.  For example, our assessments determined that during the period of 2013- 2014, (N=150), 23% had a mental health diagnosis only; 7% had a substance abuse/dependence diagnosis only; and 69% of the inmates sentenced were diagnosed with co-occurring disorders.  In addition, the inmate population was determined to be almost exclusively “high” to “very high” risk to recidivate – as determined by Level of Service/Risk Need Responsivity (LS/RNR).


Out of 577 individuals screened between 4/24/2014 and 10/29/2015:

  • 53% (306 individuals) reported no heroin or non-prescribed opioid use
  • 46% (268 individuals) reported abuse or dependence on heroin or non-prescribed opioids.
  • 38% (218 individuals) reported abuse or dependence on heroin.
  • 5% (124 individuals) reported abuse or dependence on both heroin and non-prescribed opioids.
  • 16% (94 individuals) reported abuse or dependence on heroin (but not non-prescribed opioids).
  • 9% (50 individuals) reported abuse or dependence on non-prescribed opioids (but not heroin).

Level of Service Risk Need Responsivity (LSRNR)

This assessment is administered to all sentenced clients within two weeks after the client has been medically cleared.  Research has established a strong connection between eight critical domains, which if addressed, help individuals disrupt the cycle of incarceration (Andrews, Bonta, & Wormith, 2008).

  1. History of Antisocial Behavior, looks to understand to what extent an individual has had contact with the criminal justice system.
  2. Antisocial Personality Pattern, looks at an individual’s externalized behaviors such as impulsivity, high levels of reactivity, recklessness, aggressiveness, adrenaline seeking and cavalier behaviors that pose risk to self and others.
  3. Antisocial Cognition, looks at internalized verbal behaviors that function as rules governing behaviors. These include rules, reasons, judgments, beliefs, self-conceptualizations, and rationalizations which stand in for justifications for criminal behavior.
  4. Antisocial Associates, looks at interpersonal associations between the client and others who support criminality. Often times clients will report that over the long run, they struggle to commit to non-criminal behaviors because “everyone I know is a criminal; eventually I get dragged back in.”
  5. Substance Abuse, assesses to what degree an individual uses substances.
  6. Family & Marital, assesses for qualities in relationships and experiences a client has had as a child in the family of origin, (e.g., attachment qualities, inconsistency with rules, expectations, monitoring, and invalidation of valid behaviors), and current interpersonal/intimate relationships, which reinforce criminality.
  7. School & Work, assesses to what degree an individual has struggled to successfully participate in work or educational systems. Low levels of performance and satisfaction in these domains has been shown to function to promote criminality.
  8. Leisure & Recreation, assesses the degree to which an individual lacks participation in pro-social, sober behaviors that are intrinsically rewarding.


This data suggests that our County Corrections facility will likely continue to be a last line of defense for our community against an epidemic that has been ravaging the Commonwealth and the nation.  If we are to intervene effectively to disrupt this cycle of addiction and criminality a comprehensive and aggressive intervention strategy is necessary.

Informed Consent: creating a choice in a choice-less environment

The intake process for the clinical reentry program starts shortly after the client’s initial booking intake, following medical clearance and security orientations.  The client is offered a highly incentivized choice to engage in the program through an informed consent process.  The individual will sit with a clinician and review a document which functions to give the client as much information as possible before making the decision to engage in treatment while incarcerated.  The informed consent packet provides an overview of the educational, vocational, clinical, reentry and post release case work services, the milieu based therapeutic communities, and the contingency procedures which have been rolled out across the entire reentry continuum (medium security – prerelease); these include the phase up process and the program warning system.  The phase up process is an integrative model that functions to reinforce skillful behavior of identified therapeutic targets by offering concrete incentives for skillful participation; the program warning system functions by extinguishing unskillful or treatment interfering behavior. If an individual elects to participate in the program the client will sign a release of information between the medical, clinical, educational, & reentry staff and fill out an application to enter the clinical reentry program.

In future posts, I will discuss how we created an incentive based treatment system – tapping into clients appetitive drives in an effort to foster a sense of meaning and purpose beyond staying out of jail or not using drugs.  As we say — life is not only about staying clean, life is about living effectively while engaging in valued based actions that create a sense of meaning and purpose.


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