I have been thinking a lot about how ACT can be applied in various aspects of social work. It is very clear to me that ACT can be a powerful tool to affect behavioral change in multiple contexts. The most obvious is in individual and group psychotherapy. There has been a tremendous amount of research and application toward this end.
I am curious what people think about ACT as it relates to case management – another primary focus of social work. Anyone anyone out there that is using ACT as a case management tool?
As the director of a program working with men and women leaving incarceration, I supervise a group of post release case workers who provide outreach services to our clients. While inside the facility, clients participate in DBT and ACT groups and receive individual therapy. Upon release, care is transferred to the reentry case workers (RCW’s) who help clients navigate the adversity of reentering society.
I would like to offer some tools that we have developed to help our RCW’s be effective. Special shout out to my colleagues Ruben Mercado-Lugo and Jenn Avery who co-created much of the material below.
First, I would like to frame the case management conversation in a tool that comes from Charlie Swenson’s comprehensive DBT training – you know an acronym is coming at you 🙂
FAVOR F – Focus A – Assess V – Validate O – Offer R – Reinforce
This acronym provides an easily accessible and memorable tool that orients the case worker to the processes involved in coaching a client through a difficult situation.
The first three processes are rather straight forward, however knowing what to “offer” comes from an accurate functional contextual assessment.
In the second process (assessing), there is a determination that needs to be made regarding the clients current state – what is the client able to functionally access? In the work that we do with individuals returning to the community from jail, we have found that there are many times when the volume of adversity a client is facing is extremely high, and a client can become highly dysregulated, at which point values/committed action work to be tricky/invalidating. At this point making a decision as to how to work with the client is vital.
Working with a client experiencing a high volume of adversity, we start with noticing, naming, defusing and accepting.
However, if the client continues to be highly dysregulated, motivating the client to commit to the use of concrete skills to regulate can be helpful:
If after that the client has become more regulated, value orientated actions can often be accessed as a higher degree of defusion has occurred, creating more space for choice. At which point perspective taking, values clarification, committed action and interpersonal effectiveness skills can be employed:
Here is a picture of the whole model:
Basically – there are times when a client has very little acceptance/defusion/present moment awareness/SAC of their emotional or cognitive state. At this point the case worker can assist the client to commit to putting “roadblocks” in their way so as to protect themselves from harmful, unproductive behavior. Roadblock strategies can include, but not limited to, many of the distress tolerance and emotional regulation skills offered through DBT skills modules.
We have found that this strategy can be very effective in helping client move toward value driven behavior. It also frames the use of behavioral skills learned in DBT (and other modalities) as committed actions that can move clients toward vital workable lives.
As always, I am interested in feedback and in particular, how do you conceptualize the processes found in ACT as applied to case work?
This webinar was completed for the Council of State Governments and the National Reentry Resource Center. Scaffolded by the functions and modes of DBT, and an overarching paradigm of contextual behavioral therapies, the Franklin County Sheriff’s Office in Greenfield MA has implemented an evidence based clinical reentry program.
Public Safety Through Treatment: A New Direction for County Corrections
Levin Schwartz, LICSW
SOCIAL WORK VOICE | NOVEMBER/DECEMBER 2018 11
Amid a national opioid epidemic, the political context continues to lean toward the over incarceration of people struggling with addiction and mental health. Typically, people are sent to facilities ill-equipped to intervene effectively, keeping them stuck in disenfranchised positions upon release. Evidence suggests the way to improve the system is by focusing on the process to change the outcome. Operating on behavioral health principles and evidence-based strategies and acknowledging that high recidivism is partly due to historically ineffective “correctional” environments, the Franklin County Sheriff’s Office (FCSO) decided to transform the context of incarceration into a locked treatment facility.
Sheriff Christopher Donelan’s philosophy is that “reentry starts on day one.” The assessment data indicated that 86 percent of indi- viduals were high-risk for recidivism. The proportion of clients who self-report heroin or opioids as their primary problem contin- ues to steadily increase: 30 percent (2016), 39 percent (2017), to 40.2 percent (2018, first quarter). Most clients had severe child- hood trauma, and about 85 percent met diagnostic criteria for co- occurring disorders. The data was clear: it was not enough to offer a program to a cadre of individuals, FCSO needed to transform the entire system by offering clinical treatment, educational and vocational programs, reentry services, and post release case management to all resi- dents in the facility – while maintaining an individual’s agency to opt-out.
Housing units became therapeutic step-down communities, or- ganized similarly to social model recovery homes: lights out re-gimes for adequate sleep, nutritional diets, community building activities, and invitations to connect with appetitive behaviors (e.g., guitar lessons, yoga, acting, art, gardening, exercise, college classes). Medically Assisted Treatment (MAT) became included in the menu of services. Both on admission and before release, clients who meet medical criterion for opioid use disorder are offered Buprenorph- rine/Nalaxone (generic brand of Suboxone) or injectable Naltrex- one (Vivitrol). A comprehensive reentry plan is established for every resident: securing identification documents (state identification, birth certificate, and social security cards); Department of Children and Families, Department of Mental Health, and Veteran’s care coordination; and aftercare planning including activating insurance, ordering prescription medication, and making primary care, outpatient therapy, and MAT appointments. Once in the community, clients are offered post release outreach support by Reentry Case Workers (RCW).
The FCSO clinical reentry program is based on two core frame- works: 1) risk-need-responsivity (RNR) and 2) a behaviorist ap- proach to trauma-informed dual-diagnosis treatment and reentry case management. The program begins by having clients complete three assessments: the LS/RNR (criminogenic risk/needs assess- ment), a comprehensive clinical assessment by a LICSW/LMHC, and a reentry assessment by a Correctional Case Worker (CCW).
The clinical model does not focus on symptom reduction as a treat- ment target; rather, it is a transdiagnostic model that aims to in- crease behaviors whose absence play a role in human suffering and behavioral dysfunction: psychological flexibility, emotional regula- tion, behavioral inhibition, empathy, distress tolerance, and inter- personal skills. Treatment is organized to address the eight crimino- genic risk factors identified in the LS/RNR using clinical modalities such as Acceptance and Commitment Therapy (ACT) and Dialecti- cal Behavioral Therapy (DBT), Thinking for a Change, and voca- tional, educational, family, and prosocial leisure programming.
According to the Council of State Governments, 60 percent of individuals released from county correctional facilities have five or more prior convictions. Breaking the cycle of recidivism takes remarkable motivation and commitment; for this reason, FCSO has found that Motivational Interviewing (MI), DBT, and ACT can be a particularly effective combination. These modalities help professionals teach clients concrete behavioral change strategies in a way that empowers individuals to maintain their motivation in the face of tremendous adversity.
Initially, the old adage “you can lead a horse to water but you can’t make it drink” was heard from some recalcitrant participants and staff; however, the third often forgotten stanza is particularly apt: “but you can salt the oats.” FCSO salted the oats utilizing a series of contingency management strategies that link earned good time and classification in lower levels of security to individual’s lev- el of participation in treatment. The other major structural compo- nent is the “phase-up system” (FCSO’s version of a token econo- my) in which effective individual and community behavior is reinforced through client-identified incentives: elective program- ming, phone cards, portable DVD players, additional time off their sentences, barbeques, and family activities.
After a client leaves FCSO, they are provided intensive, wrap- around reintegration services in the community from RCWs. The RCW focuses on long-term case planning rather than crisis resolu- tion, collaborating with community partners to build relationships and address stigma by empowering the clients and educating the community. The RCW delivers evidence-based interventions within the context of the standardized clinically focused model, working to reinforce and generalize the skills learned in FCSO into their natural environment: enhancing life skills and capacities, support- ing effective system navigation, behavioral coaching and reinforce- ment of valid and effective behaviors, and working with clients to stay in the moment, noticing behavior in context and clarifying if a behavior moves them toward or away from who and what truly matters most.
Correctional environments have a long history of ad- verse control policies which vicariously affects clients and staff. To increase capacity and resiliency, regular training and team meetings occur. CCWs and their licensed behavioral health care partners complete cross-training on security, trauma-informed treatment principles, and evidence-based treatment interventions. During the academy, all new uniformed officers participate in train- ing on RNR, behaviorism, and substance use disorder principles, with annual in-service trainings. All human service personnel re- ceive intensive three-day training in criminogenic risk and need andare certified to administer the LS/RNR. Weekly, DBT and ACT con- sultation meetings occur, and each unit has a case management meeting focused on specific client needs. Monthly didactic lectures are held to further staff skills in ACT, DBT, and MI. Finally, quar- terly training retreats provide more in-depth opportunities to re- ceive support in critical areas, such as cultural sensitivity, staff resil- iency, and secondary trauma.
Qualitative and quantitative data suggest that the clinical and reentry services are affecting positive behavioral change. With the initiation of treatment units in 2013, egregious acts of violence have declined – dropping from 103 to 57 (45 percent) in the first year. In focus group research by Alternative Solutions Associates, Inc. (ASA) and a Smith College MSW intern, participants in the program stated, “From here I feel like I’m not going out with noth- ing,” and “The program helped me [learn] to walk around the hole instead of falling in.” Recently awarded grants from NIDA and SAMSHA will support research to study post release opioid use trajectories after MAT in jail. But most significantly, the program aims to lower recidivism for the overall population. The gold stan- dard of recidivism studies are those that follow participants for three years. FCSO is in year two of a three-year recidivism study and the outcomes look promising. According to ASA, after two years, participants in the program had a 23 percent rate of recidi- vism compared to the baseline of 42 percent (19 percent reduction).
Overrepresentation of people struggling with addiction and mental health is precipitating criminal justice reform. If incarcera- tion continues to be part of the solution, enabling institu- tions to provide evidence-based treatment followed by transitional support post release is demonstratively a more effective public health strategy to address offending behaviors and lower recidivism. The FCSO’s recent efforts have made great strides toward this end, working to improve the lives of clients, their families, and the community.
Levin Schwartz, LICSW, is the Assistant Deputy Superintendent and Director of Clinical and Reentry Services at FCSO and an ad- junct professor at Westfield State University. Levin received his MSW from the Smith College School for Social Work.
Happy to have our local news center picking up the story. I would like to encourage all people covering stories like this to consider language that does not disenfranchise people stuck in the cycle of addiction and incarceration.
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.