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.
SOCIAL WORK VOICE | NOVEMBER/DECEMBER 2018 11
Check out this article featuring Dr. Ruth Potee. She is an incredibly kind, intelligent and driven person whom I have the pleasure to work with at the Franklin County Sheriff’s Office.
Go Public Radio!
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.
Thanks News Center 22!
This is a piece that Chris James, CNN Producer (Beme News), completed after visiting our facility.
Published on Jun 21, 2018
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.
Ninety minutes west of Boston, Greenfield has a population of 17,000, and like so many rural places across the U.S., it has been hit hard by the opioid epidemic. Greenfield, though, has waged an ambitious response — one that may be a blueprint for other communities.
In 2013, Greenfield residents formed the Opioid Task Force, and its members have since won significant victories, including the launch of a 64-bed treatment center a mile from downtown, and an upending of the way the local jail administers corrections. They tackled the easiest interventions first, such as educating the public about the problem and improving access to naloxone, the medication that reverses overdoses, says John Merrigan, a Task Force co-founder and the county’s register of probate. These are steps that many communities have undertaken; Greenfield, though, began to confront some of the deeper issues underlying drug use, including the fact that overdose deaths are more common among the underemployed and unemployed.
THE WORK THAT’S HAPPENING IN GREENFIELD IS A MICROCOSM OF WHAT NEEDS TO HAPPEN ALL ACROSS THE COUNTRY.
MICHAEL BOTTICELLI, FORMER DIRECTOR, NATIONAL DRUG CONTROL POLICY
Greenfield’s Franklin County Jail is now at the vanguard of U.S. correctional facilities, offering something that’s common in European jails but rare in the U.S.: Qualifying inmates receive medication-assisted treatment, including buprenorphine, which curbs opioid cravings, or Vivitrol, which blocks the effects of opioids. Clinicians encourage inmates, whom they call clients, to name what truly matters to them, as part of an approach known as dialectical behavior therapy, or DBT. In a facility where around 90 percent of the roughly 200 inmates at any point report a substance use disorder, these services are critical.
Greenfield is also striving to rebuild an economy that depended on a thriving manufacturing industry in the 20th century. It is emerging as a hub for the food industry, sparking hopes that it will once again be able to offer living-wage jobs to the city’s residents.
At the treatment center, medical director Dr. Ruth Potee — who also holds the same post at the jail — is trying to facilitate the recovery of patients by giving them more than just medication: a reason to get better.
“Everybody needs a sense of purpose,” Potee says. “It could be taking care of your kids, or having a job, or going back to school, or walking your neighbor’s dog.”
What works in a small city in Massachusetts may not in other parts of the country. But the multipronged, holistic approach the city has taken to deal with the crisis represents a model worth emulating, suggests Michael Botticelli, executive director of the Grayken Center for Addiction at Boston Medical Center and former director of the Office of National Drug Control Policy.
“The work that’s happening in Greenfield is a microcosm of what needs to happen all across the country,” says Botticelli.
At the heart of the city’s strategy is the Franklin County Jail, located on the west side, at the base of Greenfield mountain. Sheriff Chris Donelan and his staff treat the jail as a “locked treatment facility.” There’s appropriate medication on offer, and also DBT. Clinicians encourage inmates to articulate the triggers associated with their inclination to use drugs, such as sadness, stress and memories of traumatic experiences. According to Levin Schwartz, the jail’s director of clinical and re-entry services, such awareness creates a split second, a tiny window, in which former drug users can consider whether using will move them toward or away from what they really want. “You see things one way, then DBT gives you another way of reacting,” says Sheperd, who was held at the jail twice, most recently for a 10-month sentence that ended in 2016.
The city’s treatment center is offering similar therapy. Adam S. checked in to the Franklin Recovery Center last April and participated in intensive group sessions that covered coping skills and developing a sense of purpose, as well as practical tactics like picking up the phone rather than isolating himself when he was at risk of relapsing. Those sessions helped, Adam says — but his insurance only covered a week and a half of inpatient care, so he was discharged. He relapsed, though he has been clean for the past two months. It’s easier to offer intensive therapy at the jail than at the civilian treatment center, where patients stay for 30 days max, says Potee. Greenfield wants to do both.
But any long-term success will also hinge on Greenfield’s success in rebuilding its economy. Once a manufacturing hub, the city boasted a local silver company, Lunt Silversmiths, that employed 800 people as recently as 2001. By 2009, though, Lunt’s had filed for bankruptcy and shut its doors. The city’s low official unemployment rate of 2.9 percent may be misleading. According to the Census Bureau, more than 2,000 residents in Greenfield between the ages of 18 and 64 are neither employed nor looking for work, and therefore are not counted among the jobless.
The food industry is emerging as a savior. Housed in a squat building with solar panels on its gently sloping rooftop and a Black Lives Matter sign in one window, Real Pickles makes fermented foods from regionally sourced produce. It sells its products in around 400 stores from Pennsylvania to Maine, including 50 Whole Foods Markets. Real Pickles, which employs 20 people, and a couple of other local companies — like the Artisan Beverage Cooperative, which distributes ginger beer and kombucha to a thousand stores nationally — have found a niche in the production of locally sourced packaged foods that command a high price. Across the street from Real Pickles is the Western Massachusetts Food Processing Center, which helps entrepreneurs incubate businesses that turn agriculture into packaged products.
The jail, meanwhile, has created explicit pathways from addiction and incarceration to the food industry through vocational training. Abrah Dresdale, who sports rectangular glasses and an asymmetrical haircut, coordinates the jail’s Farm and Food Systems program and teaches some of its college-accredited classes. One of Dresdale’s former students, Russ Lilly, was hired by Real Pickles when he still had nine months left to his sentence, so officers transported him to work and back. “The gardening and food programs are fast becoming the most popular here,” says Donelan.
Other former addicts have found their way into Greenfield’s new economy without assistance from the jail. Miguel Morales, who became addicted to heroin in his teens, now works at a nearby farm that raises free-range meats and eggs.
Greenfield’s food industry is still modest in size. The food-processing facility has directly created 100 jobs. Still, those employed find the work meaningful. At Real Pickles, Lilly is part of the company’s mission to build a better food system. “I feel like I’m making a difference,” he says.