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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).

N=150

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.

 

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.

Can This Small Town Lead America in Fighting the Opioid Crisis

Can This Small Town Lead America in Fighting the Opioid Crisis?

Downtown Greenfield, Massachusetts

Chris Sheperd lost 14 friends to heroin overdoses, including a girlfriend who was pregnant with his child. But what made him stop using heroin was an organic gardening class he took while incarcerated in Greenfield, Massachusetts.

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.

Screen shot 2018 04 11 at 12.35.19 pm

 

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.

Welcome

Levin Schwartz, LICSW is a licensed independent clinical social worker, whose primary training occurred at Smith College’s MSW program and at the Veterans Administration on the Specialized Inpatient PTSD Unit. Levin currently holds multiple positions in the greater community of Western Massachusetts.  Levin is the Assistant Deputy Superintendent of Clinical & Reentry Services at the Franklin County Sheriff’s Office; a member of the MPTC; a consultant to the Greenfield District Court’s Drug Court; an adjunct professor at Westfield State University; and sits on a number of boards including the Human Services Program Advisory Board at Greenfield Community College; Department of Mental Health Site Board; Transitions from Jail to Community Core Task Force and Mental Health & Law Enforcement Board of Franklin County.

Levin is a cognitive behavioral therapist who has worked with a variety of client populations including: combat veterans, uniformed first responders, forensic populations, drug courts, couples, families, adolescents, and children. Levin specializes in providing Acceptance and Commitment Therapy (ACT) and Dialectical Behavioral Therapy (DBT); in addition he has extensive experience in large scale program implementation and evaluation.