I will answer the question I promise 🙂 But first I need to say that most treatment protocols designed for working with people who are incarcerated are problematic. I think the primary root of this problem can be essentialized into three main points.
First, in the 1960’s an erroneous perspective led to carceral environments being divorced from our care continuum and set in course a two tiered system, one where the general public is provided treatment that conforms to standards of practice enshrined in the rules and regulations of Medicaid funding; and one that does not – carceral environments. This divide has blunted the ability for carceral systems to stay up to date with modern treatment modalities. Established in 1965, the Medicaid Inmate Exclusion Policy (MIEP) prohibited Medicaid from covering incarcerated individuals, despite any prior eligibility.
The Social Security Act (Sec. 1905(a)(A)) prohibits use of federal funds and services, such as Veterans Affairs, Children’s Health Insurance Program (CHIP) and Medicaid, for medical care provided to “inmates of a public institution.”
- Functionally this set up a wall around institutions (forgive the pun) that blunted these systems from being seen as part of the continuum of safetynet services.
- To manage treatment costs, many correctional facilities nationwide offer low-quality care that inadequately follows established clinical guidelines. While hospitals and clinics abide by the Center for Medicaid & Medicare Services guidelines, jails and prisons do not.
Second, outdated and stigmatizing perspectives about the character and morality of people in the justice system has stood in for racist and stigmatizing perspectives about the needs of this population – one example is Moral Reconation Therapy (MRT) – a protocol from the early 1980’s, used across Massachusetts by the Office of Community Corrections (a program of the trial court) until August 2023.
- From this lens, people who are incarcerated have been seen as moral failures struggling with character deficits. The language used to “explain” the problems the clients experience is often infantilizing and stigmatizing.
- MRT, for example, co-opted Lawrence Kohlberg’s theory of moral development from the 1950’s and used it to take the position that people’s criminal involvement is due to their moral failing – see one of my previous blog posts if you are interested to learn more about MRT.
- Another problematic treatment model used with this population is called “Charting a New Course.” This treatment protocol is built off of Dr. Samenow’s book “Inside the Criminal Mind,” which was written in 1984.
- Dr. Samenow posits that abuse, trauma, biology, socioeconomic status, addiction and parental involvement have little to no role in how a person turns out – all our actions are choices we make freely, regardless of genetics, environment, and/or upbringing. In this model, facilitators working with them are there to “teach them” – people working with them take the stance of an expert and clients have told me how invalidating of an experience it is.
At best, systems that choose to use these outdated treatment protocols, choose a method of treatment that shames and blames people struggling with trauma and addiction, and at worst, these systems weaponize flawed and outdated “evidence based” treatments to promote stigma and bias of people in the justice system.
Finally, conducting high caliber rigorous scientific studies within correctional environments is very difficult. The number of confounding variable are innumerable and correctional environments have historically not been the best research collaborators (shocking, I know). In order for the scientific community to be able to research and evaluate treatment technologies in carceral settings, facilities need to be better equipped to enter into research collaborations with universities and scientists.
This field of research in mental and behavioral health treatment in county correctional facilities is decades behind the curve and the people who are incarcerated need us to help move the field into the modern age.
Acknowledging this, institutions have tried to support the field by providing clearinghouses where practitioners can go to find “evidence based practices.” Pew Charitable Trust Results First Clearinghouse database, now operated by Pen State, catalogs treatment interventions using a three tier rating system. There are multiple data bases that comprise of the clearinghouse, however categorizing treatment modalities in this way is not without controversy – nor is it immune from misuse.
In 2018, SAMHSA suspended the NREPP (Peter G. Dodge Foundation, 2018) and declared its rating methodology unsupported (Green-Hennessy, 2018). Despite the statement from SAMHSA administration, discrediting the process used to qualify a program as evidence based, CCI continues to advertise MRT as a SAMHSA recognized research-based program (MRT, 2021).
Elinore F. McCance-Katz, MD, PhD, the Assistant Secretary for Mental Health and Substance Use at the time, stated that the NREPP was suspended because many of the treatment protocols were lacking a rigorous and peer-reviewed evidence base. “We at SAMHSA should not be encouraging providers to use NREPP to obtain EBPs, given the flawed nature of this system…. I see EBPs that are entirely irrelevant to some disorders, “evidence” based on review of as few as a single publication that might be quite old and, too often, evidence review from someone’s dissertation” (McCance-Katz, 2018).
Now to answering the question ….
Mindfulness based treatments tap into something that we intuitively know and already have inside of ourselves. On an experiential level, we have all had moments of being mindful. Put simply, being mindful is the action of creating space between stimulus and response. In that space there is choice – how do I choose to respond to this situation, rather than reacting impulsively. If I add to this a focus on values clarification and behavioral strategies to support acceptance, awareness and tracking of thoughts, perspective taking and value based committed action, now I am doing mindfulness based CBT.
Mindfulness based treatment is a modern, highly evidenced model for working with people. It is a transdiagnostic model, meaning that it is a helpful treatment beyond any one diagnosis and works to support the well being of people and to successfully navigate adversity in any form. However I would say that the most profound and important point mindfulness based treatment offers is the stance the clinicians take. A mindfulness based stance is one of mutuality and of non-confrontation; for a population as sensitive to invalidation as this one, the importance of this stance can’t be overstated; the philosophy of treatment can be exemplified by this story:
“We are all in this together – It’s like we are both climbing our own mountains that have lots of places where we can get stuck. My job is to watch out for you and to let you know if I can see places you might slip or hurt yourself. But I’m not able to do this because I’m standing at the top of your mountain, looking down at you. If I’m able to help you climb your mountain, it’s because I’m on my own mountain, just across a valley. Simply because I have a different vantage point, I can look across the valley and help see the places that could cause you to get stuck. I don’t have to know anything about what it is exactly to climb the mountain you are on to be able to see where you are about to step and what might be a better path for you to take.”
More than offering any particular protocol, we have designed the system to be a mindfulness based intensive treatment environment. The program at FCSO is a scientifically based model of treatment that emphasizes learning by doing. The overall process involves increasing one’s engagement in valued living while decreasing one’s struggle with pain. Science tells us that successful treatment must address the connection between trauma, harmful substance use, and also mental health. Research also tells us that helping people with their mental health and substance use can help keep people out of jail.
The program promotes values-consistent actions, development of skills to promote committed action toward specific goals and ultimately an increase in the quality of life for both the client and the community. Our treatment environment includes educational programs, vocational programs, group counseling, individual therapy, trauma responsive treatment and reentry services.
The core goals of our treatment communities are to:
• Promote a more holistic lifestyle
• To identify areas of value in individuals’ lives
• Develop skills to address unworkable personal behaviors–social, psychological, and emotional–that can lead to incarceration and substance misuse
• And to commit to actions that will move individuals toward a life worth living.
Activities are typically performed in groups. Peers have leadership roles within the community and uniformed and clinical staff facilitate and guide the process. The typical day is highly structured. Time is dedicated to community activities, clinical treatment groups, education classes, vocation classes, meals, chores and other responsibilities, and formal and informal interaction with peers and staff members. The usefulness of the treatment community model is that it offers multiple opportunities to integrate the lessons learned in treatment into workable ways of living.
We use both Dialectical Behavioral Therapy as well as Acceptance and Commitment Therapy as our two primary mindfulness based treatment strategies.
DBT is an evidence-based cognitive-behavioral treatment (CBT) originally developed in the 1970’s by Dr. Marsha Linehan and some credited as being the first psychotherapy to formally incorporate mindfulness. DBY is a treatment with two key characteristics: a behavioral, problem-solving focus blended with acceptance-based strategies, and an emphasis on dialectical processes. DBT emphasizes balancing behavioral change, problem-solving, and emotional regulation with validation, mindfulness, and acceptance of clients.
ACT is an evidence-based CBT treatment developed by Hayes, Strosahl, & Wilson, 1999. ACT is a contextually focused form of cognitive behavioral therapy that uses mindfulness and behavioral activation to increase a participant’s psychological flexibility — the ability to engage in values-based, positive behaviors while experiencing difficult thoughts, emotions, or sensations. ACT has been shown to increase effective action; reduce unhelpful thoughts, feelings, and behaviors; and alleviate distress for individuals facing a broad range of difficult experiences.
