Author: Levin Schwartz, LICSW

Check out our podcast episode on Incarceration and Traumatic Stress. I promise, it is not as boring as it sounds …. though I get it if you want to binge The Pitt instead 🙂

The International Society for Traumatic Stress Studies is dedicated to sharing information about the effects of trauma and the discovery and dissemination of knowledge about policy, program and service initiatives that seek to reduce traumatic stressors and their immediate and long-term consequences.

The blog can be found here if you want to here more.

As many of you know, I have spent the past 11 years working to support smart and evidence driven changes in the criminal justice system in Franklin County Massachusetts. After 11 years of full time work for the State, my family decided to pour ourselves into an immersive experience to learn another language (spanish) and give our children an opportunity to gain perspective about this beautiful world we live in.

In August 2024, I transitioned to a part-time contract position with an agreement to return to full time work in July 2025 at the Franklin County Sheriff’s Office.  However, with the recent retirement of Christopher J Donelan (1/31/25), I was notified on Monday (2/3/25) that the appointed Sheriff decided to not-renew my position.  Though this is somewhat expected, I can’t deny that I am sad to receive this news and troubled by the accelerated timeline – February 7, 2025 is my last day.

This closes a chapter on what has been one of the most rewarding professional experiences of my career – thus far.  Along the way not only did I get to work with some remarkable colleagues, but I also had the opportunity to work with countless amazing people in adjacent professions from across the country.

I want to take a moment to let you know how truly grateful I am to have had the opportunity to do this work.  I have evolved in so many ways because of the people I worked with and the opportunities to learn from it. I will cherish time and am grateful to have been part of the process of such important work – and excited about what comes next.

I plan to continue to work in the field of wellness and recovery, though I am not yet sure of exactly what form that will take.  My business, VBBS, LLC will continue to provide technical assistance and consulting, and I may expand to take on a small private practice or additional remote work in the short term … time will tell.

Once again, thank you for all that you do in this world.  I am very proud and humbled by the collective accomplishments and I look forward to what comes next.  There is some great work happening across the country at the intersections of wellness, addiction, mental health, trauma and incarceration. 

With my sincerest respect and gratitude,

Levin

The overrepresentation of people struggling with addiction and mental health is a well-known problem. If incarceration continues to be part of the solution, resourcing institutions to provide evidence-based treatment and transitional support post-release is clearly a more effective public health strategy than “tough on crime” strategies. The Franklin County Sheriff’s Office (FCSO) has made great strides toward this end, working to improve the lives of clients, their families, and the community. 

The Americans with Disabilities Act and the Opioid Crisis: Combating Discrimination Against People in Treatment or Recovery

NOTE: The information below is directly quoted from the DOJ publication – you can read below or click the hyperlink above to view the original document.

Date issued: April 5, 2022

The opioid crisis poses an extraordinary challenge to communities throughout our country. The Department of Justice (the Department) has responded with a comprehensive approach prioritizing prevention, enforcement, and treatment. This includes enforcing the Americans with Disabilities Act (ADA), which prohibits discrimination against people in recovery from opioid use disorder (OUD) who are not engaging in illegal drug use, including those who are taking legally-prescribed medication to treat their OUD. This guidance document provides information about how the ADA can protect individuals with OUD from discrimination—an important part of combating the opioid epidemic across American communities. While this document focuses on individuals with OUD, the legal principles discussed also apply to individuals with other types of substance use disorders.

1) What is the ADA?

The ADA is a federal law that gives civil rights protections to individuals with disabilities in many areas of life. The ADA guarantees that people with disabilities have the same opportunities as everyone else to enjoy employment opportunities,1 participate in state and local government programs,2 and purchase goods and services.3 For example, the ADA protects people with disabilities from discrimination by social services agencies; child welfare agencies; courts; prisons and jails; medical facilities, including hospitals, doctors’ offices, and skilled nursing facilities; homeless shelters; and schools, colleges, and universities.

2) Does an individual in treatment or recovery from opioid use disorder have a disability under the ADA?

Typically, yes, unless the individual is currently engaged in illegal drug use. See Question 5. The ADA prohibits discrimination on the basis of disability. The ADA defines disability as (1) a physical or mental impairment that substantially limits one or more major life activities, including major bodily functions; (2) a record of such an impairment; or (3) being regarded as having such an impairment.

People with OUD typically have a disability because they have a drug addiction that substantially limits one or more of their major life activities. Drug addiction is considered a physical or mental impairment under the ADA. Drug addiction occurs when the repeated use of drugs causes clinically significant impairment, such as health problems and or an inability to meet major responsibilities at work, school, or home. People with OUD may therefore experience a substantial limitation of one or more major life activities, such as caring for oneself, learning, concentrating, thinking, communicating, working, or the operation of major bodily functions, including neurological and brain functions. The ADA also protects individuals who are in recovery, but who would be limited in a major life activity in the absence of treatment and/or services to support recovery.

3) Does the ADA protect individuals who are taking legally prescribed medication to treat their opioid use disorder?

Yes, if the individual is not engaged in the illegal use of drugs. Under the ADA, an individual’s use of prescribed medication, such as that used to treat OUD, is not an “illegal use of drugs” if the individual uses the medication under the supervision of a licensed health care professional, including primary care or other non-specialty providers. This includes medications for opioid use disorder (MOUD) or medication assisted treatment (MAT). MOUD is the use of one of three medications (methadone, buprenorphine, or naltrexone) approved by the Food and Drug Administration (FDA) for treatment of OUD; MAT refers to treatment of OUD and certain other substance use disorders by combining counseling and behavioral therapies with the use of FDA-approved medications.

Example A
A skilled nursing facility refuses to admit a patient with OUD because the patient takes doctor-prescribed MOUD, and the facility prohibits any of its patients from taking MOUD. The facility’s exclusion of patients based on their OUD would violate the ADA.

Example B
A jail does not allow incoming inmates to continue taking MOUD prescribed before their detention. The jail’s blanket policy prohibiting the use of MOUD would violate the ADA.

4) Does the ADA protect individuals with opioid use disorder who currently participate in a drug treatment program?

Yes. Individuals whose OUD is a disability and who are participating in a supervised rehabilitation or drug treatment program are protected by the ADA if they are not currently engaging in the illegal use of drugs. See explanation in Question 5. It is illegal to discriminate against these individuals based on their treatment for OUD.

Example C
A doctor’s office has a blanket policy of denying care to patients receiving treatment for OUD. The office would violate the ADA if it excludes individuals based on their OUD.

Example D
A town refuses to allow a treatment center for people with OUD to open after residents complained that they did not want “those kind of people” in their area. The town may violate the ADA if its refusal is because of the residents’ hostility towards people with OUD.

5) Does the ADA protect individuals who are currently illegally using opioids?

Generally, no. With limited exceptions, the ADA does not protect individuals engaged in the current illegal use of drugs if an entity takes action against them because of that illegal drug use. “Current illegal use of drugs” means illegal use of drugs that occurred recently enough to justify a reasonable belief that a person’s drug use is current or that continuing use is a real and ongoing problem. Illegal use, however, does not include taking a medication, including an opioid or medication used to treat OUD, under the supervision of a licensed health care professional.

Example E
A mentoring program requires its volunteers to provide test results showing that they do not engage in the illegal use of drugs. The program dismisses a volunteer who tests positive for opioids for which the volunteer does not have a valid prescription. This does not violate the ADA because the dismissal was based on current illegal drug use.

In addition, an individual cannot be denied health services, or services provided in connection with drug rehabilitation, on the basis of that individual’s current illegal use of drugs, if the individual is otherwise entitled to such services. But a drug rehabilitation or treatment program may deny participation to individuals who engage in illegal use of drugs while they are in the program.

Example F
A hospital emergency room routinely turns away people experiencing drug overdoses, but admits all other patients who are experiencing emergency health issues. The hospital would be in violation of the ADA for denying health services to those individuals because of their current illegal drug use, since those individuals would otherwise be entitled to emergency services.

Example G
A drug rehabilitation program asks a participant to leave because that participant routinely breaks a rule prohibiting the use of illegal drugs while in the program. This is not discrimination under the ADA because the program can require participants to abstain from illegal drugs while in the program.

6) Does the ADA protect individuals with a history of past opioid use disorder, who no longer illegally use drugs?

Yes. The ADA protects individuals with a “record of” disability. As explained above in Question 2, OUD typically qualifies as a disability. Therefore, individuals with a “record of” having OUD usually will be protected under the ADA. Individuals would fall into this category if they have a history of, or have been misclassified as having, OUD.

Example H
A city terminates an employee based on his disclosure that he completed treatment for a previous addiction to prescription opioids. The city may be in violation of the ADA for discriminating against the employee based on his record of OUD.

7) Does the ADA provide any legal protections for individuals who are regarded as having an opioid use disorder, whether or not they actually have an opioid use disorder?

Yes. The ADA protects individuals who are “regarded as” having OUD, even if they do not in fact have OUD.

Example I
An employer mistakenly believes that an employee has OUD simply because that employee uses opioids legally prescribed by her physician to treat pain associated with an injury. The ADA prohibits an employer from firing the employee based on this mistaken belief.

8) Does the ADA protect individuals from discrimination based on their association with individuals who have opioid use disorder?

Yes. The ADA protects individuals from discrimination based on their known association or relationship with an individual who has a disability, such as a friend, coworker, or family member. The ADA also protects organizations, such as OUD treatment clinics, from discriminatory enforcement of zoning rules based on the organization’s known association with or relationship to individuals with OUD.

9) Can employers have a drug policy or conduct drug testing for opioids?

Yes. Employers may adopt or administer reasonable policies or procedures, including drug testing, designed to ensure that individuals are not engaging in the illegal use of drugs. However, some individuals who test positive for an opioid, which may include MOUD, will be able to show that the medication is being taken as prescribed or administered and a licensed health care professional is supervising its use. These individuals may not be denied, or fired from, a job for this legal use of medication, unless they cannot do the job safely and effectively, or are disqualified under another federal law.

10) What can I do if I believe I have been discriminated against because of my opioid use disorder or treatment for my opioid use disorder?

Individuals may file a complaint with the Department of Justice if they believe that a public accommodation or a state or local government is discriminating or has discriminated against them because of OUD. Individuals may also bring private lawsuits under the ADA.

Information about filing an ADA complaint with the Department is available at civilrights.justice.gov. More information about the ADA is available by calling the Department’s toll-free ADA information line at 800-514-0301 or 800-514-0383 (TTY), or accessing its ADA website at ada.gov.

Complaints about a state or local government’s programs, services, or activities relating to the provision of health care and social services can also be filed with the Department of Health and Human Services Office for Civil Rights (HHS OCR). Information about filing an HHS OCR complaint is available at hhs.gov/civil-rights/filing-a-complaint, by email at OCRMail@hhs.gov, by phone at 1-800-368-1019, or at 1-800-537-7697 (TTY).
Complaints about employment discrimination (called “charges”) on the basis of disability can be filed with the Equal Employment Opportunity Commission (EEOC). Information about filing an EEOC charge is available at eeoc.gov or 800-669-4000, 800-669-6820 (TTY), or 844-234-5122 (ASL Video Phone). Additional EEOC resources regarding employees and opioid use are available at eeoc.gov/laws/guidance/use-codeine-oxycodone-and-other-opioids-information-employees and eeoc.gov/laws/guidance/how-health-care-providers-can-help-current-and-former-patients-who-have-used-opioids.

Individuals who believe they have been discriminated against under the ADA and would like to file a complaint should file as soon as possible. For instance, there are specific filing deadlines for a charge of employment discrimination, either 180 days or 300 days from the date of the alleged discrimination, depending on the jurisdiction where the charge is filed.

11) Where can I find treatment for opioid use disorder?

Information about treatment for opioid use disorder is available at hhs.gov/opioids, findtreatment.gov, samhsa.gov/medication-assisted-treatment/practitioner-program-data/treatment-practitioner-locator, and dpt2.samhsa.gov/treatment.

42 U.S.C. §§ 12111-12117. The Equal Employment Opportunity Commission (EEOC) and the Department of Justice jointly enforce the ADA’s ban on employment discrimination. For more information or to file a complaint of employment discrimination, visit eeoc.gov.
Id. §§ 12131-12134.
Id. §§ 12181-12189.
Id. §§ 12112, 12132, 12182.
Id. § 12102(1)-(2).
28 C.F.R. §§ 35.108(b)(2), 36.105(b)(2). Regulations implementing Title I of the ADA define the term “physical or mental impairment” as including “any physiological disorder or condition.” 29 C.F.R. § 1630.2(h).
See Substance Abuse and Mental Health Services Administration, Mental Health and Substance Use Disorders, samhsa.gov/find-help/disorders (last visited Apr. 1, 2022).
42 U.S.C. § 12102; 28 C.F.R. §§ 35.108(c)(1) (listing examples of major life activities, which include the operation of major bodily functions), 36.105(c)(1) (same).
28 C.F.R. §§ 35.108(d)(1)(viii), 36.105(d)(1)(viii).
42 U.S.C. § 12210(d); 28 C.F.R. §§ 35.104, 36.104.
See Substance Abuse and Mental Health Services Administration, TIP 63: Medications for Opioid Use Disorder, store.samhsa.gov/product/TIP-63-Medications-for-Opioid-Use-Disorder-Full-Document/PEP21-02-01-002 (last visited Apr. 1, 2022); see also Health Resources and Services Administration, Caring for Women with Opioid Use Disorder: A Toolkit for Organization Leaders and Providers, hrsa.gov/sites/default/files/hrsa/Caring-for-Women-with-Opioid-Disorder.pdf (last visited Apr. 1, 2022).
See Substance Abuse and Mental Health Services Administration, Medication-Assisted Treatment (MAT), samhsa.gov/medication-assisted-treatment (last visited Apr. 1, 2022); see also Substance Abuse and Mental Health Services Administration, MAT Medications, Counseling, and Related Conditions, samhsa.gov/medication-assisted-treatment/medications-counseling-related-conditions (last visited Apr. 1, 2022).
42 U.S.C. § 12210(b)(2); 28 C.F.R. §§ 35.131(a)(2)(ii), 36.209(a)(2)(ii).
42 U.S.C. § 12210(a); 28 C.F.R. §§ 35.131(a)(1), 36.209(a)(1).
28 C.F.R. §§ 35.104, 36.104.
42 U.S.C. § 12210(d); 28 C.F.R. §§ 35.104, 36.104.
42 U.S.C. § 12210(c); 28 C.F.R. §§ 35.131(b)(1), 36.209(b)(1).
28 C.F.R. §§ 35.131(b)(2), 36.209(b)(2).
42 U.S.C. § 12102(1)(B); 28 C.F.R. §§ 35.108(a)(1)(ii), 36.105(a)(1)(ii).
42 U.S.C. § 12102(1)(B); 28 C.F.R. §§ 35.108(e), 36.105(e).
42 U.S.C. § 12102(1)(C); 28 C.F.R. §§ 35.108(a)(1)(iii), 35.108(f), 36.105(a)(1)(iii), 36.105(f); see also 42 U.S.C. § 12201(h); 28 C.F.R. §§ 35.130(b)(7)(ii), 36.302(g); 29 C.F.R. § 1630.2(o)(4) (noting that individuals who meet the definition of “disability” solely because they are “regarded as” disabled are not entitled to reasonable modifications or reasonable accommodations under the ADA).
42 U.S.C. § 12112(b)(4); 42 U.S.C. § 12182(b)(1)(E); 28 C.F.R. §§ 35.130(g), 36.205; 29 C.F.R. § 1630.8.
42 U.S.C. §§ 12114(b), 12114(d); 29 C.F.R. §§ 1630.3(c), 1630.16(c); see also 42 U.S.C. § 12210(b); 28 C.F.R. §§ 35.131(c), 36.209(c) (drug testing by Title II and Title III entities).
24 See, e.g., 42 U.S.C. § 12111(3); 29 C.F.R. §§ 1630.2(r), 1630.15(b)(2), 1630.15(e).

The Americans with Disabilities Act authorizes the Department of Justice to provide technical assistance to individuals and entities that have rights or responsibilities under the Act. This document provides informal guidance to assist you in understanding the ADA and the Department’s regulations.

The contents of this document do not have the force and effect of law and are not meant to bind the public in any way. This document is intended to provide clarity to the public regarding existing requirements under the law or Department policies.

The standard metric people use to measure effect size for incarceration is recidivism.  It is important because it is the commonly referred to term for determining the effectiveness of policies and programs to prevent post-release criminal behavior. However, the success of someone leaving jail expands far beyond scope of recidivism.  In our work we have seen that someone’s overall well being, sense of hope, clarity of who and what is most important to them, and sense of connection to chosen community is pivotal to successful reentry after incarceration.  

In this publication, “The Limits of Recidivism,” the authors make a compelling case that we need to expand our definition of what success means – I mean consider this – if our metric of success is recidivism, an individual who dies after being released from jail has a positive result for recidivism numbers as that individual is no longer alive and hence commits’ no further crimes. I don’t mean to disparage recidivism as an outcome metric – it is important and good researchers will be able to control for this variable for sure, however it is not simply the only outcome measure we should be thinking about.

I will return to the topic of recidivism, after considering another way to think about results coming in the form of narratives.

Case Study 1:

“On Tuesday we received a call from a client.  They self-reported that they were at a Restaurant, and was ready to hurt the manager.  The client’s tone of voice and manner of speech on the phone were congruent with a person experiencing anger and emotional distress. The client said that they were tired of being mistreated and was fed up.  We asked the client to remain on the phone with at all times. The client made comments stating that they were near the dish-sink area of the restaurant, there were no security cameras, and that they knew that if they acted, they would never get out of jail again.  The client said that they wanted to get revenge on the manager, and the client’s tone and manner of speech sounded serious. 

We asked the client to please leave the restaurant while remaining on the phone and the client accepted. We asked the client to slow down and explain the situation again while walking away from the restaurant. As the client was telling his story, we gently reframed statements about the event into the past tense ‘back then, when you felt that, you…’  This approach motivated the client to contact the present moment, and was then reinforced through prompting questions like, “and now what do you see around you, can you feel your heart beating, can you feel the pavement under your feet, etc…’  After this the client engaged in perspective taking processes, identifying how hurting the manager could have escalated to the point that it would be awful for the children at the restaurant to witness the violence.  The client then tracked their experience, stating that they were about to lose it when they decided to call for help.  We thanked the client for calling and told them that it is clear, that deep inside they knew what they wanted to be moving toward, and that calling for support was a step in that direction. We validated that the client was agitated by the way they were talked to, looked at, and treated by the manager.  They said that they had a history with the management who were not involved in good things.  Then we worked to transform the function of the pain into something worth having – it was clear that the client had some very important values and that their pain/anger was only there because they cared about something very much.  We wondered with the client, were they also moving toward something when they left the restaurant?

We continued to speak with the client on the phone and we talked about what a toward move could be – what values are important to them right now, something that they could act on right now.  The client spoke about the risk of relapse, indicating that they often use substances when dealing with difficult situations. The client stated that they were committed to their recovery and said that they were going to walk to the local AA meeting to connect with other people in recovery. We spoke with the client for about one hour total and by the end of our conversation the client sounded more calm, grounded in next steps, and proud that they had walked out of the restaurant.  We talked about not returning to the restaurant and instead made a plan to look for a new job with supervisors who share similar values.  Later in our conversation they said that they were going to hang up to enter the meeting and connect with others in recovery.  We invited the client to please call the following day to make plans to meet in the morning.   We told him how impressed we were with their choices this evening.  The following day we met the client early in the morning and made a referral to a local outpatient therapist.”

In this case study you can see how interventions such as these help reduce the overconsumption of emergency and police and court involvement when someone is in a behavioral health crises.  It is hard to quantify the potential costs of an averted crisis, however hypothetically if the client in this scenario acted on their thoughts, this event would have set in motion:

• A traumatic incident potentially witnessed by patrons and employees of the restaurant
  • And whatever the long term costs of this might be.
• Emergency Medical Services (EMS) Response
• Police Response 
• Utilization of the hospital’s emergency room
• Incarceration at the local jail
• District attorney and defense bar engagement
• Court services at the district or superior court
• Potential trial by jurors
• Potential incarceration and probation supervision

Case Study 2:

“During a wellness check, a reentry client who was living in our residential post release program was found to be intoxicated.  A reentry case worker spoke with the client and observed that they were in violation of both our tenant agreement and their conditions of probation – and that the client needed report to his probation officer.  Simultaneously our case worker started working to secure the client a bed a treatment program; ultimately finding an available bed at a regional acute stabilization unit.  The probation officer asked that the client present to probation immediately after completing treatment.  

Detox is the first in line of a corridor of care: acute detox, the client was referred to Clinical Stabilization Services (CSS), then to a locked Transitional Support Services (TSS) where the client had to apply to three long term recovery programs (½ way houses) and go to the first bed available, which was ultimately a local long term recovery program.  Each step of the way the reentry case worker and probation officer worked together with the active case workers of each program.”  

The Assistant Chief Probation Officer at the time was supervising the case. They reported “Initially, I was not interested in discussing treatment anymore, they were already in violation status. The Reentry Case Workers from FCSO are here in the probation office daily, I allowed them to do their job. I was fully intending to ask for detention when the client came back into the court. However, by the time the client came back they had completion letters from all three treatment programs and a new look about themself.”   

In this case, we worked with the Probation Department and their thinking evolved. Initially, they wanted to send the client back to jail for one year at the HOC. Instead, they supported the client’s process: participating in treatment, successfully completing all programs designed to support their recovery, and ended up completing probation.

Returning to the metric of recidivism, it has been a helpful tool at the mezzo and macro levels as it helps legislators and policy makers think about resource allocation. 

Lets look at our recidivism data at the Franklin County Sheriff’s Office, Greenfield MA:

In 2011 we started working with a consultant (another MSW, Kevin Warwick of Alternative Solutions Associates, inc.  https://alternativesolutionsassociates.com/about-us/) to conduct 10 years of recidivism analysis on people who were released from FCSO.  When implementing the work with this population, it always felt unethical to conduct a randomized controlled study as we felt all people deserved access to our most advanced treatment modalities.  As such, the study that was conducted was a natural experiment of those individuals exposed to the intensive treatment program and to those who were not for various natural reasons.

We defined recidivism as someone who left the Franklin County Sheriff’s Office and was reincarceration anywhere in Massachusetts after release from FCSO within a specific date range for 1) conviction of a new crime, and/or 2) a violation of a condition of probation for which they returned to incarceration.  Information for this analysis was gathered utilizing the Massachusetts Criminal Justice Information System (CJIS) – a state wide system that anyone can access.

Measures:

Recidivism was calculated by dividing the number of former sentenced inmates who recidivated by the number who were released during 2013 to 2018 while comparing the rate to the baseline rate of recidivism.

Results:

The control group is the baseline cohort of 2011 and the experimental groups included sentenced individuals released from custody from FCSO between 2013 through 2018.  

Our baseline study was the control group. The yearly recidivism rate for the 133 clients released in the calendar year of 2011 – before evidence based treatment existed at FCSO, was a one year recidivism rate of 23.7%.  Using the same methodology for each year, we analyzed the yearly recidivism rates for each of the clients who left the facility from 2013-2018, showing a modest reduction each year as compared to the baseline.

This slide shows similar data, except that we looked at two years worth of data.  The control group showed a two year recidivism rate of 45.5% – almost double the one year rate.  Using the same methodology for each year, we analyzed the yearly recidivism rates for each of the clients who left the facility from 2013-2017, showing a more sizable reduction each year as compared to the baseline.

This slide shows similar data, except we looked at three years worth of data.  The control group showed a three year recidivism rate of 53%.  Using the same methodology for each year, we analyzed the yearly recidivism rates for each of the clients who left the facility from 2013-2015, showing a reduction each year as compared to the baseline.

Based upon these metrics, FCSO achieved a reduction in recidivism by 39.2% .

Measuring success in this field is very hard and filled with many contradiction and inconsistencies, but one thing remains perfectly clear – the people that we serve deserve to receive the best, most humane and effective treatment/care available.

In Depth Magazine, Fall 2023

Story by: Tynan Power

I am very grateful to be featured in the Fall 2023 InDepth Magazine. Tynan Power and Smith College School for Social Work featured social workers caring for people at the intersection of criminal and legal involvement.

Click here to download the article

How are decisions made about what type of treatment a person participates in when incarcerated?

This infographic (below) represents the assessment process for an individual at the intersection of criminal and legal involvement.  When an individual is found guilty of a crime and then sentenced to jail, current best practices involve the person participating in a Risk/Need/Responsivity assessment. Some parts of this assessment are very well evidenced; however there some spin-off’s of the assessment I have questions about – particularly the part that determines what specific treatment modalities to offer.

The assessment is done in order to find out (among other things) three categories of things:

1. What the individuals “Risk” is to engage in future illegal activity?
2. What are the 8 “Need” areas that could result in future illegal activity and should be targeted for treatment?
   • History
   • Thinking/beliefs
   • Personality
   • Peers/Social
   • Supports
   • Harmful substance use
   • Family/marital
   • Relationships
   • School/work
   • Recreation
3. What are the unique characteristics of a person so that treatment can be tailored to fit the client’s needs – “Responsivity”
   • Level of motivation
   • Mental health needs
   • Unique strengths
   • Learning style
   • Mental health needs
   • Etc…

Some agencies in MA then use this assessment to then assign specific CBT protocols that the person has to participate in; which are somehow determined to address the specific need areas (look at the middle part of the picture above, highlighted in yellow).

Their thinking/process looks something like this:

1. Person scores Very High on assessment –> that means that they will have to complete 250+ hrs of treatment (dosage rule)
2. The person’s need areas that were scored high were (for example):
   • Antisocial cognition
   • Antisocial peers
   • Antisocial personality
   • Substance Use
   • Family/Marital
   • Leisure/Recreation
3. Then the client has to participate in a series of set curriculums that are somehow determined to address the specific need areas. (need rule)
   • During groups, the facilitator considers the person’s characteristics (responsivity rule)

I am curious about the scientific process used to measure, and then determine, if a specific protocol can be used to address a specific RNR need area (e.g., “cognition” vs. “personality” vs. “substance misuse”).  After ten years in the field, I remain confused by this process.  Here in MA, some state agencies make determinations that says specific protocols only address certain need areas …. (insert confused face with a question mark above my head) 😊. I am genuinely confused – how do you work with someone to support their recovery from harmful substance use, without addressing how one thinks, who one hangs out with, what type of social supports they have and what they do with their spare time?

Analogous to this line of thinking is like going to the gym to exercise. Its as if I went to the gym and wanted to work out my different muscle groups – I would do exercises that target specific areas of the body. This makes perfect sense for the body but that is not how the mind/psychology works.

Is there a scientific process here? I have reached out to a number of research agencies and will update this blog post as I learn more.

Basically, I am dubious of this logic and am concerned agencies are making decisions without good guidance – which has significant consequences for people and the community.  I contend that if someone is going to be incarcerated then they should be provided scientifically driven interventions that help the participants and ultimately the community. 

Despite my concern, I hold open the door that maybe I am wrong and there are scientific strategies to make these determinations.  I have reached out to a number of research agencies and will update this blog post as I learn more.

It is critical to ground oneself in up to date, evidenced models of care that help one understand the function of behavior in context.  Stepping out of biased, moral judgment traps is important both to the client and to the staff member – working with people at the intersection of criminal and legal involvement is riddled with judgment bias.  All in all, I have found that thinking about behavior in context to be a very helpful frame for both assessment and intervention on the personal, systemic and policy levels – a natural fit for social workers.  

Russ Harris, PhD explains this concept really well – particularly on the personal/evolutionary level – you can find some of his videos here.

The Function of Behavior in Context

If we zoom out a bit, we can think about most behaviors as falling into two buckets –generally as behaviors that either move us toward or away from experiences. 

There are away moves, behavior under adverse control, things that you do to move away from something you don’t want. These actions are not inherently good or bad, they just function to move away from an experience (think of some of the more benign actions, such as taking aspirin when one has a headache, or drinking coffee to get away from feeling tired). These are short term solutions driven by relief seeking, which are often very effective in the moment AND explain a lot of the behavior we see in the behavior connected to addiction.

• When a person who has overdosed decides to use the same substance shortly after in order to avoid the withdrawal symptoms;
• People who have experienced trauma using substances to numb the painful memories; 
• People who act violently because they are feeling scared, judged, angry;
• People who opt out of participating in group events (e.g., AA or NA, etc…) because they feel uncomfortable in a crowd.

The catch is that these strategies work (with various degrees of effectiveness)– IN THE SHORT RUN. Remember, away moves are neither good or bad in and of themselves; it depends upon the function of the behavior in a specific context.

Then there is behavior under appetitive control, things that you do to move toward who/what is most important. These are long term solutions, which require committed action – on a moment to moment, ongoing basis, such as being a:

• Loving husband; 
• Caring, nurturing father; 
• Dependable worker;
• Patient friend.

It is not just individuals – agencies are governed by these same controls, where success is defined by the absence of adverse consequences.

• Incarceration, probation, parole, etc…
  • Completing a sentence, completing probation/parole
• The behavioral health field
  • Someone comes to treatment and through therapy their symptoms no longer bother them.

There is significant evidence to suggest that long term behavioral change is not just connected to the absence of adverse control but the development of appetitive controls – in other words engaging in behaviors that connect to a sense of meaning and purpose is one’s life. Research also shows that one’s subjective sense of suffering is preceded by a return to appetitive behaviors – meaning – we need not wait to feel better before doing the things in our lives that are important; and moreover, the act of engaging in meaningful ways actually leads to a reduction in suffering. 

If you want to read more about this perspective, here is the referenced research paper. Gloster, A.T.,Klotsche, J., Ciarrochi, J., Eifert, G., Sonntag, R., Wittchen, H.U., Hoyer, J. (2017). Increasing valued behaviors precedes reduction in suffering: Findings from a randomized controlled trial using ACT. Behaviour Research and Therapy, 64-71. 

I find this work inspiring in so many ways but I have a particularly sweet spot for the young humans connected to people who are incarcerated.  When someone is incarcerated it effects a whole system of people – and the one’s most fundamentally effected are probably the children.  One of the questions on the Adverse Childhood Experiences questionnaire that looks at household dysfunction is – “Did you live with anyone who went to jail or prison?”

If you are unfamiliar with the importance of this groundbreaking research, check out this website from the centers for disease control and prevention.  And if you want something a little less technical, here is a cool piece from the National Public Radio.   Essentially the higher the score (i.e., the rougher the childhood) the higher the risk for various health problems later:

So, seriously, how do we interrupt this cycle for the children of parents who are incarcerated?  I think there are some experiences that I have had that inspire me to believe that this is possible. 

For many years I have been fortunate to work with a team of people who really get this, and are committed to working to mitigate this family disruption (when appropriate – there are unfortunately incarcerated people whose behavior has had adverse [and at times tragic] consequences for their family).

We host regular family events for people who are incarcerated – usually 4x’s/year; typical events coalesce around holidays such as: mother’s and father’s day, 4th of July, Halloween, and end of year celebrations such as Christmas or Hanukah.  Another activity that one of our fantastic clinicians organized is an ongoing group called “staying connected.” This is a group for incarcerated people to stay connected with their children, spouses, family and friends to ensure healthy relationships are maintained while an individual is incarcerated.  These types of experiences help to ensure that people being released back into the community have a better chance of having established positive support systems.  The group is constantly evolving to better fit the needs of clients and their families.  This group model covers really important topics designed to support the values of being a loving, nurturing and present father/mother – even while a person is incarcerated:

• Discussion about what is family, who we consider to be our family, ages of children, what do our children like… characters, games, etc.
• What do we tell our children about incarceration, what message are we sending
• Typical ways we already stay connected with our family and children while incarcerated.
  • Letters
  • Phones
  • Visits
• Exploring ways to stay connected through the mail, how to write an age appropriate letter for your child
• Games to be played through the mail – battleship, tic tac toe, hangman, dots
• Coloring pages to send to children – their favorite characters, client colors half, the child can finish the picture at home.
• Provide pictures and games for the clients
• Always tailor curriculum to upcoming holiday or special event.  Couple times a year bring in things to make cards for birthdays/anniversaries/thinking of you/graduations, etc
  • Cards for Mothers Day, Fathers Day, Valentines Day
  • Coloring pages for Easter, Thanksgiving, Christmas, Spring, Summer, Fall, Winter
• Discuss movies that their children are talking about, what is an age appropriate movie for children
• Make a list, vote on which children’s movie to watch.
• Provide coloring pages which relate to the movie.
• Discuss Children’s books
• Teacher clients how to pick an age appropriate book and how to read to their children (Andre)
• Provide client with facetime or video client reading book to child… sent video and book to child

Another important area of work potentiating family/social connection is organizing community events for people who have been released.  This past year our team hosted a “spring fling” where all of the people who continue to receive support post release were invited to a community celebration.  These events typically bring 50-100 participants together to celebrate the joy of being together.  I have found that with this population, people are most at risk when they internalize stigma and they are living in relative isolation.  This fusion with the thought that one is “less than/not good enough” – the internalized result of stigma and bias – can stand in for “reasons” to act on [insert ineffective behavior here].  People will say they get the “fuck-its, if you think I am this bad then I might as well act that bad.”  These events are meant to bring people together and for them to hear the message that they are more than the worst moments of their past and that they deserve community and to be celebrated.  This is a form of functional validation – they are worthy of celebration!

One year the FCSO hosted a holiday party for clients who have been released.  We rented out a local church basement and invited all people who have been released back to celebrate the holidays with us.  85 former clients came with their families (mothers, fathers, brothers, and children).  We served food, holiday music, had presents for their children, kids activities and raffle prizes.  I find these events remarkable – how many former incarcerated people would you guess would come back to a sheriff’s office event after they have been released?  It is an indication to me that we continue to be on the right track of implementing a trauma responsive environment.

More than anything the participants attending these events came because they felt like it was safe.  Despite the reason why they ended up in jail, they encountered staff that genuinely cared about helping the client take the unwanted stimulus of incarceration and use it as a catalyst to clarify what matters most to them and use awareness to move toward who and what matters most to them.  In a heartbreaking moment, one of our clients showed up in the lobby with their partner holding their newborn child.  The client was so happy to share their joy with staff and particularly the manager of the treatment unit at the time, sadly stating that they wanted to introduce the newborn to “the only family I know.”