There is inherent tension when finding the middle path through the two dialectical points of view of incarceration and liberation. Carrying this weight after many years is probably the biggest challenge.
A good example of this is when COVID-19 was tearing through our western MA counties in early 2020. We were able to quickly pivot and successfully adapt programming because of its history of applying public health approaches to address the opioid epidemic – the Franklin County Sheriff’s Office (FCSO) is among the first jails nationwide to provide correctional populations with access to all three medications to treat opioid use disorder (MOUD, i.e., buprenorphine, methadone, naltrexone). FCSO’s COVID-19 mitigation measures were highly effective – FCSO had no COVID-19 outbreaks until late 2021 and the incarcerated population at FCSO had a 91% uptake of vaccination due to our vaccine education strategy – DPH was estimating that 10% of the incarcerated population would take the vaccine while incarcerated. For more information about this, please see this article published in the Journal of Substance Abuse Treatment.
In March 2020, Massachusetts Supreme Judicial Court mandated the release of non-violent pre-trial detainees, resulting in rapid de-population of the jail. From March 12, 2020 to May 10, 2020, the jail’s average daily count decreased from 205 to 131. While the rapid releases were suitable given the circumstances, the majority of the clients released had complex health and psychosocial needs:
About 41% of individuals rapidly released were on Medication for an Opioid Use Disorder (MOUD) – meaning they needed medication within 24 hours of their last dose or they could begin to experience adverse symptoms associated with withdrawal (note: methadone/buprenorphine users are advised to detox in a medical environment). We were given typical only a matter of hours notification that someone would be leaving.
For example, an individual scheduled for rapid release was unhoused (their plan was to live in a tent if released), was on methadone, insurance was inactive, didn’t have a car, needed transportation from the court to a rural town to pick up their belongings, and was on a GPS monitoring bracelet issued by the court (remember they were living in a tent – and they had no means to charge the bracelet – and if the battery runs out the court views this as a violation and a warrant for their arrest will be issued and they will be sent back to jail). So within 2 hours, if we were not able to activate their insurance, figure out a way for them to charge their GPS bracelet, connect the client with a methadone provider and figure out how they were going to get to the methadone clinic, the person would be going through severe withdrawals, living in a tent, in March 2020.
Would the client not have been safer spending a few more days at FCSO while we established proper aftercare support, rather than being rapidly released without any support established – this is the dialectic that can be challenging at times. Are there times when it is safer for a person to be in jail than out in the community? Many clients say yes; despite my emotional mind’s objection.
Of course, I want people to have their liberty but more than that, I want people to be alive.
Holding this level of complexity is required of social workers who work within the prison system – and it is complicated and easily leads to burn out. It is easy for these environments to chafe up against the social work values of social justice, dignity and worth of the person and service (who exactly am I serving in this environment). If incarceration is going to play a role in “the solution” to criminal activity, these systems must adopt modern evidence-based behavioral health trauma responsive strategies to transform what has objectively been historically ineffective “correctional” environments.
There is wisdom found in so many places, perhaps even from the great fictional character Jean-Luc Picard, “change always later than we think it should,” …. “as much as people try to provoke change, or dictate when it should arrive, it comes precisely when it needs to. It’s never too late for change to occur.” And currently, change is happening because it needs to! So I will continue to show up as we make this road by walking – lets continue to work to support the transformation of carceral systems in an effort to move toward effective modern evidence based treatment environments.
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.
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.
This environment is particularly well suited for social workers; on any given day I am challenged to intervene on a micro, mezzo and/or macro level and to be mindful of person-in-environment and contextual behavioral factors while working to support incarcerated people. Whether it is providing trauma responsive treatment with an incarcerated person; designing, implementing and evaluating treatment interventions or leading an integrated treatment team, or engaging in legislative advocacy and presentations at the community, state and/or national level, this work is well suited for a social worker.
Contextually, our politically elected leadership sets the paradigm, tone and context for how people are treated in the environment. Sheriff Christopher Donelan (initially elected in 2011) is the reason why we were able to develop a locked treatment facility. He wanted to move away from a paradigm of punishment, or even containment, and toward an environment that could achieve public safety through treatment.
Unfortunately we are all too familiar with the revolving door of incarceration. In 2015, the Council for State Governments conducted a justice reinvestment analysis in MA and discovered that 60% of clients in county correctional systems have been incarcerated 5 to 11 or more times.
It is a positive feedback loop; according to actuarial assessments that measure a person’s likelihood to recidivate, the more often a person has been incarcerated, the more likely they are to recidivate. The carceral system has compounded the problem by inadvertently reinforcing institutionalized narratives and fusion with a ‘criminal’ self-identity in clients. There are few people more fused with their self story than folks who are incarcerated, their story has been so rehearsed due to the institutionalized nature of their lives.
Punishment and adverse control strategies became the society’s primary method of behavioral change (think school to prison pipeline) – it has been a tragic failure. Correctional systems were historically built from a ‘security’ lens rather than a ‘treatment’ lens; operating from a hierarchical, top down model, which created artificial ‘silos’ – dividing people…department vs department…staff vs. inmate … community from facility. Security staff had little to nothing to do with behavioral staff and vise versa. The community had little to do with the facility and vise versa. This system lacked collaboration… it blunted communication between the different departments.
Once one understands the set and setting of the problem, it allows for opportunities to transform the environment: What time lights go out so people got enough sleep; providing a better nutritional diet; more opportunities to mind one’s health; modern evidence based clinical programming, treatment of trauma and addiction, creation of a therapeutic step down community; developing opportunities for clients to connect with appetitive behaviors (guitar lessons, yoga, acting, art, gardening, exercise). Transforming the context of incarceration from a top down approach to a hub and spoke model – with the client at the center – allows for person centered treatment. Move away from terms like ‘inmate’ and replaced it with ‘client.’ This approach allows for an integrated behavioral health model, which allows all departments to work together as one
Prior to my career as a social worker, I was a touring musician. This experience enabled me to see the exquisite diversity and beauty of the United States and also witness the devastating effects of addiction, trauma, and individual and systemic racism – I am conscious that if not for my many privileges, my life course would likely be very different.
Early in my social work career I worked with military combat veterans experiencing the persistent effects of traumatic events and learned effective evidence-based strategies to successfully treat addiction and trauma. In my current work with incarcerated populations, I see similar trauma histories and health conditions; however, the typical cause is not experiences of war but social disadvantages, social stigma/bias, and systemic racism. Both populations have similar life trajectories: addiction, difficulty pursuing positive life goals, and ineffective coping skills. Both populations greatly benefit from similar evidence-based strategies to treat co-occurring addiction and trauma. First-hand experience of their effectiveness is my motivation to implement evidence-based treatment strategies in correctional environments. This approach is aligned with my personal and professional values: advancing social justice, valuing the dignity and worth of each person and engaging in relationships and social connections as vehicles for healing and change.
This post is an invitation to join me into the land of social work within the context of carceral environments. These blog posts are an outgrowth of a recent opportunity I had to respond to a series of questions posed by a journalist for the Smith College School for Social Work’s In Depth Magazine. The author took some of this content and is publishing a piece that will be coming out sometime this fall (2023) I think 🙂 I have chosen to publish the unabridged responses. I hope they provide some insight into the work being done; the transformation of more humane and just work with people at the intersection of trauma, addiction and criminal/legal involvement.
Back at Episode 26, Ed Hayes and Levin Schwartz of the Franklin County Sheriff’s Office in Western Massachusetts stopped by to share some snippets of their work behind the wall, their travels and education of best practices to states and counties that are not as forward moving as Franklin County, and the factual research behind the high levels of incarceration. With much left on the table, Ed and Levin return to continue the conversation and discuss the upcoming Federal Medicaid that will be available to incarcerated individuals in 14 states starting in 2025.
TO HELP OTHERS WE MUST FIRST UNDERSTAND WHAT THE JOURNEY ENTAILS
Did you know that until recently this treatment protocol was used in Massachusetts? It was a core treatment modality for many people with criminal and legal involvement. Thank you to our elected officials and representatives of the Trial Court for their recent collaboration to end this practice as of August 2023.
The MRT curriculum uses many images that should be forbidden in a treatment text because they could be triggering of people’s trauma. The pictures are poor quality, dehumanizing, racist, and reinforce the stigmatizing nature of addiction and justice involvement. Unfortunately, the text is no better. The language used to “explain” the problems the clients experience is infantilizing and stigmatizing. Built on Lawrence Kohlberg’s theory of moral development from the 1950’s, MRT posits that people’s criminal involvement is due to their moral failing. MRT 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.
The following images were taken from a draft document that was provided to our elected officials and advocacy groups to raise awareness about this concerning practice taking place in Massachusetts. Take a look for yourself:
Criminal Justice and Prison Reform may vary from State to State, but for those who understand that trauma is at the core of most incarcerated individuals, the key goal to their success, both behind the wall and upon returning to society, is to keep moving forward. Sadly, not all jails and prisons consider the value of moving incarcerated individuals forward. Thanks to researchers and change makers like Ed Hayes and Levin Schwartz, best practices and improved treatment of incarcerated individuals are being shared and implemented.
Presented February 2021 as a Social Work SIG sponsored webinar
Overview: Life is hard, even when we aren’t living through a pandemic. We all struggle; we all at times strive for something different. At times, I am certainly guilty of overlooking the magic that is happening right in front of me because my mind is filled with that “have to’s” and “musts” of the day. If I tune in, I frequently notice a well-rehearsed story in the background of my mind, full of corroborating evidence and facts for why I “must do X,” or the reasons for my “beliefs about Y.” In these times, the story I tell myself can close me off from being present and flexible. In these moments, the story seemingly justifies my non-presence or my unwillingness to DO something different – which may be important depending upon what I am overlooking in my environment. So, it all depends, which is why psychological flexibility is vital. Being flexible in how and what we attend to is the practice – and the point of this webinar.
Our time together will be spent first by cultivating a common understanding of cognitive defusion as practiced in Acceptance and Commitment Therapy. After this overview, the webinar will introduce you to a novel exercise referenced in Jill Stoddard and Niloofar Afari’s publication “The Big Book of ACT Metaphors https://www.newharbinger.com/big-book-act-metaphors. The experience of listening to music can provoke many powerful sensations, thoughts, experiences, evaluations, and judgments. Consider that this is what our minds naturally do – this is our mind programming and it is happening all the time. To facilitate the experience, you will be provided with a handout of the exercise and facilitation strategies to try out for yourself and with your clients.
Learning Objectives: Participants will learn a novel approach using music to facilitate experiential cognitive defusion as referenced in “The Big Book of ACT Metaphors,” by Jill Stoddard and Niloofar Afari. Participants will have the opportunity to practice the processes of psychological flexibility (i.e., cognitive defusion, acceptance, self as context, present moment awareness, values and committed action) by noticing how quickly our thoughts take us away from the present moment and to return to the present moment – over and over again.
I have been thinking a lot about how ACT can be applied in various aspects of social work. It is very clear to me that ACT can be a powerful tool to affect behavioral change in multiple contexts. The most obvious is in individual and group psychotherapy. There has been a tremendous amount of research and application toward this end.
I am curious what people think about ACT as it relates to case management – another primary focus of social work. Anyone anyone out there that is using ACT as a case management tool?
As the director of a program working with men and women leaving incarceration, I supervise a group of post release case workers who provide outreach services to our clients. While inside the facility, clients participate in DBT and ACT groups and receive individual therapy. Upon release, care is transferred to the reentry case workers (RCW’s) who help clients navigate the adversity of reentering society.
I would like to offer some tools that we have developed to help our RCW’s be effective. Special shout out to my colleagues Ruben Mercado-Lugo and Jenn Avery who co-created much of the material below.
First, I would like to frame the case management conversation in a tool that comes from Charlie Swenson’s comprehensive DBT training – you know an acronym is coming at you 🙂
FAVOR F – Focus A – Assess V – Validate O – Offer R – Reinforce
This acronym provides an easily accessible and memorable tool that orients the case worker to the processes involved in coaching a client through a difficult situation.
The first three processes are rather straight forward, however knowing what to “offer” comes from an accurate functional contextual assessment.
In the second process (assessing), there is a determination that needs to be made regarding the clients current state – what is the client able to functionally access? In the work that we do with individuals returning to the community from jail, we have found that there are many times when the volume of adversity a client is facing is extremely high, and a client can become highly dysregulated, at which point values/committed action work to be tricky/invalidating. At this point making a decision as to how to work with the client is vital.
Working with a client experiencing a high volume of adversity, we start with noticing, naming, defusing and accepting.
Credit: Ruben Mercado Lugo & Jenn Avery
However, if the client continues to be highly dysregulated, motivating the client to commit to the use of concrete skills to regulate can be helpful:
Credit: Ruben Mercado Lugo & Jenn Avery
If after that the client has become more regulated, value orientated actions can often be accessed as a higher degree of defusion has occurred, creating more space for choice. At which point perspective taking, values clarification, committed action and interpersonal effectiveness skills can be employed:
Credit: Ruben Mercado Lugo & Jenn Avery
Here is a picture of the whole model:
Credit: Ruben Mercado Lugo & Jenn Avery
Basically – there are times when a client has very little acceptance/defusion/present moment awareness/SAC of their emotional or cognitive state. At this point the case worker can assist the client to commit to putting “roadblocks” in their way so as to protect themselves from harmful, unproductive behavior. Roadblock strategies can include, but not limited to, many of the distress tolerance and emotional regulation skills offered through DBT skills modules.
Credit: Ruben Mercado Lugo & Jenn Avery
We have found that this strategy can be very effective in helping client move toward value driven behavior. It also frames the use of behavioral skills learned in DBT (and other modalities) as committed actions that can move clients toward vital workable lives.
Credit: Ruben Mercado Lugo & Jenn Avery
As always, I am interested in feedback and in particular, how do you conceptualize the processes found in ACT as applied to case work?
This webinar was completed for the Council of State Governments and the National Reentry Resource Center. Scaffolded by the functions and modes of DBT, and an overarching paradigm of contextual behavioral therapies, the Franklin County Sheriff’s Office in Greenfield MA has implemented an evidence based clinical reentry program.
