Transcript Document

Residential Substance Abuse Treatment
(RSAT)
Training and Technical Assistance
April 12-13, 2011
Stephen K. Valle, Sc.D., M.B.A.,
Licensed Psychologist, LADC I, CADAC
This project was supported by grant No. 2010-RT-BX-K001 awarded by the Bureau of Justice Assistance. The Bureau of Justice Assistance is
a component of the Office of Justice Programs, which also includes the Bureau of Justice Statistics, the National Institute of Justice, the
Office of Juvenile Justice and Delinquency Prevention, the SMART Office, and the Office for Victims of Crime. Point of view or opinions in
this document are those of the author and do not represent the official position or policies of the United States Department of Justice.
Evidence-Based Integrated Modified
Therapeutic Community Model
Correctional Residential
Substance Abuse Treatment
(RSAT) Programs
PURPOSE:
• TO ENSURE THE MOST EFFECTIVE APPROACH IS
UTILIZED TO PROVIDE THE MOST SUCCESSFUL
OUTCOME FOR OFFENDERS BY INTEGRATING THE
HIGHLY EFFECTIVE EVIDENCED BASE TREATMENT
APPROACH WITH OTHER OEVIDENCED BASED
TECHNIQUES.
PRINICIPLES AND
STANDARDS
Evidence-Based Programs in Corrections
13 Principles of Drug Abuse Treatment for Criminal Justice Populations
Drug addiction is a brain disease that affects behavior.
1.Recovery from drug addiction requires effective treatment, followed
by management of the problem over time.
2.Treatment must last long enough to produce stable behavioral
changes.
3.Assessment is the first step in treatment.
4.Tailoring services to fit the needs of the individual is an important
part of effective drug abuse treatment for criminal justice populations.
National Institute on Drug Addiction
March 2011
www.drugabuse.gov
13 Principles of Drug Abuse Treatment for Criminal Justice Populations -continued
6.
Drug use during treatment should be carefully monitored.
7.
Treatment should target factors that are associated with
criminal behavior.
8.
Criminal justice supervision should incorporate treatment
planning for drug abusing offenders, and treatment providers
should be aware of correctional supervision requirements.
9.
Continuity of care is essential for drug abusers re-entering the
community.
National Institute on Drug Addiction
March 2011
www.drugabuse.gov
13 Principles of Drug Abuse Treatment for Criminal Justice Populations -continued
10. A balance of rewards and sanctions encourages pro-social
behavior and treatment participation.
11. Offenders with co-occurring drug abuse and mental health
problems often require an integrated treatment approach.
12. Medications are an important part of treatment for many drug
abusing offenders.
13. Treatment planning for drug abusing offenders who are living
in or re-entering the community should include strategies to
prevent and treat.
National Institute on Drug Addiction
March 2011
www.drugabuse.gov
Principles of Drug Addiction Treatment: A Research Based Guide
Principles of Effective Treatment
1.
Addiction is a complex but treatable disease that affects
brain function and behavior.
2.
No single treatment is appropriate for everyone.
3.
Treatment needs to be readily available.
4.
Effective treatment attends to multiple needs of the
individual, not just his or her drug abuse.
5.
Remaining in treatment for an adequate period of time is
critical.
National Institute on Drug Addiction
March 2011
www.drugabuse.gov
Principles of Drug Addiction Treatment: A Research Based Guide
Principles of Effective Treatment - Continued
6.
7.
8.
9.
Counseling – individual and/or group – and other behavioral
therapies are the most commonly used forms of drug abuse
treatment.
Medications are an important element of treatment for many
patients, especially when combined with counseling and other
behavioral therapies.
An individual’s treatment and services plan must be assessed
continually and modified as necessary to ensure that it meets
his or her changing needs.
Many drug-addicted individuals also have other mental
disorders.
National Institute on Drug Addiction
March 2011
www.drugabuse.gov
Principles of Drug Addiction Treatment: A Research Based Guide
Principles of Effective Treatment - Continued
10. Medically assisted detoxification is only the first stage of
addiction treatment and by itself does little to change longterm drug abuse.
11. Treatment does not need to be voluntary to be effective.
12. Drug use during treatment must be monitored continuously, as
lapses during treatment do occur.
13. Treatment programs should assess patients for the presence
of HIV/AIDS, hepatitis B and C, tuberculosis, and other
infectious diseases as well as provide targeted risk-reduction
counseling to help patients modify or change behaviors that
place them at risk or contracting or spreading infectious
diseases.
National Institute on Drug Addiction
March 2011
www.drugabuse.gov
GOAL:
• The Overall GOAL of this presentation is to explore the
foundational aspects of the RSAT Therapeutic Community
and discuss advanced application of Evidence-Based
Practices. We introduce the framework/concept of an
Evidence-Based Integrative Modified Therapeutic
Community RSAT Program.
OBJECTIVES:
• Discuss the different theories of Addiction.
• Provide an overview of the Therapeutic Community Model.
• Discuss the application of the Essential and Key Elements of
•
•
•
•
•
the Therapeutic Community
Examine Key Elements of Treatment Readiness, Responsivity,
and Motivation for Change.
Discuss Stages of Changes and Associated Features.
Review components of Cognitive Behavioral Techniques.
Review Twelve Steps Programs and Process
Explore the integration of the model utilizing the Therapeutic
Community as the foundation.
The Mission of Correctional RSAT Programs
To promote public safety by
reducing recidivism through
effective programming
WHY RSAT IN CORRECTIONS?
• More than 80% of inmates have substance abuse problems
• Substance abuse is the largest contributing factor to
recidivism
-This directly contributes to overcrowding and increased costs
• Common Mission
-The Mission of Corrections and Treatment is to correct / change
criminal behavior
• Effective inmate management tool
• Enhances staff morale
WHY RSAT IN CORRECTIONS?
• Overwhelming research evidence that treatment works
 Reduces recidivism from 10-50%
 Reduces direct corrections operational costs
 Reduces victim related costs
 Delaware/Crest Program (1999)
 BOTEC Barnstable County RSAT Program
Correctional RSAT Program
Core Conditions
• The Program must use a consistent model of treatment
• Staff and inmates must feel ownership in the treatment program
• Treatment must be structured
• The treatment program's rules must be clearly stated. Sanctions must
be clearly defined and consistently applied
• Inmates must be held accountable for their behaviors on and off the
treatment unit
• Treatment must involve the inmate's peer group
• The treatment program must demonstrate a balance between support
and confrontation
• Staff as Role Models in RSAT
Delaware/Crest Program:
3-Year Re-Arrest & Drug Use Rates
WHAT IS A CORRECTIONAL RSAT
PROGRAM?
• Minimum of six months of program services
• Highly structured schedule of behavior
change strategies
• Proven Criminal Justice / Corrections
Habilitation Model for Pro Social Change
•
Based on Evidence Based Practices
EXAMPLE OF AN RSAT
CORRECTIONAL PROGRAM MODEL
Accountability Training®
 Incorporates the integration of the 12-Step selfhelp philosophy, bio/psycho/social perspective on
addiction, cognitive behavior change strategies,
moral reasoning and character development
principles
 Uses Standardized and evidence based
assessment instruments to determine risk of reoffending and needs that may be addressed for
change to occur
 Manual based curriculum targeting the learning
of pro-social skills
 Results / Outcome Driven Model
HOW DOES RSAT WORK?
Structure, Discipline, Consistency - Critical
for model to be successful (inmates and staff)
•
“Hymn Book Principle”
 Essential for uniform and non-uniform staff to be on the same page.
 Consistency is key.
 There is no “ I ” in TEAM!
•The Therapeutic Community (TC) is the
method
for change, not the treatment
specialist or the
individual
• Training is critical and on-going.
HOW DOES RSAT WORK?
• Staff as role models (examples developed by staff)

Consistency – all staff follow consistent rules and schedules
every day and every shift; orderly entrance to groups, chow,
morning inspections, etc. Guidelines should be agreed upon and
followed by all staff. For instance - How to schedule breakfast,
showers, and time to prepare for inspection.

Staff does not talk about their own current use.
(“I got so drunk last night”)

Staff model the behaviors that inmates are taught. They listen
and respond respectively, even when holding an inmate
accountable for unacceptable behaviors. Direct supervision
training demanded this type of behavior of all staff. The Sheriff
stated that he supports it and will not have any tolerance for staff
not complying.
Staff as role models (examples developed by staff)

Staff will not intentionally “set up” an inmate.

Staff will not refer to inmates sarcastically. (“Are you retarded?”)

Staff will emphasize praise for positive efforts rather than
punishment for mistakes.

Address bad behavior as much as possible within the Unit as
opposed to lugging / disciplining inmates out of the Unit.

Treatment staff and Correctional Officers should combine efforts
to address bad behavior.

Avoid public humiliation.

Confrontation should focus on negative behavior and attitudes,
not on the individual. Staff will establish a base of respect.

Staff are capable and willing to run a community meeting.

Staff refrains from the use of coarse language and outbursts of
anger.
Core Components of Accountability Training®
Correctional RSAT Program
 Bio / Psych / Social / Spiritual Perspective on Addiction
Disease Model
 12-Step Programs, other Self-Help Programs and Clinical
Treatment
 Cognitive-Behavioral Change Strategies and
Criminogenic Rick / Need / Principles
 Re-socialization and Peer Accountability
(Therapeutic Community – TC)
THE THERAPEUTIC
COMMUNITY
Evidence-Based Integrated Modified
Therapeutic Community Programs in
Corrections
The Therapeutic Community Model*
•
As a Belief System - demands that practitioners / staff
believe that this model works; that the individual CAN
change and that it is the group, the community, that
facilitates this change.
•
As a Scientific System- has theories, researched
methods and measurable behaviors at work that yield
predictable outcomes regardless of where the model is
practiced.
*Taken from Therapeutic Community: History and Overview video featuring David Deitch, Ph.D., 1998.
The Therapeutic Community Model
•
Community as Method of Change
 TC members interact in structured and unstructured ways to influence
attitudes, perceptions, and behaviors associated with drug use and criminal
behaviors.
•
Hierarchy of Responsibility
 A hierarchy structure is utilized within the community to create
responsibility for all community members using mentors and team leaders.
•
Accountability
 TC members learn to be accountable to themselves and peers through
participation in community meetings, work details and learning experiences.
Therapeutic Community
• The term Therapeutic Community has come to represent a distinct
approach that can be applied in almost any setting with almost any
population.
• Therapeutic Community model has been adapted for use with
what populations?
Almost any ethnic or special population. It is a cross-cultural
model. Includes adolescents, geriatrics, adults, head injury,
PSTD, women, PRISON, etc.
• To maintain integrity as a TC, the basic components of the generic
TC program and the eight essential concepts of using community
as method must be preserved.
Community As Method
• The essential element of the TC is COMMUNITY. What
distinguishes the TC from other treatment approaches is the
purposive use of the community.
• COMMUNITY is the primary method to bring about needed social
and psychological change in the individual.
• Every activity in a TC is designed to produce therapeutic and
educational change in the individual participants.
• It is the participants who are the mediators of these changes. The
COMMUNITY is both teacher and healer.
The Therapeutic Community Model
•
Community as Method
•
The Therapeutic Community Perspective

View of the Disorder
 View of the Person
 View of Recovery
 View of Right Living
•
8 Concepts
•
14 Components
Therapeutic Community Perspective
•
•
•
•
View of the Disorder
Substance abuse is viewed as a disorder of the whole
person.
View of the Person
The person or individual is distinguished along dimensions
of psychological and social dysfunction.
View of Recovery
The goal of treatment is a global change in lifestyle and
identity.
View of Right Living
In the TC view of right living, certain beliefs and values are
essential to recovery, personal growth and healthy living.
Eight Concepts of Therapeutic Communities
1.
2.
3.
4.
5.
6.
7.
8.
Use of Participant Roles
Use of Membership Feedback
Use of Membership as Role Models
Use of Collective Formats for Guiding
Individual Change
Use of Shared Norms and Values
Use of Structure and Systems
Use of Open Communication
Use of Relationships
Fourteen Components of Therapeutic Communities
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Community Separateness
Community Environment
Community Activities
Peers as Community Members
Staff as Community Members
A Structured Day
Phase Format
Work as Therapy and Education
TC Concepts
Peer Encounter Groups
Awareness Training
Emotional Growth Training
Planned Duration of Treatment
Continuance of Recovery
ADDICTION
Understanding Addiction as a Brain Disease
Paradigm Shift
“JUST SAY NO” vs.
THE DISEASE MODEL
OF ADDICTION
The Disease Model
Addiction is a chronic, progressive, relapse - prone illness that
has the potential to be fatal if left untreated.
Chronic - The World Health Organization defines chronic diseases as having:
•
A clearly defined onset
•
An identifiable and predictable set of symptoms
•
A responsiveness to treatment as evidenced by a decrease in symptoms
•
The ability to be arrested ( not cured) by appropriated treatment
•
A progressive nature without treatment
Addiction is a chronic, progressive, relapseable illness
that has the potential to be fatal if left untreated.
Progressive diseases:
•
•
Get worse, not better, over time.
Tolerance develops.
Relapse:
• Relapse is a common aspect of all chronic diseases. But
relapse is not pre-determined. Relapse, for some, can be
avoided. Relapse, for many, is common and can be
managed effectively.
Fatality:
•
Chronic diseases can and do kill. Addiction is no different
Symptoms of Addiction
• Physiological Symptoms

Withdrawal

Tolerance
• Psychological Symptoms

Irritability and Craving

Emotional Discomfort

Social Avoidance

Choosing the Drug over family, community, job, school, etc.
Addiction impacts the physical, social, psychological, and
spiritual aspects of the individual’s life.
Symptoms –Areas Affected by Addiction
• Physical
• Psychological
• Mental
• Emotional
• Behavioral
• Spiritual
• Social
• Cultural
• Environmental
• Socio-Economic/Political
Choice and Addiction
Individuals do not choose the
diseases that they suffer but they
do choose how they treat them.
Pleasure Unwoven
Pleasure Unwoven: An Explanation of the Brain
Disease of Addiction (2010)
DVD
Kevin McCauley (Director)
Accountability Training® Recidivism Reduction Pyramid
RECOVERY
SERVICE
SPIRITUALITY
WE ARE WHAT WE THINK
(COGNITIVE BEHAVIORAL SKILLS)
12 STEPS/MUTUAL-HELP CONNECTIONS
ADDICTION IS A BRAIN DISEASE
RESPECT
Others – Self - Authority
© 2009 Dr. Steve Valle
ASSESSMENT
Standardized Assessment of Criminogenic
Risks and Needs
Overall Goals of Assessment in the
Criminal Justice System
• Determine level of supervision of clients in order to
maximize and facilitate public safety and to determine the
service needs of clients to prevent / reduce recidivism
• Identify clients in the criminal justice system that need
educational / vocational services, and treatment
intervention for substance abuse and criminal conduct
• Match client problems and level of severity with
intervention and treatment services
Multidimensional Assessment
• Comprehensive Assessment of RSAT Participants will
ideally include standardized, evidence-based assessment
of the individual in each of the following areas:
• Criminogenic Risk/Need
• Substance Abuse
• Motivation for Change/Treatment Readiness
• More accurate and comprehensive assessment practices
lead to more precise interventions.
Structured Interview Assessments
• Assessments that are administered by a trained
correctional worker in an one-to-one format using an
prepared “guide” to lead interview through a semistructured interview.
• Benefits include the opportunity for a client to develop a
cooperative working relationship with assessment
administrator that can begin treatment experience in a
positive light.
Self-Report Assessments
• Assessments that are completed by the client individually
which can, in some cases, increase the veracity of
response particularly in regards to areas of substance
abuse.
• When paired with structured assessment responses,
results of both are generally more robust and meaningful
for case planning and program placement.
• Assessment in correctional settings involves predicting
the likelihood that offenders will engage in criminal
conduct in the future.
Risk/Needs Assessment Instruments
• Identifying offenders’ criminogenic needs and placing
them in appropriate intervention programs can reduce
recidivism.
• Criminogenic needs are offender characteristics or traits that
contribute to inappropriate behavior, negativistic attitudes and
recidivism (Andrews & Bonta, 1994).
• Criminogenic needs are risk factors that are capable of change.
• When these needs are changed in treatment, they affect changes
in the offender’s chances of recidivism
Risk Principle
The intensity of treatment services should be matched to
the risk level of the offender.
High-risk offenders require more intensive and extensive
services while low-risk offenders require minimal or no
intervention.
“If it ain’t broke, don’t fix it!”
Need Principle
The need principle identifies two types of offender needs:
criminogenic and non-criminogenic
•To reduce criminal behavior, we have to focus treatment
efforts and resources on those risk factors that have been
shown to be most strongly linked to criminality and can
change with interventions.
•Criminogenic needs are those offender risk factors that
when changed are associated with changes in recidivism.
Responsivity
• Current research documents that when a client’s
strengths, motivational level, personality characteristics,
learning style and particular bio-social characteristics are
identified and taken into account when deciding upon
appropriate programming, recidivism can be significantly
reduced. (Kennedy, S., & Serin, R. C. 1997)
• Specific responsivity considerations are becoming
increasingly more important to include in effective
offender assessment and treatment
The Major Risk Factors - THE BIG FOUR
1.
Antisocial supports - peers
2.
Antisocial thinking - ways of perceiving that
support criminal behaviors
3.
Antisocial personality factors - poor social skills,
impulsive, risk-taking
4.
Criminal history
The Mid-Range Risk Factors
•
Familial factors
•
Low levels of personal, educational, vocational, and
financial achievement
•
Alcohol / Drug Abuse
The Level of Service Inventory – Revised (LSI-R)
Criminal History
Education/Employment
Financial
Family/Marital
Accommodations
Leisure/Recreation
Companions
Alcohol/Drug Problem
Emotional/Personal
Attitudes/Orientation
Research on Treatment Matching
• High-risk offenders should be placed in intensive
intervention and treatment programs
• Low-risk offenders should be matched with low levels of
intervention and treatment.
• Placing low-risk offenders in intensive intervention or
treatment programs is found to be counter productive and
produces increased recidivism.
Static and Dynamic Risk Factors
• According to Andrews & Bonta (1994), predictors of
recidivism include two types of risk factors:
• Static risk factors involve aspects of the offender’s past
(e.g., previous convictions) that are predictive of
recidivism but do not change.
• Dynamic risk factors are criminogenic needs (e.g.,
antisocial thinking, violence and substance abuse).
• Risk / Need Assessment Instruments that include more
dynamic criminogenic scoring items vs static items have
been found to have much better in predicting recidivism
and success in treatment.
Criminogenic Risk/Needs Assessment Instruments
• The following standardized assessment instruments are
have been empirically validated and are appropriate for
inclusion in evidence based programs:
• Level of Service/Case Management Inventory (LS/CMI)
• Level of Service/Risk Needs Responsivity (LS/RNR)
• Ohio Risk Assessment System (ORAS)
• Correctional Offender Management Profiling for
Alternative Sanctions (COMPAS)
Level of Service/Case Management Inventory
• Combines Risk/Needs Assessment and Case
Management into one Evidence-Based System
• Can be used by any TRAINED professional, including
parole, probation and correctional officers; caseworkers,
and program facilitators.
• Training in proper administration, scoring, and
interpretation is essential to ensuring the validity of the
instrument.
LS/CMI Continued
• Includes Assessment Form, Case Management Plan,
Progress Reports, and Discharge Plan
• Previous versions of the instrument (LSI and LSI-R) did
not include the Case Management Component
• The LS/CMI was normed on 157,947 North American
youth and adult offenders - 60,156 US adult and youth
offenders from 10 jurisdictions, and 97,791 Canadian
community and institutionalized adult and youth offenders
• Computerized versions available
Level of Service/ Risk, Need,
Responsivity (LS/RNR)
• Designed for Public Safety Programs that already have a
Case Management Component in place
• The LS/RNR normative sample consisted of 157,947
North American youth and adult offenders - 60,156
American adult and youth offenders from 10 jurisdictions
and 97,791 Canadian community and institutionalized
adult and youth offenders
• Assesses the:

Rehabilitation Needs of Offenders

Risk of Recidivism

Responsivity, the most relevant factors related to
supervision and programming
LS/RNR Continued
• General Risk/Need Factors Assessed:
Criminal History
Education/Employment
Family/Marital
Leisure/Recreation
Companions, Alcohol/Drug Problems
Pro-criminal Attitude/Orientation
Antisocial Pattern.
• Special Risk/Need Factors Assessed:
Personal Problems with Criminogenic Potential
History of Perpetration, including sexual and nonsexual
assault and other forms of violence and anti-social
behavior.
• Special Responsivity Considerations are also included.
Ohio Risk Assessment System (ORAS)
• Five assessment instruments were created using items
that were related to recidivism:
• Pretrial Assessment Tool
• Community Supervision Tool
• Community Supervision Screening Tool
• Prison Intake Tool
• Reentry Tool
ORAS Continued
Designed to:
1. Separate offenders into risk groups based on their
likelihood to recidivate
2. Identify dynamic risk factors that can be used to
prioritize programmatic needs
3. Identify potential barriers to treatment.
4. Aid in decision-making regarding the allocation of
financial, rehabilitation and supervision resources.
Correctional Offender Management Profiling for
Alternative Sanctions (COMPAS)
There are four major risk assessment scales included in
the COMPAS design:
•Violence
•Recidivism
•Flight
•Community Non-Compliance
In addition to the assessment of an offender's
appropriateness for community corrections, these scales
can be used in decisions regarding release and case
management supervision.
COMPAS, continued
Risk Assessments are based on a comprehensive set of
over twenty well validated criminogenic factors including:
criminal history
violence history
early onset of delinquency
substance abuse
criminal associates
criminal attitudes
criminal personality (impulsivity, low self-control)
criminal opportunity (high risk lifestyle)
Substance Abuse Assessment
Research indicates that inmates with substance abuse problems are at
higher risk for a number of problems and conditions that, left
unidentified and unaddressed, can increase the probability of relapse
and reincarceration. (Langevin, C.M., Moser, A.E., and Weekes, J.R.
1999)
• Identify and verify the existence of a problem warranting
intervention
• Provide detail and shed light on the nature and
seriousness of the client’s substance abuse problems
• Identify the link with criminal behaviors
• Guide decision-making in the placement of clients into
appropriate programming and services
Substance Abuse Assessment
• While SCREENING for substance abuse is usually a one-
time event, performed at intake, ASSESSMENT of
substance abuse is an ongoing process.
• Substance Abuse is a DYNAMIC criminogenic risk/need
• Assessment of Thoughts, Beliefs and Attitudes about
Substance Use are as Important as Assessment of
Behavior (Use of the Substance)
• Repeated assessment can identify progress and the risk
of relapse over the course of treatment
Substance Abuse Assessment, con’t.
• There is research to support the notion that SELF-
REPORT assessment instruments of Substance Abuse
are more accurate and valid than their counter-parts
(Beal, Weekes, Millson and Eno, 1996).
Selected Valid, Evidence-Based Instruments:
Adult Substance Use Survey-Revised (ASUS-R)
Substance Abuse Subtle Screening Inventory (SASSI)
Addiction Severity Index (ASI)
Texas Christian University Drug Screen (TCU-DS)
Adult Substance Use Survey (ASUS-R)
• The ASUS-R is a 96 item psychometric-based, adult self
report survey comprised of 15 basic scales and three
supplemental scales. It is appropriate for clients 18 years
or older, and may be self or interview administered
• Assesses Drug Use/Involvement in 10 Common
Categories
• Other Scales Include
• Drug Benefit Scale
• Mental Health Screen
• Social Non-Conformity Scale
• Legal Non-Conformity Scale
• Disruption Caused by Drug Use
ASUS-R Continued
• Additional Information from the ASUS-R:
• Motivation and Treatment Readiness
• Defensiveness
• Resistance to Self-Disclosure
• The ASUS-R rater scale allows a comparison of the evaluator's
perception of the client's drug use and abuse with the client's
perception of that use.
• Can be used to assess changes over time in treatment
Substance Abuse Subtle Screening Index
(SASSI)
• Self-Report Screening Instrument for Substance
Dependency
• Especially Effective for Classification of Early-Stage
Chemically Dependent Individuals who are either:
1.
2.
In Denial or
Attempting to Hide their Dependency
Research Demonstrates Accuracy in Assessing Chemical
Dependency but the SASSI has not been normed on the
Criminal Population (unlike the ASUS-R)
Addiction Severity Index (ASI)
The ASI focuses on seven functional areas, or subscales, that have
been widely shown to be affected by the substance abuse:
•medical status
•employment and support
•drug use
•alcohol use
•legal status
•family and social status
•psychiatric status.
•Each of these areas is examined individually by collecting information
regarding the frequency, duration, and severity of symptoms of
problems both historically over the course of the patient's lifetime and
more recently during the thirty days prior to the interview
ASI, Continued
The Addiction Severity Index (ASI) provides a general
overview of substance-abuse problems rather than a focus
on one particular area (200 questions on 7 subscales).
•The interview is based on the idea that addiction to drugs
or alcohol is best considered in terms of the life events that
preceded, occurred at the same time as, or resulted from
the substance-abuse problem. The ASI focuses on seven
functional areas, or subscales, that have been widely
shown to be affected by the substance abuse
•Excellent reliability and validity across a range of types of
patients and treatment settings
CRIMINAL THINKING
Recognizing the thinking patterns that lead to
substance use and criminal behavior
Recognizing Thinking Patterns
Thinking
Behavior
Style of
Interaction
Core
Beliefs
Attitudes
Criminal Behavior is Preceded By
Criminal Thoughts and Criminal Decisions
• Most often, individuals who become involved in criminal
conduct chose to do so. They make a conscious
decision about who to victimize and how to victimize.
• Once criminal conduct is engaged in, it sets off new
cognitive reactions that reinforce the underlying criminal
thinking. (Techniques of Neutralization)
• Finally, the cognitive responses and reactions to the
criminal conduct are reinforced which strengthens the
criminal behavior itself.
The Cycle of Criminal Thinking
Core Beliefs
and Psychology
of Criminal
Conduct
Decisions to
Engage in
Criminal
Conduct
Reinforcing
Techniques of
Neutralization
Neutralization
• A technique, which allows the person to rationalize or
justify a criminal act. There are five techniques of
neutralization; denial of responsibility, denial of injury,
denial of victim, condemnation of the condemners, and
the appeal to higher loyalties.
Denial of Responsibility
“It was not my faulty because_____________________”
Denial of Injury
• “It was a private argument, it was between my gang and
his”
• “It wasn’t stealing, I was gonna pay it back”
• “Nobody got hurt”
Denial of Victim
• The act doesn’t count as criminal because the person
doesn’t count as a victim
• Hate Crimes:
“Gays aren’t even human”
• Crimes Against Rivals:
“Bloods don’t count”
• Exaggerated “Robin hood” Philosophy:
“They are so rich they probably won’t even know it’s gone”
Condemnation of the Condemners
• Displacement of anger and antisocial sentiments onto
those in position of judgment/authority
• “All the Judges are hypocrites”
• “Every Cop is Corrupt”
Appeal to Higher Loyalties
• The crime against society (the large group) is warranted
out of loyalty to the family/community/gang (the small
group).
• “The law that matters most is my family’s law”
• In it’s extreme form, this type of neutralization is evident in
terrorism
Identifying Thinking Patterns
• To help clients to change these attitudes, treatment
professionals in the criminal justice fields must first help
them identify those thinking patterns that lead them into
high-risk situations and increase their chances of
engaging in illegal and self-destructive behaviors.
Selected Thinking Errors and Distortions
• Power Thrust: Putting someone down so you can be in
control.
• Closed Channel: Seeing your way as the only way.
• Victim Stance: Blaming others for what’s happening to you.
• Pride and Superiority: You really feel superior to others and
know it all; you feel the world owes you a living.
• Lack of Empathy and Concern for how Others are
Affected: not thinking how your actions affect others or the
emotional / physical pain you cause others.
Selected Thinking Errors and Distortions continued
• Seeing trust as a one way street - can’t trust anybody: You
demand people trust you but you do not trust others.
• I can’t: You refuse to do something you don’t want to do.
• Irresponsible commitment: You want what you want right now and
will spend little time getting it; don’t follow through with commitments
or complete the task, particularly if it doesn’t give you immediate
reward.
• Take what you Want from Others: I deserve it.
• Rejection Dependency: You refuse to lean on someone, to depend
on someone, to ask others for help because this is a sign of
weakness. Yet you take from others which makes you dependent on
others.
Selected Thinking Errors and Distortions continued
• Put off Doing what Should be Done: You put off things; you put off
changing. You say “tomorrow I’ll quit”, or someday you will stop
taking part in actions that make other people victims.
• Rejecting obligations – I don’t have to do that: You may have
enough money to get drunk but you delay paying the rent.
• Concrete and rigid thinking: You have your ideas and will not
change.
• Either or, black or white thinking: one is either successful or not
successful, pretty or ugly. There is no in-between, no shades of gray.
• Mountains out of Molehills: This is catastrophizing. It is blowing up
something out of proportion; treating something common as a
catastrophe.
Selected Thinking Errors and Distortions continued
• Feeling Singled Out: Feeling that what is happening to you in unique; feeling picked
on.
• They Deserve It: If they hadn’t been so stupid and locked their doors, they wouldn’t
have been robbed.
• I Feel Screwed.
• Selected Attention: Tuning out what one should hear; focus on one statement, one
result. Hear the negative but tune out the positive.
• Antisocial Thinking: You spend a long time thinking about criminal things and are
busy planning doing unlawful things.
• Lying or Exaggerating the Truth: You may lie so often that it becomes automatic;
you exaggerated the truth to look important or big.
(Source: “Criminal Conduct and Substance Abuse Treatment” by Wanberg, Kenneth W.,
and Milkman, Harvey B., Sage Publications, 1998.)
The Cycle of Criminal Thinking
Criminal
Thinking/Core
Beliefs
Techniques
of
Neutralization
Thinking Errors and
Distortions
What’s Next?
• Teach the Client to Recognize these Thinking Errors by
• Implementing Cognitive-Behavioral Techniques that
• Illuminate the Pattern of Thinking that Leads to Criminal
Acts
Attitude + Behavior = Consequence
MOTIVATION FOR CHANGE
• Helping Offenders Change often involves increasing
motivation
• The incarcerated offender is often at a pre-pre-
contemplative stage and requires specific interventions to
shift along the change spectrum
• IMTC programs can help the individual by increasing his
awareness of the discrepancy between what he wants to
achieve and what results his behavior usually generates.
• TCs = ideal place to learn and rehearse new behavior
MOTIVATION FOR
CHANGE
Assessing and Enhancing Offenders
Motivation in the Treatment Process
Readiness To Change-Motivation
• Identifying a client’s stage in the change process helps
placement into appropriate programming and services.
• Motivation is a dynamic process that can be changed by
internal and external factors.
• Individuals may be in one stage of change regarding a
particular issue in life (earning their GED) and another
stage of change regarding another issue (discontinuing
heroin use).
The Stages of Change
• Pre-contemplation
• Contemplation
• Preparation
• Action
• Maintenance
Identifying what most motivates a client towards changing
behaviors helps shape treatment / placement decisions
and is the beginning of a “common goal” between service
provider and client.
Motivation
• ANY motivation towards change is as step in the right
direction.
• Entering treatment programming “just” for the “good time”
is alright.
• Our job as facilitators is to increase the offender’s
motivation to change in a variety of ways
Selected Assessment Instruments
• Prochaska and DiClemente’s Motivation for Change Scale
• University of Rhode Island’s Change Assessment
(URICA)
• Stages of Change Readiness and Treatment Eagerness
Scale (SOCRATES)
• All of these instruments measure where a client is in the
stages of change and can be repeated over time.
Offender Profile
• Action Oriented
• Poor reflective skills
• Resistant to punishment
• Defensive
• Need to be right
• Self-centered
• Competitive
• Sees self as victim
•Unable to delay gratification.
COGNITIVEBEHAVIORAL
INTERVENTIONS
Implementing Evidence-Based Treatment Services
Thinking and Behavior
How we think affects
the ways we behave in the world.
thus
If we can change the way we think,
we can change the ways we behave
The Cognitive Cycle
Situation
Automatic
Thoughts
Consequences
Beliefs
Behaviors
Feelings
Four Steps of Cognitive Self Change
1. Recognize Your Thoughts and Feelings
2. Recognize When Your Thoughts and Feelings are
destructive
3. Change the destructive thoughts
4. Practice the change
Thinking Report
Situation:
Thoughts:
1.
2.
3.
4.
5.
Feelings:
Beliefs:
Successful RSAT Program completion means an individual
can demonstrate a change in behavior by:
•Recognizing his high risk situations
•Recognizing the thinking behind the choices in the high
risk situation
•Choosing a safe way to think
•Put the new thinking into action
ACCOUNTABILITY
TRAINING PROGRAM®
Core Concepts and Philosophy

An Example of an Evidence-Based
Integrated Modified Therapeutic
Community RSAT Program
(The following Accountability Training TC Training slides,were developed by Dr. Steve Valle,
President, AdCare Criminal Justice Services, Inc. for Essex County Sheriff’s Office, Essex County
MA, September 2008 and Barnstable County Sheriff’s Office, 2001 2004)
Three Assumptions of Accountability Training® Programs:
1. Substance abuse offenders CAN change their behavior.
2. Implementation of EVIDENCE BASED PRACTICES
(clean time, structure, firm, fair, and consistent) DOES
result in positive outcomes.
3. Motivation to change is not required – “motivation myth”
• Offenders are motivated – but not necessarily to change
• “What’s in it for me”? – conditional buy-in is good enough
• Commitment to “ACT AS IF” is key; velvet covered brick
metaphor – AT brings motivation to clients by applying
therapeutic leverage factors as motivators to participate (“the
only failure is the failure to participate”).
Elements of Behavior Change:
Accountability
Responsibility
RESPECT FOR
SELF & OTHERS
Pro-social Thinking & Action
Internalization
Stages of Offender Change in
®
Accountability Training
(precedes pre-contemplation stage)
Stage I: DEFIANCE
Stage II: RESISTANCE
ACCOUNTABILITY
Stage IV: COOPERATION
Stage III: COMPLIANCE
Process of Offender Change
4 C’s of Applying Accountability Training in
Criminal Justice Systems (CJS):
1.
Customer (CJS) is the primary Client –not the offender
2.
Commitment of staff to model Accountability and Respect
is key
3.
Continuity of resources from institutional to community
based supervision, caregivers, & re-entry resources (safe
housing, work, accountability) & supervision
4.
Pro-Social Connections are essential
Accountability Training® Recidivism Reduction
Content Variables
 Addiction is a Brain Disease that effects behavior
 12 Step/Mutual-Help Connections
 We Are What We Think
 Spirituality
 Service
(Cognitive Behavioral Skills)
Accountability Training® Recidivism Reduction
Process Variables
1. Respect

For Others – Self - Authority
2. Accountability

Others – Self – Higher Power
3. Community



Relationships & Pro-social Connections
Safe, Drug Free Housing
Meaningful Work
↓
“RECOVERY”
The 3 R’s of the Accountability Training® Paradigm:

Right Thinking

Right Living

Right Now
1. Right Thinking - historical origins
 “As a man think-eth, so he is”
(The Holy Bible, Proverbs 23:7)
 We are shaped, created & led by our thoughts. (Teachings
of the Buddha 500 B.C.E.)
 “Men are disturbed not by the things which happen, but by
the opinions about the things.” (Epictetus - 2nd century A.D.
philosopher)
 “I think, therefore I am.” (René Descartes -16th Century Philosopher)
1. Right Thinking -historical origins continued
Man’s Search For Meaning — a philosophical
reflection on his experience as a prisoner in a Nazi
concentration camp — Victor Frankl wrote:
“…everything can be taken from a man but one thing: the last
of the human freedoms — to choose one’s attitude in any
given set of circumstances, to choose one’s own way.”
1. Right Thinking -historical origins continued
 “You can if you think you can.” (Norman Vincent Peale)
 “I am convinced that a person's behavior springs from his
ideas.”
(Alfred Adler, Founder of the School of Individual Psychology)
 We are what we think; by changing the way we think, we
can change our behavior. How you think, determines how
you feel. (Modern Cognitive Behavioral Theorists & Practitioners- Beck,
Ellis, etc.)
1. Right Thinking Continued
 ”As long as we remain unaware of our thinking, then
actions will follow automatically. When we become aware
of our thoughts, then we have the freedom to choose
whether or not we want to act upon them.”
(Dr. Dennis Humphrey, summarizing the teachings from Buddhism Literature)
 “We define who we are by consciously choosing our ways
of thinking, the attitudes and beliefs that determine how we
act and who we are. Choose how you will think, and be
aware that you and you alone are doing the choosing. You
and you alone are responsible for the person you will be.”
(Jack Bush: Cognitive Self-Change, 2002)
2. Right Living
Respect of others
Accountability
Responsibility
Pro-Social life skills & Relationships
Spirituality
Service
3. Right Now
“The past is history, tomorrow’s a mystery,
TODAY is a gift… that’s why it’s called the
present!”
“It matters not what we’ve done, but who we
can become.” (Mimi Silbert, Delancey Street Foundation)
Steps for Learning Accountability
 Awareness that our behavior has an effect on others
 All behavior has Consequences for self and others
 Recognize that, with awareness, behavior is a Choice
 Acceptance – Owning one’s role in the behavior
 (Dr. Steve Valle, Essex County Sheriff’s Office TC Training, 2008)and in
the consequences
Accountability means taking empathic Action to change
Core Standards of Care Expected of All Staff:
Always show respect, for self and others
Professionalism before personal
preferences
Practice ethical behavior and integrity
Demonstrate compassion and empathy for
clients and colleagues
Be trustworthy and practice trustworthiness
Consistently model ACCOUNTABILITY to
colleagues and clients
INTEGRATIVE ISSUES
• Twelve-Step Programs
• Spirituality
• Co-Occurring Disorders
• Trauma Informed Care
• Gender Responsive Treatment
• Cultural Proficiency
12 STEP PROGRAMS
Understanding and Integrating 12 Step
Programs with Professional Treatment
Services
TWELVE STEP, SELF-HELP, AND TREATMENT RESOURCES
•
The principles of AA/NA are incorporated into many substance
abuse treatment programs but professionally provided treatment
services are not AA/NA or self-help groups.
•
Clinically driven groups include the use of professional knowledge
and technique in addition to the concepts of twelve step programs.
•
AA/NA and RSAT programs share many key values:
Personal accountability
Accountability to the group
 Honesty
 Placing “we” before “me”
 Spiritual recovery
TWELVE STEP, SELF-HELP, AND TREATMENT RESOURCES
•
Alcoholics Anonymous (AA) and the concept of powerlessness:
The addict is powerless over the effect the drug has on him / her
and the bio psychosocial aftermath. The addict who recognizes
this powerless and surrender to a power greater than him / herself
to cease using the substance opens the doors to recovery.
•
The Twelve Steps and Twelve Traditions, the Fellowship of
AA/NA, and the concept of anonymity are core components of
twelve step programs.
TWELVE STEP, SELF-HELP, AND TREATMENT RESOURCES
•
Religion and Spirituality are different. Religion is about an
organized system of faith and worship practices while Spirituality is
about a relationship. The innermost relationship we have with
ourselves and a Higher Power, and as a result with all other
people and things, is spirituality.
•
Addiction changes people’s values and distorts their spiritual
nature and through recovery and a relationship with the Higher
Power the individual is able to be “restored to sanity”.
•
Effective treatment programs include a spiritual (not religious)
component.
•
How we think, how we feel, and how we act can reflect either
disease or recovery.
THE TWELVE STEPS OF ALCOHOLICS ANONYMOUS
1.
We admitted we were powerless over alcohol—that our lives had
become unmanageable.
2.
Came to believe that a Power greater than ourselves could restore
us to sanity.
3.
Made a decision to turn our will and our lives over to the care of
God as we understood Him.
4.
Made a searching and fearless moral inventory of ourselves.
5.
Admitted to God, to ourselves, and to another human being the
exact nature of our wrongs.
6.
Were entirely ready to have God remove all these defects of
character.
THE TWELVE STEPS OF ALCOHOLICS ANONYMOUS continued
7. Humbly asked Him to remove our shortcomings.
8.
Made a list of all persons we had harmed, and became willing
to make amends to them all.
9.
Made direct amends to such people wherever possible, except
when to do so would injure them or others.
10. Continued to take personal inventory and when we were wrong
promptly admitted it.
11. Sought through prayer and meditation to improve our
conscious contact with God, as we understood Him, praying
only for knowledge of His will for us and the power to carry that
out.
12. Having had a spiritual awakening as the result of these Steps,
we tried to carry this message to alcoholics, and to practice
these principles in all our affairs.
SPIRITUALITY
Integrating Spirituality and Evidence-Based
Treatment
Spirituality and Religion
• Much has been written about the distinction between
spirituality and religion. In very simplistic terms:
• Religion tends to focus on a specific dogma and specific
sets of beliefs, traditions, and rules.
• Spirituality is not focused on these alone but rather on the
interconnectedness of all things and the awareness of
that same interconnectedness.
• Religion is a path to God.
• Spirituality may be a path to God but God is not the
desired endpoint.
Spirituality and Religion
• Spirituality rejects fear and focuses on love and inclusion
• Religion often incorporates fear and, in some cases,
integrates fear into dogma
• Addicts often reject spirituality because they confuse it
with religion OR because they do not know how to be
present with themselves long enough to gain a sense of
their own spiritual being.
• Spirituality and religion do not have to be mutually
exclusive –they can be integrated and many do
Characteristics of Spirituality?
• Belief that true happiness does not come from the
material world but from a profound sense of contentment,
centeredness, and peace with things just as they are.
• Equanimity, a quality of being content and peaceful in
the most stressful kinds of situations, can only be
developed from the inner work of meditation, prayer, and
12-step type programs that emphasize internal change.
• Addiction is the attempt to sustain a continual state of
happiness or freedom from distress. It cannot last.
“Everything is Linked”
Sir Richard Branson
• Interconnectedness with other people, nature, and a
Higher Power is central to being human.
• In active addiction, the addict often deludes himself that
his actions only affect himself, and that he doesn’t need
anyone.
• In reality, addicts are dependent not only on their drug of
choice but on the people who provide it and the people
who enable a lifestyle of addiction. They are highly
dependent but choosing to live as disconnected
individuals.
Everything is linked!
We Are Not Alone
• “When we think we are separate, we put
ourselves in constant conflict, trying to get
ours, always in fear of losing what we have,
alienating others whom we use for our
selfish purposes. This is the essence of
the addict – self-centered, fearful, and
isolated.”
Dr. Dennis Humphrey
“It is what it is”
• Our control of both our external circumstances
and our internal state is limited.
• In active addiction, individuals seek to control
their internal state through their use of the drug of
choice
• Spirituality results in a letting go of the need to
control and an increased awareness, acceptance,
and tolerance of changing emotional states.
Embarking On A Spiritual Path
• The first step on the path is creating the value that says
that sacrificing immediate gratification for something more
substantial is a worthy goal.
• For addicts and offenders, this requires new ways of
thinking and behaving that take time and practice.
• Cognitive-Behavioral interventions which teach an
offender to think about his thinking and to become aware
of the thoughts and feelings that lead to his behaviors are
also skills that are necessary for spiritual awareness.
Sadah
• Sadha is a tested faith, based on experience and wisdom,
and not “blind faith”.
• The wisdom of the 12 steps, and the reports of the many
thousands of people who have followed the path to
maintain their sobriety, is an example of sadha.
• Sadha gives us the courage to take the next right action.
It helps us to overcome the fears that our minds throw up
in front of us at every juncture.
• Faith – “belief system validated by one’s experience”
(Valle 2011)
Fear
• Fear is one of the biggest barriers to change. We fear new
behaviors, we fear new thoughts, we fear what we do not
know.
• Even when we know that what we know is not working,
we are reluctant to change it.
• Sadha, tested faith, moves us past fear. In the tradition of
the 12 Steps, we rely on a Higher Power to move us past
the blocks that we place in our own path.
Twelve Steps and Spirituality
• Step One emphasizes “powerlessness” over addiction.
• Step Two logically follows in that we are dependent upon
a “Higher Power” to restore us.
• Step Three requires a “conscious decision” to trust in that
Higher Power
• Twelve Step Programs can become intertwined with
specific religions but the program was designed
specifically to be spiritual, not religious.
Trauma Informed Care
• In 2005 SAMHSA established the National Center for
Trauma Informed Care
• Estimates of the prevalence of various types vary but
most data support the notion that nearly all incarcerated
adults have experienced some type of significant trauma
at some point in the lifespan.
• Changes the question from “What’s WRONG with you?”
to “What HAPPENED to you?”
• Website with curriculum resources:
• http://www.samhsa.gov/nctic/default.asp
CO-OCCURRING
DISORDERS
Recognizing and Responding to Mental
Health Issues in RSAT Programs
Co-Occurring Disorders
Taken from: http://coce.samhsa.gov/cod_resources/webinar/justice/.html
Taken from: http://coce.samhsa.gov/cod_resources/webinar/justice/.html
Taken from: http://coce.samhsa.gov/cod_resources/webinar/justice/.html
Taken from: http://coce.samhsa.gov/cod_resources/webinar/justice/.html
Taken from: http://coce.samhsa.gov/cod_resources/webinar/justice/.html
Taken from: http://coce.samhsa.gov/cod_resources/webinar/justice/.html
Taken from: http://coce.samhsa.gov/cod_resources/webinar/justice/.html
Integration of MET, CBT, and Self Help
Approaches Into the TC Model-Overview 1
• Our model is a recovery oriented, evidence-based,
highly focused program. Using the social learning
TC model as the foundation, and the stages of
change as a major focus, we also integrate
motivational enhancement therapy (MET),
cognitive behavioral therapy (CBT), 12-Step and
other self help approaches, in a treatment
program to meet the needs of the specific
treatment populations.
(Valle & Vasquez, ACA 2010)
Integration of MET, CBT, and Self Help Approaches
Into the TC Model-Overview 2
• The basic model modifies the traditional TC approach to
be uniquely suited for varied populations. In addition to
focusing on Substance Abuse and Mental Health issues,
the staff prepares the person for long-term stability,
employment and right living by providing educational and
vocational services, employment readiness training, and
other needed life skills and/or services.
• (Valle & Vasquez, ACA 2010)
The Therapeutic Community Model
Phased System Integration
• The following format depicts the integration of the of the
Stages of Changes, Motivational Enhancement Therapy,
Cognitive Behavioral Techniques and the Twelve Steps
into the Therapeutic Community Model and Approach.
Stephen K. Valle and Cecilia Velasquez, ACA 2011 Winter Conference
Integration of MET, CBT and 12 Step
Approaches into the TC Model
TC Model – (40 years)
Phases of Treatment
MET and CBT (10 years)
Activities/Groups
12 Step and Other Self Help (30
years)
Phase I – Orientation
Phase I – Orientation
Goal:
Assess person in terms of Stage of
Change
Phase I – Orientation
Goal:
Introduction To Self-Help (5
Sessions)
Phase II – Primary/Intensive
Goal: Identify and examine behavioral,
relational, emotional, and cognitive patterns
and risk factors and develop and implement a
behaviorally oriented long term plan of
change. Conform to TC Community norms,
rules, etc. Begin to demonstrate behavior and
attitude changing and right living
Phase II – Primary/Intensive
Phase II – Primary/Intensive
Goal: Identify Cognitive distortions
Goal: Exposure to Self- Help Meetings
Phase III – Re-Entry
Goal: Demonstrate recovery and readiness for
community transition as a productive,
recovering, crime-free person.
Phase III – Re-Entry
Goal: Demonstrated change positive thinking
and behaving
Phase III – Re-Entry
Goal: Participation in Self- Help Meetings
Phase IV – Continuing Care/Transition
Goal: Sustain changes and address relapse
prevention and transition issues (e.g.,
employment, education, family, etc.) as they
arise.
Phase IV – Continuing Care/Transition
Phase IV – Continuing Care/Transition
Goal: Internalization of positive thinking and
behaving
Goal: Emersion in Self-Help Program
Goal: Orient person to the TC Treatment,
structure, expectations, and assess motivation
and readiness to change.
Stephen K. Valle and Cecilia Velasquez, ACA 2011 Winter Conference
TC Model – (40 years) Phases of
Treatment
CBT
12 Step and Other Self Help (25
years)
CONTENT DIRECTED
1. Extent of compliance with rules: ¨ Support through
evidence of use of House Tools
2. Completion of Individual Treatment Plan for Phase 1:
3. Degree of personal responsibility: ¨ a. Support through
review of individual, group notes as well as willingness to
use house tools?
b. Have homework assignments been completed?
4. Has he/she demonstrated an understanding of the TC
concepts and components, of Addiction, Stages of Change,
and Cognitive Behavioral Concepts?
5. Has he/she demonstrated positive management of
his/her identified self defeating behavior pattern? Have
behavioral goals been met?
6. Has identified Stages of Change and appropriate plan to
move forward?
MET sessions focusing on
 Good and not-so-good things about use.
 A typical day involving use.
 Reasons to quit or change.
 Ideas about how change might occur.
 Explore Value system
CBT Addiction Concepts (8 Sessions) (Criminal Thinking
Overview (8 Sessions) (Motivational Enhancement
Therapy (MET)
Review Only
Step 1 – Powerlessness (Life unmanageability)
Step 2 – Insanity (acceptance of)
Step 3 – Surrender (I can’t do it alone)
1. Extent of compliance with rules:
- Support through evidence of use of House tools?
- Has he/she modeled the use of the concepts of the TC
community?
2. Completion of Individual Treatment Plan for Phase 2:
3. Degree of personal responsibility: - Level of sharing
during community meetings
- Level of sharing and disclosure during therapy group
- - Practice of CBT Plan for AOD Groups
- Practice of CBT Plan for Criminality
4. Degree of leadership role in Therapeutic Community: - Has there been successful mentoring role, i.e., Big
Brother/Big Sister?
- - Has there been positive crew leadership and positive
initiative?
5. Has identified Stage of Change and appropriate plan to
move forward?
CBT Problem Solving (2x/week) CBT Skill Building
(4x/week) )
* Unrealistic Expectations (8 Sessions) *Assertiveness (3
Sessions Commitment to Change (12 Sessions
of Videos)
* CBT Relapse Prevention (12 Sessions)
Review Only
Step 4 - Inventory – self
Step 5 - Disclosure
Step 6 – Defects (list of)
Step 7 - Id Shortcomings
God/Spirituality
1.
2.
3.
4.
5.
6.
7.
CBT Skill Building
CBT Relapse Prevention ( (6+ Sessions)
Review Only
Step 8- Reconciliation
(List of persons we had harmed)
Step 9- Make amends
(going to person when possible)
Step 10- Daily Practice Keep Check
Extent of compliance with rules:
Degree of personal responsibility:
Completion of approved Aftercare Plan:
Degree of willingness to follow Aftercare Plan:
Degree of leadership role in Therapeutic Community:
Degree of awareness of relapse setups:
Completion of personal Relapse Prevention plans:
Transition to the next level of care IOP/OP Services
Continue group therapy with Phase 2 mentee
Aftercare Outpatient Cognitive Groups
Review Only
Step 10- Daily Practice
Keep Check
Step 11 – Spirituality (conscious contact)
Step 12 - Integration
Having had a spiritual awakening. Carried message to
other addicts
MAT: Treatment Matters
Kevin Fiscella, MD, MPH
University of Rochester School of Medicine & Dentistry
How is opioid dependence treated?
• Medication-Assisted Treatment (MAT).
• Methadone
• Buprenorphine
• Counseling – behavior change, new skills.
• New ways of living (changing people, places and things).
• New ways of coping
• New ways of relating
• Treatment of other health problems.
• Mental health
• Physical health
What does MAT do?
• Restores brain function – removes craving and prevents
•
•
•
•
withdrawal. .
Blocks “high” – no euphoria.
Minimizes risk of overdose.
Frees up brain for counseling.
Provides a hook for continued treatment
Methadone treatment
Advantages
• Gold standard
• 40+ years of experience
• Low cost of medication
• May used during pregnancy
• No dose limit
Disadvantages
• Stigma
• Risk for overdose
• Risk for diversion
• Ingestion must be witnessed
• Requires facility license
Buprenorphine Treatment
Advantages
• Minimal sedation
• Low risk for overdose
• Less risk for diversion
• Less stigma
• Fewer ancillary expenses
Disadvantages
• Medication expense
• May not fully control cravings in those dependent on high doses of opioids
• Requires physician training and amended DEA license
• Limited experience during pregnancy
Does treatment work?
There is overwhelming scientific evidence that treatment is
effective.
NIH Consensus Statement, 1997
Effective Medical Treatment of Opiate Addiction
http://www.drugpolicy.org/docUploads/opiate_consensus.pdf
National Institute of Drug Abuse (NIH), 2006
Principles of Drug Abuse Treatment for Criminal Justice
Populations
http://www.nida.nih.gov/PDF/PODAT_CJ/PODAT_CJ.pdf
What are the benefits of treatment?
• Elimination of opioid obsession/compulsion.
• Improved health and reduced mortality.
• Elimination of opioid use.
• Reduction in HIV/HCV infection.
• Improved employment.
• Reduction in property crime.
• Reduction in arrests/re-arrests.
• Reduction in costs to state (Medicaid and criminal justice).
MAT: Criminal Justice Matters
Kevin Fiscella, MD, MPH
University of Rochester School of Medicine & Dentistry
How prevalent is opioid abuse among
criminal justice populations?
About 14 million arrests are made annually
In the United States - one million arrests involve persons
who abuse opioids.
10% of jail and prison inmates report regular use of
opioids.
Rates differ widely between community.
Long arm of justice
- short arm of treatment
• 7 million persons under jurisdiction in the US.
• 2.1 million in jail or prison.
• 60% - Black or Hispanic.
• 45% of men and 54% of women have any substance disorder.
• Less than one in ten are treated.
What is the state of opioid treatment
in criminal justice?
• Rates of opioid treatment are low – both in community
criminal justice populations and even worse among those
incarcerated.


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Prison <1%
Jail <2%
Probation/Parole <1%
• Many correctional facilities fail to provide even minimal
standards for detoxification – much less ANY treatment.
• High rates of death following release.
Inadequate assessment and
treatment is pervasive
• Arrest/pretrial/probation.
• Drug courts.
• Jails/prisons.
• Re-entry.
Failing grades for treatment
Failure to offer systematic assessment for opioid
dependence throughout system.
Failure to continue MAT during confinement.
Failure to meet minimum standards for detoxification.
Failure to offer MAT throughout system.
Failure to refer to MAT upon release or during parole.
Time for a change?
• Neither threat of incarceration nor prolonged incarceration
cures an opioid dependent brain – Zombie behavior
persists.
• Failing to assess and adequately treat opioid dependence
results in a costly, wasteful revolving door for opioid
dependent persons.
Mindless system for a mindless disease
What do you call a system that locks up people with opioid
dependent brains - at considerable tax payer expense –fails
to treat them, and releases them into the community in the
same condition they came in, over, over, and over again?
“The definition of insanity is doing the same thing over and
over again and expecting different results.”