Substance Abuse Treatment for Adults in the Criminal Justice System TIP 44

Foreign. I'd like to welcome everybody today's presentation. This is treatment improvement protocol 44 or TIP 44, substance abuse treatment for adults in the Criminal justice system. And you can find the full text of tip44 on the SAMHSA website. If you go to samsa.govslstore I believe is what the URL is. Now you can find tip44. We're really going to talk today not only about substance abuse treatment, but about co occurring disorders treatment because we now know that co occurring disorders are the expectation, not the exception. Thank you, Minkoff. So we're going to identify the purpose, sources of information and areas of concern for screening for, for people in the criminal justice system. We'll explore the pitfalls of diagnosis in the criminal justice system, identify preferred screening and assessment instruments and what they measure. Not going to spend a whole lot of time there because that can be kind of mundane. Examine placement strategies based on criminality, mental health and addiction issues and just discuss some general treatment issues in criminal justice scenarios. As I said before class started, it is really important when we're working with people who are incarcerated to make sure that during the period of their incarceration, if they need to develop skills, they develop some skills for coping and distress tolerance and anger management and that kind of stuff. But we want to make sure that they are mentally, physically and psychologically stable when they are discharged. And that when they're discharged, they're provided the resources and the connections to, to continue getting those needs met so they can maintain that stability and reduce recidivism. The first thing we do when somebody comes into the criminal justice system is screening. Basically we want to screen out certain people. We want to figure out if they have mental health issues, substance use issues, those are going to be screened in to the, you know, treatment age area, if you will, and then screen out people who are not presenting with current mental health or substance abuse issues. We want to assess their needs. And this isn't just treatment needs. We need to assess their life skills needs. We need to assess their ability to maintain a clean and sober and legal lifestyle when they are discharged. So there may be needs for ged, there may be needs for life skills, there may be needs for budgeting, connecting to housing when they get out. There are a lot of things, there's a lot of case management and wraparound services that go with screening. And you might be saying to yourself, well, you know, they just got into jail or prison. Well, yes, they did, potentially. Hopefully this is happening when they first get into the system. However, it Takes a while to build up to develop these skills. It also takes a while sometimes to connect people with the resources they're going to need when they discharge. We talked, when we were talking about homelessness last week, about the fact that public housing, for example, often is in very short supply. It may take several months to figure out adequate placements for. For some of the offenders who are being discharged. During screening, we also gather information, this is, you know, your general screening and assessment stuff about their history in the criminal justice system. If they have been in and out of the system most of their life, they may be institutionalized, meaning they may not have developed a lot of the skills that they need in order to live independently and legally in outside of prison. They may feel much more comfortable in a jail or prison setting. They may. And one of my clients told me one time, you know, out of, out of his mouth, that he had more friends and family that were in jail than were out of jail. Therefore, he felt more comfortable being in the jail area. He had a roof over his head, he had meals, and he had friends there. He had somebody who had his back. So he didn't feel threatened, he didn't feel scared, and he was getting his basic Maslow needs kind of met. So we want to gather information to figure out what does jail mean to you? For some people, it's devastating. For others, it's a welcome relief in some ways. So we want to figure that out. We want to figure out, you know, from their cultural perspective, you know, what are their needs, what do they hope to have, what do they hope life will be like when they are eventually released? We want to gather information about their perception of their mental health issues and their substance use issues, if any, you know, do they think they have any? And if so, what do they think is causing them and what do they think the most effective treatments will be? One of the challenges, and as usual, I'm getting ahead of myself. One of the challenges with treatment in a institutional setting, jail or prison, is there. There is a lot of criminogenic thinking that is pervasive, and criminogenic thinking and addictive thinking are often very similar. Criminogenic thinking and antisocial thinking. Antisocial behaviors are often very similar. And it's really hard for people to address those cognitive distortions and begin to adopt a healthier way of approaching life when they are immersed in a criminogenic environment. So we do need to remember this. Baby steps. One of the most frequent discussions. I don't want to say arguments. Well, Yes, I do. One of the most frequent arguments we would have with judges would be, you know, they would send somebody to our facility for treatment, and then they would say, okay, when, when Jim Bob finishes treatment, I want him to go to jail for six months. And we were like, okay, if, if that happens, you're basically undoing a lot of the work that we did because we've helped Jim Bob, you know, start taking steps forward. Then if you put him back into that old environment, you know, some of the old habits, ways of thinking, ways of interacting and emotional distress may reemerge. We also want to evaluate eligibility and suitability for different programs. A lot of jails and prisons have a variety of different programs, and based on their criminal history, based on their substance use issues, based on their mental health issues, they may be more or less suitable to certain programs or certain pods. How do we get all this information? Well, you know, obviously we're going to talk to the offender themselves. We also want to look at booking records, find out, you know, how long is the person's criminal history. We want to use some screening instruments, tools to identify needs and, you know, perceptions of things. We want to look at presentence investigations. Just because somebody wasn't convicted of something doesn't necessarily mean they didn't do it. Doesn't necessarily mean they did. But if you look at somebody's, you know, criminal history and you've got three pages of possession with intent that wasn't prosecuted, that kind of gives you a clue that maybe something was going on there. We also want to look at past treatment records, police reports and drug tests. If somebody has been in treatment before, we want to ask them about that experience. Did it help them stay clean and sober? If it didn't, why not? If it did, what parts of it were helpful and, you know, so we can build on those and what parts weren't so helpful. If they've had periods of sobriety, we want to ask them what triggers your relapses? Let's start making a relapse prevention plan. Now, obviously, we're also screening for mood disorders and we want to figure out, you know, if they've been in treatment for mental health issues, what worked, what didn't. Were they on medication? Did that help? If. If yes, what medications? If no, you know, well, obviously what medications there too. But we want to get an idea. So we are building on strengths and we're not repeating things that didn't work in the first place. Areas of concern. Well, the first one is accuracy in a, an in. In an Sorry. In an institutional setting, sometimes people are not really forthcoming about what's going on with them. Sometimes because of cultural issues or power dynamics, the person you're working with is not going to be totally forthcoming or even honest. And we need to bear that in mind, which is why you want to look at some objective information as well as the interview with the offender. Other areas of concern are continuity and system wide sharing, which are usually pretty dag on point core in the criminal justice system and the mental health system. A lot of times those two systems don't play nice together. And it's important that, you know, the people who are providing treatment communicate, for example, with the corrections officers so they can continue to implement the treatment strategies, the thinking strategies, those sorts of things that are trying to be communicated in treatment. Another one of my soapboxes, just bear with me for a second. Continuity is also an issue with medication. A lot of institutions, jails and prisons, the as a cost saving measure, the offenders will be taken off of their medications as soon as they are admitted and they are not put back on their medications unless they become a behavioral issue. And that is just so, in my opinion, unethical and detrimental and bad in so many different ways. So the continuity of treatment, they may have been relatively stable when they were, you know, before they got arrested and then when they got put into jail, they were taken off all of their meds. And now not only do they have all these other things going on, but now they're also dealing with mental health issues when they are discharged. We know that it takes medications, you know, four to six weeks, especially your SSRIs, to really build up in the person's system. And a lot of times the person, if they haven't been on medications before, the first medication isn't going to be necessarily the ideal medication for that person. So there can be a period of trying to get the dose and the type of medication stabilized. That is really important to remember. Re screening and reassessing is another area of concern. We don't want to screen somebody when they come in in August of 2020 and then not re screen or reassess until they are ready to discharge 18 months later. You know, a lot changes even in jail, even in prison for people that are incarcerated. We need to regularly rescreen and reassess. They're going to. Their life outside may continue to go on. They may have kids on the outside that are growing up, or hopefully not, but maybe getting into legal trouble. There may be other issues on the outside that are going to get to them. They're going to find out about them and they're going to impact that person. We do need to remember that re screening and reassessing is just as important. Another issue that we see that kind of goes with continuity is the fact that a lot of times the medical and mental health providers in jails and prisons are not full time staff of the institution. They are contracted employees. That may come once a week, may come twice a week, may come sporadically, and there is a whole lot of turnover. A lot of people really don't like working in an institutional setting, which is a problem. Again with that continuity. If you're starting to establish rapport with somebody and then they disappear and you have to start over with somebody else, it can be very frustrating and disempowering and make you feel like, you know, what's the point? You're just going to disappear in two months as well. Timing is of the essence. We need to make sure that we get the timing right for treatment. Like I said earlier, you want to make sure that the person has treatment skills. The interventions you're applying last through their discharge. You don't want to do something the first six months they're in incarcerated and then let them go the last six months or a year or two years or whatever it is. It's important to time the interventions so the positive thinking skills, the empowerment, the self esteem, all that kind of stuff is just at its peak when they are ready to discharge. Drug testing is important. I hate to break it to you. If you've never worked in the jails or prisons, you may think that they don't get drugs in there. That is false. They do. And it just, it is what it is. So drug testing is really important because you don't want to assume that people are staying clean. We do need to meet people's detoxification needs. If they do, you know, use when they're in prison or in jail, they will need to be detoxed. We need to make sure that we're addressing them and providing them interventions that are appropriate to their level of readiness for care. If you remember Prochaska's stages of change, pre contemplation, contemplation, preparation, action and maintenance. If somebody is in pre contemplation, they don't think they've got a problem. You're probably not going to want to put them in the same activities as a group of people who say, yeah, I screwed up, I was drunk, I was high, I've got an addiction, I've got, you know, bipolar disorder, That I wasn't taking my meds, whatever it is. Those people who are ready to make a change in their life need to be in a different program than those people who are still not. We want to look at a history of trauma. Trauma is, can be triggered in a lot of different ways in the institutional setting. And remember, when people feel traumatized, experience trauma, they are disempowered and they don't feel safe. What do we do when we are disempowered and we don't feel safe? We tend to become hyper vigilant, irritable, anxious, maybe even depressed. And a trauma history may explain some of the less helpful behaviors of clients, especially the. Within the criminal justice system, you know, while they're in the institution, because they feel again, like they are in a place where they are not safe and they are disempowered. It's important to examine a person's behaviors and remember, behaviors are communication. What is this person's behavior telling me? What is the benefit to Jim Bob for acting this way? Um, and for those of you who haven't been in my classes before, I always use Jim Bob as my classic client because there aren't a whole lot of Jim Bobs out there, so there is much less risk of anybody accusing me of HIPAA violations. So Jim Bob and Sally sue are my two faux clients, if you will. We want to screen for psychopathy, and that includes personality disorders, that includes psychotic disorders. That includes, you know, everything in the dsm. We want to see if there are other things that are contributing to people's behaviors. When people are in a florid, bipolar manic episode, they are going to do things, they're going to be more impulsive, they're going to be, you know, doing things, and they're going to be more at risk for abusing certain substances than maybe they would be if they're in a depressive episode. So we do want to look at what's going on with them. Remember, though, always look at symptoms of a person's, you know, presenting disorder in terms of what does this mean, how is this symptom protective, or how does it make sense? A lot of times, even with personality disorders, or maybe even especially with personality disorders, the symptoms can be traced back to trauma and, and that can include abandonment issues, attachment issues in, in early childhood. But we want to look and figure out, you know, why did this symptom develop and in what way was it functional for the person at some point in the past and what can they do differently now? We also want to assess their risk for violence. Obviously we don't want that to happen. And recidivism planning ahead of time is going to be really important. Like I said, sometimes it takes months in order to get the case management widgets in place for your clients to discharge into an environment that is supportive of their continued recovery. Happiness, health and legal living. We do want to consider what has caused you, for each person, what has caused you to recidivate in the past. It may be hanging around with, you know, old friends, it may be going back to the same neighborhood, it may be poverty. You know, there are a lot of different issues that we need to look at. Diagnosis pitfalls. As I said earlier, sometimes it's difficult to get people to be honest with you because there's a stigma around mental health diagnoses, especially not as much around substance use issues, but more, more so around mental health diagnoses. So some people may not want to admit the feelings that they're having. We can also have some inaccuracy in our assessments of their symptoms based on their withdrawal. A lot of people when they enter jail, you know, when they first get into jail, they're arrested the first month or so, they may be going through some significant withdrawals. That's not uncommon. And remember, post acute withdrawal syndrome lasts for up to 18 months. So even if somebody has been in, incarcerated or in an institution, as they say, for a couple of months, they may periodically have episodes that are akin to withdrawal. And we do want to be sensitive to that and recognize, you know, what may be causing these symptoms. If they have a substance abuse diagnosis, it may obscure the mental health diagnosis. When people are detoxing from stimulants, for example, they're probably going to evident symptoms of clinical depression. When people are detoxing from benzodiazepines, from your anti anxiety medications, from your downers, they're often going to become much more anxious and agitated. Doesn't necessarily mean they've got generalized anxiety disorder. It may be their neurotransmitters trying to balance out. It could be that they were self medicating a mental health issue, you know, ahead of time. We won't know until they've got some clean time. What's important in the early phases is to help them cope with the symptoms that they're experiencing. And that's, you know, between the mental health practitioner, the physician and the client. And a substance abuse diagnosis may limit offenders access to certain programs. So sometimes you don't want somebody to come up with a substance, substance abuse diagnosis because you want them to be able to be engaged in a work release program, for example, which may be prohibited if they have an active substance use issue. Not saying not to diagnose it, that would be unethical. But these are some of the pitfalls with diagnosis. If you're, if you do it, there are a lot of difficulties with accuracy. It's also another reason why reassessment is so important. Reassessment after three months gives you a much better picture of whether the symptoms were presenting as a result of substance use withdrawal or whether the symptoms are actually an underlying mental health issue. Why do we diagnose in the first place then? Well, reimbursement. It is what it is. You know, we need to provide services to some people who have mental health or substance use issues that are incarcerated. They need help, they need treatment. In order to provide that treatment, it don't come free. We have to be able to pay for it somehow. Whether it's from state funds, TANF funds, Medicaid, Medicare or insurance or whatever. There are pots of money that we can pull from to provide treatment. But in order to do that, people have to have a diagnosis. A diagnosis can also support pharmacological interventions. Remember, pharmacology only works for about 30% of people, but for that 30% it works and it may be essential to helping them maintain stability and good behavior. If you have somebody who has bipolar disorder, for example, who is unmedicated, you're setting them up for failure. It is essential that people have pharmacological interventions when needed. And if we can show that there's a diagnosis, we obviously then we have a little bit better of, a little bit more of a leg to stand on to argue that the person needs to stay on their meds. We need to have the ability to diagnose when psychiatric concerns emerge. That way maybe somebody can be moved to a different pod if they need to get more intensive care because of the emergence of the psychiatric issue. We need to be able to diagnose to clarify co occurring issues. Too often, unfortunately, in institutions, substance misuse, substance abuse is often seen as an isolated diagnosis. And there is a lot of evidence that substance misuse in and of itself messes up the brain chemicals. So there are going that people are going to have mood issues when they're detoxing until their brain heals from the substance misuse. But we also have a lot of people that self medicate their anxiety, their depression, their trauma with substances. And it's important to be able to identify those. It helps people Understand sometimes why they use, and it also can provide a clearer path for treatment. People with co occurring disorders that only treat the substance abuse issue are likely to relapse and recidivate in under six months. And sometimes research and evaluation is a reason for diagnosis. The more we understand about this population, the better chance we're going to have to prevent criminogenic behavior from starting and to prevent recidivism once people are released. There is a greatly disproportionate number of people in jails and prisons with substance use disorders, trauma histories, and mental health diagnoses. It's, you know, way up there in the majority. Some diagnoses are up into the 90% range. So it's really important to understand what may be going on with these people that that may have ended up making them more vulnerable to incarceration. So what do we do if we have to diagnose? How can we destigmatize it? Help people understand that diagnosis is just shorthand. If I say this person has major depressive disorder, that tells everybody else who reads the chart generally what symptoms that person may have. We also want to destigmatize the diagnosis by evaluating their presenting issues and differentially diagnosing. That means don't assume it's necessarily just major depressive disorder caused by cognitions. Maybe you're working with somebody who has major depressive disorder because they've got low testosterone or because they've got hypothyroid or a variety of other issues. There are a lot of different biochemical things that can happen that can present as bipolar disorder, major depressive disorder, anxiety, and even adhd. So we do want to make sure that we're figuring out what the root cause of these symptoms is. That also helps destigmatize it. When people start understanding, hey, it actually does. This actually is something with my body. It's not just, you know, all in my head, so to speak. It's because of a chemical imbalance. You can also normalize the diagnosis by helping people identify people that they respect who have that diagnosis. You know, depression, schizophrenia, substance use disorders, whatever it is. It's not hard to go online and find people in from just about every walk of life that has just about any diagnoses. And also having the people do complete an all about me worksheet. And that's a worksheet where they write down their strengths, they write down their positive qualities, they write down their accomplishments. Screening instruments that can be used. You want to assess for reliability and validity, make sure that you're testing. The answers that you're getting are providing you information about what you think gets better. Providing you can use the Addiction Severity Index, the Alcohol Use subscale, the ASI Drug Use subscale, the Drug Use Drug Abuse Screening Test, or the dast, or the Michigan Alcoholism Screening Test, or the mast, or the simple screening instrument for Substance Abuse, which is the SSI for Substance Abuse. All of these can be found in the SAMHSA tip 44 in the appendices. So they're easy to find. They're free. With assessment, the Addiction Severity Index can be reproduced. It's in a structured interview format and examines functioning in the areas of drug and alcohol use. How much do you use? Do you use recreationally? Is it a problem? The history looks at their relationships, their employment history, legal involvement, physical health and mental health. So you can start seeing how all of these things may be contributing to or impacting each of the other areas. For substance abuse, we want to assess their history. When did you start using? What did you start with? Let's look at the progression of their substance use. We want to look at their motivation for using, the severity and frequency, their detoxification needs, and their treatment history. We want to assess their criminal involvement, including their criminogenic thinking. And there are. I have other videos on criminogenic thinking on the YouTube channel, but a lot of it surrounds cognitive distortions. And then also, if you look into the characteristics of people who have more antisocial personality disorder, you'll see more and more narcissistic personality disorder. You'll see more thinking patterns that are akin to criminal thinking. Not saying that they're necessarily diagnosable with a personality disorder. I'm just saying that those thinking patterns kind of overlap. We want to look at their offenses. Are we looking at just petty drug possession or are we looking at an escalating pattern of violent crime? Look at their probation history, their use of diversionary programs, and any other diagnoses that they've already received. For health, look at their intoxication. We want to assess them for infectious diseases, including hepatitis, aids, you know, the gamut, especially these bloodborne diseases and tuberculosis. Any of those health issues can also contribute to mood issues, can also be worsened by substance abuse. So we want to make sure that we're helping somebody get the best restart that they can if they're female. Assess for pregnancy, look at general health and any acute conditions that need medical care. For mental health, you want to look and assess their suicidality. Like I said, some people, when they go to jail or prison, it's not a huge big deal. They've been there before or they expected to go there. For other people, it feels like their world has come crashing down and they may be suicidal. For some people, even people who've been in the system before, if they are readmitted to the system and, and taken off their medication, they may become suicidal. It is important to regularly assess and encourage the corrections officers to also periodically just scan for indications that somebody may be decompensating. Find out again their mental health, diagnoses that they've gotten in the past and their treatment history. Assess for any acute symptoms, symptoms that may be going on, and any current medications. Physiological medications like cholesterol medications and blood pressure medications also affect mood. So if those are altered, then you also may see an alteration in the mood, even though those don't directly aren't directly used for mental health medications. Special considerations that we need to think about when we're doing these assessments and placements include the person's educational level, their reading level or their literacy, any language or cultural barriers, any physical or developmental or learning or cognitive disabilities, their ability to access and secure housing when they're released, any dependent or family issues that they may be dealing with while they're incarcerated or when they get out, and any history of abuse, whether they were the victim or the perpetrator, that is going to affect their mental health and potentially some of their options when they're discharged. The continuum of services include pre treatment, outpatient and inpatient. And when we're talking about this in the criminal justice system, pre treatment is your assessment and detoxification. Wherever that's done. Outpatient may be, you know, once a week, seeing a therapist at, in the facility, and then obviously traditional outpatient when they're discharged, and then inpatient. Some jails and prisons actually have special wards that are basically like Level 4 inpatient residential treatment facilities. Key staff preparations. People who are working in this field and with this population need to have a resource database, and they need to know what resources are available in the community for everything from housing to child care to medical care. You know, when the person gets out, they're going to need a lot of options, what the eligibility and suitability is for admission to any of those programs once they're discharged, and how to document the referral process with each of those agencies. It is ideal to have a memorandum of understanding in place ahead of time that details the information to be shared, the supervision and treatment responsibilities, and the ongoing effectiveness of the relationship. You know, how are we going to assess whether this is a good partnership or not. When this person, it leaves the the facility, is released and enters into my treatment program, for example, you know, who's responsible for treatment? Well, obviously if it's a treatment program, I am. Who's responsible for supervision? You know, is the jail still wanting a call for head count twice a day? Exactly. Who is responsible for supervision of this offender at this time? People with moderate to high risk of recidivism. We need to really dig down into that criminal history. And you know, the people who are at more high, at higher risk, have a longer criminal history, a poor employment history, a poor support environment, often experience homelessness and may have some antisocial traits. Now, I'm not saying a diagnosis, I'm saying traits including impulsivity, lack of empathy, anger issues and entitlement. Now think, remember, behavior is communication. What might cause someone to lack empathy if you are severely traumatized or lack attachment when you are growing up, if you are exposed to those adverse childhood experiences when you are growing up and they are severe, you may build up this wall and have difficulty empathizing with other people. Children learn empathy. It's not something that we're born with. So without nurturance growing up, some people grow up lacking empathy. Homelessness, poor support and poor employment, those are all super stressors. When people are super stressed, guess what? A lot of times they're going to do whatever they have to do to survive. And sometimes that means criminal behaviors. Not saying that it's right, but somebody who has to steal food to eat or somebody who becomes a prostitute because they are homeless and they need to earn money and they want to have a pimp that is going to help keep them safe. You know, think about it from their perspective. How does this behavior, how does their criminal behavior make sense from a survival standpoint and what factors contributed to that? If people have moderate to severe to severe substance abuse problems, they're going to show substance dependence. They're going to likely have substance related arrests, DUIs, possession, possession with intent. They may have a history of substance abuse with or without treatment and often have positive drug tests, especially if they've been on probation or in diversionary programs or when they're arrested. They may test positive to identify moderate to severe mental health issues. You know, these people may have symptoms of suicidal or violent ideation or behaviors. They may have acute symptoms of major depressive disorder, ptsd, anxiety, schizoid personality, whatever it is, they may have cognitive impairment, including problems with concentration and problem solving. Now another soapbox here. Sorry, y'. All. I'm gonna try to get through this before the end of the hour. When people are heavy alcohol drinkers and they are detoxing, alcohol prevents the absorption of thiamine. If somebody who did not have a cognitive impairment suddenly starts evidencing cognitive impairment. Even if they, you know, were binge drinkers and you know, they, they drank heavy over the weekend and then they got arrested on Monday and then all of a sudden they start showing symptoms of cognitive impairment. It is essential to get them evaluated for Wernicke Korsakoff syndrome, which is that deficiency of thiamine. It can cause long term brain damage if it is not immediately addressed, usually by IV thiamine. So that's, that's up there. Some people have cognitive impairment like fetal alcohol spectrum issues. Again, I have more videos about that on the YouTube channel. Fetal alcohol spectrum issues make people more likely to be gullible, make them have difficulty learning from their consequences. There's a lot of issues with FASDs that make those people more susceptible to criminogenic involvement. And if they've got mental health issues, we also want to look at their interpersonal skills, their frustration tolerance and any emotional dysregulation issues. We want to look at the person's perceived severity of problems. Remember we talked about the stages of readiness for change, Pre contemplation, contemplation, preparation, action and maintenance. You can use the Socrates, which is in treatment improvement protocol 35. Again, that's free on the SAMHSA website. In order to assess people's motivation really easily, you want to look at prior evidence of attempts to improve and their perception of the importance of treatment to help gauge their engagement or willingness to engage in the treatment process. Implementing treatment involvement and treatment planning don't do it for them. Get them involved. Develop mutually agreeable goals. Use motivational interviewing to enhance their sense of personal empowerment. Coordinate with the team and that includes the correctional officers and anybody that they interface with on a daily basis. Update any status changes with regularity with the entire team in order to make sure that everybody's on the same page with what this person's program is at the moment. And make sure that there are community based linkages at reentry. We don't want to just kick somebody out the door and go, good luck because that ain't gonna cut it. We want to provide outreach and low intensity interventions to all offenders at, when they enter the system, during daily activities and at exit and re entry. When we do it at entrance and do it during their daily activities. We're engaging, we're developing rapport, we're learning more about that person so we can provide more effective services and referrals at reentry. Skills to consider include communication and social skills, self regulation, self soothing, problem solving, and goal setting. Cognitive behavioral therapy works really well with the majority of this population, provided they don't have significant cognitive impairments. Components of criminality that need to be addressed in the treatment process. Criminal thinking, criminogenic thinking, the criminal code, or the inmate value system. You know, stitches gets, snitches get stitches. We've all heard that on TV and there are many other codes and manipulation. Part of criminality and part of antisocial behavior is manipulation to get what you want. You will see this in people who have been incarcerated, especially for a long time or multiple times, or they've learned how to work it, that's okay. But we need to help them use that skill. And, and I look at it as a transferable skill. Use it for good instead of evil. You know, look at how good you are at working with people, at convincing people to do things. You know, what great leadership skills this could be translated into if used appropriately. You know, look at how some of these things can be used for the person's benefit. Criminal thinking a lot of times is a learned behavior and they learn the ideas of entitlement. They learn the ideas of, you know, nobody's got my back but me. There are a lot of things that they learn. We need, when we're addressing criminal thinking, we need to help them recognize their thinking errors and, and their impact on behavior. And you can do a Google search for criminogenic thinking patterns and come up with a bunch of those again. Got more videos on the YouTube channel on that? No. Time to go into it in this hour and use cognitive behavioral therapy and staff and peer confrontation. If somebody is acting out or is engaging in criminal thinking, sometimes they need to be called out on it. And we do it gently, we do it compassionately. But it's important to present to them objectively. Think intervention. Present the information objectively to them so they can see their behavior. One of the benefits to institutional settings is that everything's recorded. So sometimes you actually can get a video that has audio and video and you can help the person actually see, see their verbal and nonverbal dynamics and how that impacts the people around them. Criminal code includes refusal to cooperate with authority, refusal to confront negative behaviors, and participation in treatment viewed as a weakness. You know, those are things that we're Going to have to work with. Instead of having them see us as much of an. As much of an authority figure, we want them to see us as a team member. And it's not going to completely happen. We always. We get to leave. We do have an authority position, but we do want to help develop rapport. And it's going to take some time. If they don't want to confront negative behavior, remember, resistance tells us something. Resistance tells us it's too scary to change. If they confront their negative behavior, they that may be seen as weak in general population and that's not safe. So what is the benefit to them not confronting their negative behavior? It could be too scary or too threatening or too dangerous to do. They may not have the skills to do it. They may not know how to confront this behavior or how to do anything different. They don't have tools to. To handle their anger, for example. So we want to look at what is the resistance telling us. Why is it more beneficial to them to do one thing instead of what I want them to do? Manipulation takes the form of throwing focus, team splitting, and demeaning others. When we throw focus, you know, it's taking the focus off of me. So I may be sitting in session with somebody and they start telling me instead of about what's going on with them, Especially if I hit one of those hot button areas and it gets uncomfortable all of a sudden they may start telling me about what so and so is doing and how they've smuggled in contraband. And it's important to recognize when somebody is diverting. Team splitting is very common because it's much easier to manipulate people when they are split than when there is a unified whole. Because as a team, we have many more eyes seeing what's going on. But if we are split, then we're. You don't have as you don't have that unified front. Noticing as much and demeaning others can sometimes be a way that the offender communicates when he or she feels threatened or when they feel vulnerable. They may demean other people to bring them down because they feel like they're being attacked in some way. Recognize the meaning of the behavior. We also see a lot of excuse making, blaming, justifying, throwing focus, lying, making fools of people and building up and bringing down. So sometimes offenders will build somebody up, you know, and get them on this peak and then just pull the rug out from under them just to let that person know that you're never safe. I've always got control and I can pull that rug out from under you, whenever I want to the, excuse me, making the blaming, the justifying and the throwing focus, those are not uncommon cognitive errors or problems in treatment, whether it's a criminal justice population or, you know, something else. And we do want to have people start taking responsibility. And I use the finger pointing theory. When you're pointing your finger at somebody, two fingers are pointing at them, three fingers are pointing back at you. Generally it takes two to tango. So what was your part in this? And you know, why do you think it happened? Assuming is another issue that, that whole mind reading thing, and that's one of those basic cognitive distortions that we need to help people address. Based on people's prior experiences, their prior life history, they make assumptions about other inmates, about correctional officers, about us, about the system. It's going to be important to encourage them to identify their assumptions and check them against the facts. They may have an idea that they're unique and the rules don't apply to them. Okay, you know, let's talk about why that doesn't apply to you. Look at the facts in, you know, help me understand where you're coming from and how you arrived at that conclusion. They may ingratiate themselves in order to manipulate you. They may be the, on, on the surface, the most compliant client that you've got on your caseload. But as soon as they walk out of your office, not so much. You may see some fragment fragmented personality behaviors that are inconsistent. Some days they show up and they're in a good mood and they're cooperative. Other days, you know, the total opposite. And we want to examine what's different on those different days. Minimizing, exaggerating, vagueness and non committal anger and power plays. These are all very common issues that you may need to address with, with your people, like vagueness and non committal. We may be talking about discharge planning and getting a job and they may say, yeah, you know, I'll apply for something when I get out. You know, that's really kind of vague. I want to know, I'm going to apply at these five places the day after I get out. You know, get some smart goals, specific, measurable, achievable, time, limited and relevant. Obviously the R comes before the T, but whatever. And yes, a lot of these behaviors actually do resemble some of these. Some of the issues that you may see in adolescents as adolescents are trying to develop their skills. Remember, the brain doesn't fully develop until the age of 24. So adolescents also tend to be much more impulsive. And some of that May come out in their behaviors. And cognitive distortions are not unique to the criminal justice population. Victim playing, being shut down, or just a complete unawareness of others boundaries are also very common issues in this population. A lot of the people in the criminal justice system have been traumatized. We don't want to minimize that, but we also want to recognize that there is a portion of those people who have figured out that holding on to that victim role can be very beneficial to them if they work it to manipulate those in charge. Not saying everybody does it, but it is a tool in their toolbox, so to speak. When addressing anger and hostility, we want to encourage the person to identify the feelings that they're feeling right then. Physical sensations as well as emotional feelings. Understand where that feeling is coming from. What thoughts are you having that are triggering that anger, or what is going on that is making you feel irritable, hostile, angry? It may be that they feel unsafe. It's triggering something from a trauma in their past, and so they're feeling more defensive. We don't know. We need to process that with them. We need to help them identify the goals anger is serving. Anger is a fight, the fight part of fight or flee. Anger is protective in some way. It either gives them power over somebody or pushes people away. Either way, it's giving them a safe boundary. Identify their goals that the anger is undermining. For example, early release for good behavior may be undermined if they're angry and acting out and help them work toward taking the longer view. You know, yes, this person did something, it made you really angry. But is it worth sacrificing all of the good days that you've had and all of the good behavior? Points for acting out to, you know, get in a fight with this person right now. Barriers to effective treatment, including inaccurate placements, poor staff training, as I said, lots of staff turnover, over reliance on institutional sanctions versus peer pressure, and, you know, over reliance on institutional sanctions. Instead of also asking yourself and the client, you know, what is it that's causing this behavior? Where is this coming from? What function does this behavior serve? Aftercare availability and compliance is also a big issue because a lot of times when people are discharged, you know, all of a sudden they start facing life and starts to get real overwhelming real fast. And treatment is the last thing on their mind. Coercion, you know, for people who don't see that they've got a problem or not interested in treatment, that's going to make it more difficult to provide effective treatment and treatment versus other facility opportunities. May also be a barrier. It may seem like a lot more fun to go or easier to go work over in this pod as opposed to going to treatment, which is really unpleasant when people get out or sometimes before they go in, they're involved in drug courts. 10 components to effective DRUG COURTS Drug courts integrate treatment with the justice system. It uses a non adversarial approach to promote public safety while protecting people's due process. It identifies people early and promptly places them in a situation where they've got contingencies on staying clean and sober. It provides immediate access to treatment of their co occurring issues. And it provides ongoing monitoring by drug testing. So you know people are really getting off to a good start. There's a coordinated strategy governing responses to compliance or non compliance. There are very specific sanctions for testing positive or not going to treatment. There's ongoing judicial interaction with the participant that actually tends to promote self esteem. As they move through the drug court process, people start developing a sense of empowerment and they also my experience has been develop a much different relationship with the, with the judges and the criminal justice system when they, when they go through a drug court. There's monitoring and evaluation of goal achievement, continuing interdisciplinary education and forging partnerships for local support and program effectiveness. So the drug court actually works with community agencies to create a recovery oriented system of care treatment accountability for safer communities or task programs Bridge treatment providers and the criminal justice system. They provide screening and assessment referrals, monitoring of treatment, case management and a court liaison. Your courts are going to know if you've got a task program. Interventions that you can use. Brief therapies, which is treatment improvement protocol 34 motivational interviewing, which is treatment improvement protocol. 35 behavior contracts, phased treatment such as, you know, starting out more intense and then gradually reducing the intensity as they move through the treatment process. Substance abuse education, detoxification day reporting and drug testing. Criminal thinking assessment and treatment is important even if you're working with substance use. We need to address the cognitions, coping skills training, relapse prevention tools, strengths building and communication skills enhancement so they're able to assertively identify and communicate their needs. Wraparound services include vocational services like job readiness, assessment and preparation and liaisons with employers that are willing to hire people with criminal histories. Literacy assessments and referrals as needed. Anger management training, HIV and other communicable disease education and testing, assistance in accessing public assistance and awareness or increased awareness of self help programs. Most treatment in jails is involuntary. There is a lack of affiliation with pro social peers while they're in jail, which can be a problem. And sometimes there can be a lack of modeling of good behaviors from peers and staff. That's something that we really need to work on. Creating a healthy community. There can be scheduling constraints, gang affiliation, confidentiality issues, trauma issues, and hopelessness. When somebody's on community supervision, they can be involved. Also in therapeutic communities, intensive outpatient halfway houses, or day reporting, Women have particular issues that maybe according to the tip, they may also have mental health issues. They tend to have more abuse history, they may be HIV positive, they may have poorer employment histories, child custody issues, or lower education levels. The elderly, when they are released, have often been in and out of the system. For them, prison rules are the norms and a lot of times developmental milestones are absent. This is called disculturation or institutionalization. Engage them by having them help other people. The elderly population that's in the criminal justice system also often struggles with increased health problems, a slower response to directions because the slowed cognitive processing, physical issues that are misdiagnosed as mental health issues, and lack of assertiveness. There is a unique set of learned behaviors in the criminal justice population. There are always drawbacks and benefits to giving up criminality, and we need to help people assess those for themselves. It's important to work with the client to set clear boundaries and rules, identify biopsychosocial issues, and that will help them prepare for a healthy legal lifestyle upon release and ensure that they have a strong case management and reentry plan that provides for seamless transition back into the community. All righty. Are there any questions? Yes. I love drug courts. I worked with a variety of different types of. We called them problem solving courts because we had mental health court, which was designed for people who had gotten involved in the legal system because they weren't taking their medication and they were, you know, having. Having difficulties. Then there were the drug courts. There were dependency drug courts. There were a lot of different options, and they, for the most part, really seem to be very effective at helping people. And it is important, when you're looking at their reentry plan, that you assess all of their biopsychosocial needs. Use that Maslovian pyramid, you know, wherever they're going to live, are they going to have a safe, stable housing environment that is free of drugs and criminal behavior? If not, that is something that's going to have to be addressed. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. A direct link to the on demand CEUs for this podcast is at allce.com/podcastce. That's allce. Com podcastce. To sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week, go to Allce. Com sponsor. Thank you.