Vol.12, No. 9
Welcome to the September edition of Tips and Topics (TNT). I’m glad that we have many new subscribers to join our longtime TNT community.
David Mee-Lee M.D.
It is difficult to work in the mental health and addiction treatment field without interfacing with clients involved in the criminal justice system. Some addiction treatment programs receive 90% or more of their clients from the criminal justice system.
“In a 2006 Special Report, the Bureau of Justice Statistics (BJS) estimated that 705,600 mentally ill adults were incarcerated in State prisons, 78,800 in Federal prisons and 479,900 in local jails. In addition, research suggests that “people with mental illnesses are overrepresented in probation and parole populations at estimated rates ranging from two to four time the general population” (Prins and Draper, 2009). Growing numbers of mentally ill offenders have strained correctional systems.”
Here’s another headline from the Bureau of Justice:
STUDY FINDS MORE THAN HALF OF ALL PRISON AND JAIL INMATES HAVE MENTAL HEALTH PROBLEMS
“More than half of all prison and jail inmates, including 56 percent of state prisoners, 45 percent of federal prisoners and 64 percent of local jail inmates, were found to have a mental health problem”. This was according to the 2006 study published by the Justice Department’s Bureau of Justice Statistics (BJS).
And now, note this headline on addiction and criminal justice:
NEW CASA REPORT FINDS: 65% OF ALL U.S. INMATES MEET MEDICAL CRITERIA FOR SUBSTANCE ABUSE ADDICTION, ONLY 11% RECEIVE ANY TREATMENT
NEW YORK, N.Y., FEBRUARY 26, 2010
The National Center on Addiction and Substance Abuse at Columbia University, a
drug policy organization, found that “of the 2.3 million inmates crowding our nation’s prisons and jails, 1.5 million meet the DSM-IV medical criteria for substance abuse or addiction, and another 458,000, while not meeting the strict DSM-IV criteria, had histories of substance abuse; were under the influence of alcohol or other drugs at the time of their crime; committed their offense to get money to buy drugs; were incarcerated for an alcohol or drug law violation;or shared some combination of these characteristics, according to Behind Bars II: Substance Abuse and America’s Prison Population. Combined, these two groups constitute 85% of the U.S. prison population.”
Any way you cut it, in clinical work it is increasingly important to understand Drug Courts, Mental Health/Behavioral Health Courts, other Problem-Solving Courts, and how to interface with Probation and Parole officers, Judges and their court teams.
What Are Problem-Solving Courts?
Here’s how the Center for Program Evaluation and Performance Measurement explains these courts:
“Problem-solving courts began in the 1990s to accommodate offenders with specific needs and problems that were not, or could not be adequately addressed in traditional courts. Problem-solving courts seek to promote outcomes that will benefit not only the offender, but the victim and society as well. Thus problem-solving courts were developed as an innovative response to deal with offenders’ problems, including drug abuse, mental illness, and domestic violence. Although most problem-solving court models are relatively new, early results from studies show that these types of courts are having a positive impact on the lives of offenders and victims and, in some instances, are saving jail and prison costs.
In general, problem-solving courts share some common elements:
- Focus on Outcomes Problem-solving courts are designed to provide positive case outcomes for victims, society and the offender (e.g., reducing recidivism or creating safer communities).
- System Change Problem-solving courts promote reform in how the government responds to problems such as drug addiction and mental illness.
- Judicial Involvement Judges take a more hands-on approach to addressing problems and changing behaviors of defendants.
- Collaboration Problem-solving courts work with external parties to achieve certain goals (e.g., developing partnerships with mental health providers).
- Non-traditional Roles.These courts and their personnel take on roles or processes not common in traditional courts. For example, some problem-solving courts are less adversarial than traditional criminal justice processing.
- Screening and Assessment Use of screening and assessment tools to identify appropriate individuals for the court is common.
- Early identification of potential candidates Use of screening and assessment tools to determine a defendant’s eligibility for the problem-solving court usually occurs early in a defendant’s involvement with criminal justice processing.”
Access “A Technical Assistance Guide For Drug Court Judges on Drug Court Treatment Services“
The Justice Programs Office, School of Public Affairs at American University, Washington D.C. http://www.american.edu/justice has published a very useful guide that helps judges understand what is addiction treatment. It helps treatment providers understand Drug Courts. You can Google the guide (paste in “A Technical Assistance Guide For Drug Court Judges on Drug Court Treatment Services“)and it should come right up.
There is even a small section on The ASAM Criteria (2013) which I was privileged to contribute.
In May this year, I gave a presentation on The ASAM Criteria at the National Association of DrugCourt Professionals in Anaheim, California. It was such a learning experience for me to be around so many judges, attorneys, court team professionals and treatment providers. In a session I attended on Judicial Leadership principles, I was struck by something one of the judge panelists said when speaking of client outcomes (sorry, I didn’t note which judge it was):
“People don’t failDrug Court, Drug Court fails them by not meeting their needs.”
Problem-Solving courts are focused on outcomes. But knowing how easy it is to blame the offender and participant in Drug and other Problem-Solving Courts for any poor outcome, that statement really got my attention………and got me thinking:
- How should Drug Court, the judge, court team and treatment provider work together to meet the needs of participants?
- How do we collaborate to get the outcomes of increased public and community safety and decreased legal recidivism and crime that we all want?
- When client outcomes are not going well, what is the balance between client accountability and the treatment provider’s responsibility to improve assessment and treatment planning?
- What is the role of court sanctions and incentives in holding offenders accountable for treatment adherence?
- What is the role of treatment providers to keep the court informed about the participant’s threat to public safety?
Some judges are rightly concerned that treatment providers are not watching public safety closely enough. Not sure that they trust treatment providers’ reports, judges sometimes take treatment into their own hands. This can result in judges working outside their scope of practice and issuing sanctions or mandates that are not clinically assessment based. Here are some examples:
- Mandating 90 days of residential level of care
- 90 Alcoholics Anonymous meetings in 90 days
- Ordering sanctions that may be ineffective in producing improved treatment engagement and real client functional change.
Consider these thoughts on how to deal with sanctions and incentives in Drug Court (and other Problem Saving Courts)
Drug court participants are varied and can present with addiction, mental health and physical health complexity. These diverse clinical presentations highlight the need for individualized approaches to sanctions that are:
1. Based on assessment of each client’s multidimensional needs as per The ASAM Criteria six dimensions (I’m biased of course, and there are other assessment tools and parameters that address high risk and high need). So assessing if a person is developmentally disabled and suffers from an intellectual developmental disorder (previously called Mental Retardation) is important compared with a person who has antisocial personality disorder or lifestyle and is very institutionalized and used to incarceration. The intellectually developmental disordered person has deficits in reasoning, problem solving, abstract thinking, judgment, learning from instruction and experience etc. The institutionalized antisocial person experiences sanctions like water on a duck’s back.
2. Based on treatment engagement and good faith effort of the client in treatment. Participants with co-occurring mental and addiction issues will have more difficulty with engagement and have needs that require awareness of their multiple vulnerabilities. Treatment plans need to be assessment-based and person-centered not program and compliance based. Because of different client learning styles and their array of needs, any manualized and evidence-based curriculum may require adaptation to fit each client’s problems and progress/outcomes.
This calls for a level of clinical sophistication to use Evidence-Based Practices (EBPs) in a person-centered and outcomes driven manner rather than a compliance and one-size-fits-all manner. Interactive Journaling is an evidence-based method to facilitate self-change using Motivational Interviewing, stages of change work and CBT. The Change Companies has a Drug Court journal that can be used along with other journals designed for criminal justice populations used by Federal Bureau of Prisons and many others.
3. Based on outcomes in treatment. Is the client making progress in real accountable change? Are they demonstrating improved functioning that will increase public safety, decrease legal recidivism and crime and increase safety for children and families? Active credible treatment is not just about compliance with attendance and negative drug screens. Is the client invested in a change process at a pace that fits their assessed abilities and vulnerabilities? Or is the client merely passively complying, which does not translate into lasting change and increased safety? How do we impact the revolving door of repeated episodes of treatment and incarceration, which wastes resources and does not produce the outcomes we all want?
What is the “bottom line” on how to move from punishment to accountability for lasting change – implications for sanctions and incentives?
A. Sanction for lack of good faith effort andadherence in treatment based on the clinical assessment of the person’s needs, strengths, skills and resources. Don’t sanction for signs and symptoms of their addiction and/or mental illness in a formulaic manner that is one-size-fits-all.
B. The treatment provider is responsible for careful assessment and person-centered services and to keep the court apprised of any risk to public safety. The court should be informed about the client’s level of good faith effort in treatment; and whether the client is improving in function at a pace consistent with their assessed needs, strengths, skills and resources. The provider should not just report on passive compliance with attendance and production of positive or negative drug screens….passive compliance is not functional change.
C. If the client is not changing their treatment plan in a positive direction when outcomes are poor e.g., positive drug screens, attendance problems, passive participation, no change in peer group activities and support groups like AA etc., then the client is “doing time” not “doing treatment and change.” Providers need to then inform the judge that the client is out of compliance with the court order todo treatment. The client consented to do treatment not just do time and should be held accountable for their individualized treatment plan. If the client is substantively modifying their treatment plan in a positive direction in response to poor outcomes; and adhering to the new direction in the treatment plan, then the client should continue in treatment and not be sanctioned for signs and symptoms of their illness(es).
D. Incentives for clients can be explored and matched to what is most meaningful to them. For example, incentives that allow a client to choose a gift certificate or coupon for a restaurant may be meaningful for some clients. But others may find assistance in seeing their children; or receiving help with housing; or advocacy to change group attendance times to fit better their work schedule to be more meaningful incentives to be used. This requires an individualized approach recommended to the court by providers who should know their client’s needs, skills, strengths and resources. It is too much to expect the judge can work all this out in a busy schedule of court appearances.
E. A close working relationship between the client, judge, court team and treatment providers is needed to actualize this approach.
These ideas come from my clinical bias and experience, but they are offered with awareness:
- That we need more discussion to make this work in the world of courts and criminal justice.
- That to achieve the public safety outcomes we all want, we have to move treatment from a passive compliance and a ‘jumping through the hoops’ mentality that allows many clients to “do time” in treatment instead of “doing treatment and change”.
- That treatment providers will need to rise to the occasion and improve assessment and person-centered treatment planning that values outcomes-driven services.
- That judges and court personnel can expect treatment providers to design and deliver individualized care; and to keep them well-informed on any threats to public safety. Reports need to be on functional improvement not just compliance with attendance and drug screens.
Recently a colleague was to meet up for dinner but had to cancel because he strained his back and was in a lot of pain. I know what that is like. Over 20 years ago, I reached up to place my roll aboard suitcase in the overhead bin on the plane only to be shocked by a sharp back pain that left me walking like a 120 year old.
Hopping out of a car is a quick turn to the side, swinging your legs to the outside and rising out of the car seat….right? Not when you have back pain. Even in slow motion, each of those maneuvers can be excruciating. If you think back pain is mind over matter, let me know after you get your first attack.
On the other hand, it is true that people can milk back pain for all kinds of advantages: “I’d help you move those tissue boxes, but I have a bad back.” “Sorry I can’t come to the volunteer community park cleanup, I have a bad back (and by the way, the game is on TV).” I’d help with the dishes, but you know my back is bad today.”
Twenty years ago, I had almost crippling back pain in Greece on vacation, in Australia on vacation and when I moved to California. But I haven’t had an acute episode in nearly 18 years!
Lucky streak of good health? I don’t think so. On that bad back attack in Australia, I saw a musculo-skeletal physician who was quick to prescribe not narcotic analgesics,but rather muscle strengthening exercises. They take less than five minutes a day and I swear by this preventive remedy.
Here’s the three sets of exercises the Aussie doctor taught me:
1. Modified windshield wipers – I lie on my back with knees bent and feet flat on the floor. Arms are by my side and I sway my legs back and forth like windshield wipers. This seems to loosen up the back and spinal muscles.
If you want to do the real thing, you can check out:
How to do Windshield Wipers
2. Next, do Pelvic tilt exercises. Same position on my back, feet flat on the floor, arms by my side. Then I tilt my pelvis up and down repetitively.
If you want to see a professional teach this, go to:
How to Do Pelvic TiltExercises -YouTube
3. The third exerciseinvolves abdominal crunches. Same position on my back, but this time, I raise my legs and rest my feet on a stool or chair. Keeping the neck in line with your spine, not bent forward with chin touching your chest, do some crunches to strengthen abdominal muscles. I cross my arms across my chest butyou can check out a couple of ways here:
How to Do Crunches
How many repetitions of these are necessary? I don’t know what works for you, but at first, if the back pain is still acute, just do a few to get the idea…maybe five each. But I have worked up to do 3 sets of 20 windshield wipers and pelvic tilts and 2 sets of 20 crunches in sequence: wipers, tilts, crunches to tilts,wipers and crunches and ending with tilts and wipers.
I talked to another colleague today. He is going for an MRI in preparation for back surgery, hopefully to fix his chronic back pain.
I feel bad for him and I know I don’t want to get anywhere near that. I better do my wipers, tilts and crunches.
Until next time
Thanks for joining us this month. See you in late October.