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Who Is In Charge Now
The document discusses the challenges faced by individuals with dual diagnoses of mental illness and criminal justice involvement, highlighting key statistics such as the prevalence of mental illness among incarcerated individuals and the lack of treatment received. It emphasizes the importance of motivational interviewing (MI) techniques and the stages of change model for effective rehabilitation and community reintegration. The document also outlines barriers to treatment and the need for comprehensive case management to support individuals during their adjustment periods post-incarceration.
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Who Is In Charge Now
- 1. Who is inCharge Now? Instilling Hope for Individuals with Dual Diagnosis and Criminal Justice InvolvementKimmie Jordan, M.S. , CPRP, CLC“Is Anyone Listening?”PSRANM 19th Annual Conference
- 2. US StatisticsOver 300,000offenders with mental illness in prison or jail on a daily basisOnly 60% of offenders with a mental illness receive treatment during incarceration50% of offenders with a mental illness were incarcerated on at least 3 previous occasions30% of offenders with a mental illness were homeless prior to incarcerationThere are 4 times more individuals with mental illness in prisons and jails than hospitals
- 3. Statistics in NewMexico2011 Currently incarcerated 6,6442011 Probation and Parole 18, 9052011 Total in New Mexico Corrections Department 25,437New Mexico Population 2,009,671
- 4. Statistics in NewMexicoApproximately 24% of Inmates on Psychotropic MedicationsNumber of Mental Health Contacts per month 6,062Approximately 45% identified and referred for substance abuse services
- 5. Barriers Individuals FaceTriplestigma of Mental Illness, Substance abuse and Criminal Justice issuesCommunity ReintegrationSocial Interaction difficultiesSelf-Esteem/Self Confidence problemsAnxiety and DepressionFear of failure and rejectionMistrustCulture shock
- 6. Barriers Individuals FaceHousingTransportationHealthCareEmployment/IncomeSocial SupportLegal Concerns, Probation and/or ParoleAdjustment period lasts average of 12-18 Months
- 7. Treatment Services forPeople Under Community SupervisionBasic NeedsHousingReintegration With Family Members and Social SupportVocational Training and EmploymentCase ManagementRelapse Prevention
- 8. Treatment Issues forPeople Under Community SupervisionSelf-Esteem and IdentityFinancial ConcernsBarriers to TreatmentMotivation for TreatmentNegative Counselor AttitudesLifestyle ChangesSelf-Help GroupsAdherence to Supervision ConditionsVulnerability to RelapseRoles as Workers and Taxpayers
- 9. Treatment Issues Specificto People on ParoleContinuum of CareAftercare and Continuing CareCase ManagementRecidivismParole failures now account for 35 percent of all prison admissions. Two-thirds of all parolees are rearrested within 3 years (Petersilia 2000), many on technical revocations, but most rearrests occur in the first 6 months. Offenders with mental illness are especially likely to be rearrested.
- 10. EmpowermentQuestions to askourselves as providers“Is that rehabilitative?”“How is that rehabilitative?”“What would make it rehabilitative?”
- 11. Motivational Interviewing (MI)MIis non-judgmental and non-confrontational. It recognizes that people are at different levels when it comes to making changes in their lives. It views the professional’s role as one of listening, probing, reflecting and clarifying in ways that help customers strengthen their readiness to changeTo accomplish this in a customer-centered, respectful atmosphere.
- 12. 5 Principles of(MI)DEARSDevelop DiscrepancyExpress EmpathyAmplify AmbivalenceRoll with ResistanceSupport Self -Efficacy
- 13. 5 Principles of(MI)Develop DiscrepancyWepoint out discrepancies between how customers would like things to be and how they are now. When they realize that their current behaviors are not leading toward some important future goal, they become more motivated to change. Following is a possible example of pointing out a discrepancy.“You would like to be able to support your family better. At the same time, you are finding it difficult to take the steps necessary to make that happen.” (“What do you think might be going on?”)
- 14. 5 Principles of(MI)Express EmpathyWe listen to customers to get an idea of their concerns and their reasons for behaving as they do. We view the world through their eyes, thinking as they think, feeling as they feel, and experiencing the world as they experience it. We put ourselves in their place. We continually ask, “If I were in their shoes, what would I be thinking? How would I be feeling? How would I be handling ambivalence about change? How would I want others to respond to me?” Our ability to demonstrate empathy, i.e., to understand and feel what customers are experiencing, has a major impact on their willingness and ability to change.
- 15. 5 Principles of(MI)Amplify AmbivalenceAmbivalenceis normal. However, it can become paralyzing and cause people to remain “stuck.” We help customers acknowledge their ambivalence, discuss it with them, explore the two “sides” they are dealing with, and help them work through it. If this does not occur, long-lasting behavior change becomes less probable.
- 16. 5 Principles of(MI)Roll with ResistanceLike ambivalence, resistance is a normal behavior that should be expected when people are being asked to change. Arguing with a customer, or creating a power struggle by threatening or trying to assert control, will likely make matters worse. We encourage customers to come up with their own solutions to situations as they define them. We invite them to examine new perspectives without badgering, lecturing or imposing new ways of thinking on them.
- 17. 5 Principles of(MI)Support Self –EfficacyA person’s belief that change is possible is an important motivator in making change. In MI, there is no “right way” to change. If a specific plan for change doesn’t work, customers can come up with other plans. However, for this to occur, they must believe that change is possible, i.e. that they are capable of making the changes necessary to improve their current situation. We engage customers in conversations to help them believe that change is possible.
- 18. Motivational Interviewing TechniquesOARSOpen-endedQuestionsAffirmationsReflective ListeningSummarize
- 19. MI TechniquesOpen-ended QuestionsThesecannot be answered with a ‘yes’ ‘no’ or ‘five times in the past month’. Commonly most sessions commence with an open-ended question, ‘What’s been going on since we last got together?’ This type of question allows the client an opportunity to move forward and whilst closed questions undoubtedly have their place, they do not create the same opportunity. Example: “I assume, from the fact that you are here that you have something you would like to talk over. What would you like to discuss?”
- 20. MI TechniquesAffirmationsThere arereally no better ways of building rapport with a client than offering affirmation. This is particularly relevant to clients suffering from addictions as affirmation for this group has been a historically rare occurrence. Remember that affirmation has to be commensurate with the step achieved as the client may feel that the counselor is being insincere if they are over praising them. This can lead to rapport being seriously damaged rather than built.Examples: “Thanks for coming in on time.” / “I must say, if I were in your position, I might have a hard time dealing with that amount of stress.”
- 21. MI TechniquesReflective ListeningThebest motivational advice a counselor can give to himself is to listen attentively to the client. All the information a counselor requires will come from the client, what works, what has failed them etc. However this is a directive approach. The counselor will actively guide the client by this technique; focusing more on change talk and less on non-change talk. For example “You are unsure about your readiness to change but you are aware that your drinking has damaged your relationships and your health”. If that is correct the intensity of the session deepens, if wrong the client will correct you (or the client may not be ready to deal with this) and the session moves on regardless.
- 22. MI TechniquesSummarizeSummaries area specialized form of reflective listening and are an effective way to communicate that you have been listening by calling attention to central points and moving attention and concentration. When you are about to summarize let the client know that that is what is going to occur and invite the client to correct you where he/she feels necessary. If you feel that there were points that were not clear during this period, inform the client of that when you announce your intention to summarize. Example: “So, this heart attack has left you feeling really vulnerable. It’s not dying that scares you, really. What worries you is being only half alive, living disabled or being a burden to your family.”
- 23. Motivational Interviewing TechniquesvideosMotivational Interviewing: Evoking Commitment to Change PresentationMovies\Motivational Interviewing Evoking Commitment to Change.flv
- 24. Motivational Interviewing TechniquesvideosPractice Demonstration Video – Motivational Counseling PresentationMovies\Practice Demonstration Video-Motivational Counseling.flv
- 25.
- 26. Stages of Change(SOC)Precontemplation People are not intending to take action in the foreseeable future, and are most likely unaware that their behavior is problematicEstablish RapportExpress EmpathyExplore client motivation and confidence to change
- 27. Stages of Change(SOC)Contemplation people are beginning to recognize that their behavior is problematic, and start to look at the pros and cons of their continued actionsIdentify strengthsEngage in goal explorationDevelop DiscrepancyExplore and amplify AmbivalenceReinforce commitment to changeEmpower client
- 28. Stages of Change(SOC)Preparation people are intending to take action in the immediate future, and may begin taking small steps towards changeDiscuss options and steps needed to make the changeHave client repeat goalsUse statements client has used to negotiate a change or behavioral contractConsider and lower barriers to chanceAssist the client in gaining social support
- 29. Stages of Change(SOC)Action People have made specific overt modifications in their life style, and positive change has occurredEncourage small steps towards changeHave client follow up on preparation plansIdentify reinforcements for changeAcknowledge difficulties of early stages of changeAssist client in identifying and developing coping strategies for high risk situationsBe supportive, offer assistance and guidance
- 30. Stages of Change(SOC)Maintenancepeople are working to prevent relapse," a stage which can last indefinitelySupport self-efficacyHelp recognize and manage triggersAffirm client’s commitment to changeSupport problem solving Review long term goals and progress
- 31. Stages of ChangeModel
- 32. Stages of ChangeVideosPractice Demonstration Video – Stages of Change PresentationMovies\Practice Demonstration Video-Stages of Change & Treatment.flv
- 33. References and ResourcesMotivationalInterviewing Desk Reference Guide http://www.sedgwickcounty.org/corrections/Motivational%20Interviewing/Motivational%20Interviewing%20Desk%20REFERENCE%20Guide.pdfMotivational Interviewing and Stages of Change: Integrating Best Practices for Substance Abuse Professionals. By: Kathyleen M. Tomlin, M.S. LPC, CADC III, and Helen Richardson. Hazelden. 2004Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York: Guilford Press.Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992). Motivational Enhancement Therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.
- 34. References and ResourcesKathleenHodges, M.A. LPCC, LMSW. Mental Health Manager Southern New Mexico Correctional Facility Mental Health Department. Substance Abuse and Mental Health Administration. TIP 30: Continuity of Offender Treatment for Substance Use Disorders from Institution to CommunitySubstance Abuse and Mental Health Administration. TIP 44: Substance Abuse Treatment for Adults in the Criminal Justice System
- 35. Kimmie Jordan MentalHealth Rehabilitation ServicesWebsite:WWW.MentalHealthRehabServcies.comE-Mail:KimmieJordan@MentalHealthRehabServices.com575-649-8518
Editor's Notes
- #3 9% of general population were homeless prior to incarceration.
- #4 3% of Population currently incarcerated12% of population involved with the Corrections Department
- #8 Help the client address basic needs, such as housing or employment.• A client's living arrangements are crucial to treatment. Counselors should be aware of residential resources and collaborate with corrections supervisors and probation and parole officers on finding appropriate housing for clients if needed.• A client's treatment plan should include recreational opportunities and other outlets to help them build healthy social relationships in addition to the support clients may be receiving from their family.• Try to start vocational training for clients at the beginning of substance abuse treatment rather than at the end of treatment.• Case management is an opportunity for the criminal justice and substance abuse treatment systems to collaborate to take advantage of a wide range of treatment and rehabilitation options for clients.• Relapse prevention skills should be part of each offender treatment plan, and personal relapse prevention plans should be developed for all parolees receiving treatment. These plans address how clients can refuse drugs, identify triggers, and manage cravings.• One positive urine test or one drink after a long abstinence should not be viewed as a failure but as a signal for stepped-up treatment and closer monitoring.• Graduated sanctions for relapses should be specified in the treatment plan because resumption of drug abuse can lead to resumption of criminal activity.
- #10 Prisoners released into the community face a sometimes bewildering transition. Nearly 80 percent of prisoners returning to the community are released on parole under conditional release (Petersilia 2000). A successful transition from offender to citizen often depends on successful treatment. Successful treatment helps individuals to be more realistic about their strengths and weaknesses, more skilled and willing to endure obstacles encountered in maintaining a job or obtaining an education, and more confident about meeting family and work responsibilities.Continuum of CareBecause substance use disorders are long-term, relapsing illnesses, a crucial aspect for reentry is to develop and sustain an integrated continuum of care between substance abuse treatment providers, the parole officer, and social service agencies that can assist the inmate's reintegration into the community. Ideally, cross-system integration for offender transitional services contributes to cost benefits as a result of reduced recidivism (Inciardi 1996; National Institute of Justice 1995; Swartz et al. 1996). However, the parolee does not exist in a discrete, well-coordinated system, but rather in a cluster of independent agencies and entities with separate justice responsibilities. Some entities collaborate closely; others do not. Most operate under separate funding streams, with differing organizational missions that may or may not share philosophical orientations toward public safety and offender rehabilitation. Boundary spanners and case managers can sometimes help maintain continuity. TIP 30, Continuity of Offender Treatment for Substance Use Disorders From Institution to Community (CSAT 1998b ), discusses this topic in depth.Aftercare and Continuing CareSeveral studies have supported the long-term efficacy of postprison aftercare and treatment services in the reduction of recidivism and relapse. For example, Wexler (1995) found that those who participated in prison- and community-based therapeutic community treatment committed fewer crimes than their counterparts who did not receive aftercare services. Inciardi (1996) reported similar findings: lower rates of drug use and recidivism than those enrolled only in institutional treatment programs.Residential aftercare contributes to improved postprison outcomes. For optimal results, the offender should remain in treatment in the community. Studies show, for example, that the most effective treatment lasts a minimum of 3–6 months, and outcomes improve with additional time in treatment. This is true for all treatment modalities and particularly for treatment of offenders (Hubbard et al. 1988; Simpson 1984; Wexler 1988).Case ManagementCase management is the crucial function that links the offender with appropriate resources, tracks progress, reports information to supervisors, and monitors conditions imposed by the supervising agency. These activities take place within the context of an ongoing relationship with the client. The goal of case management is continuity of treatment, which, for the offender in transition, can be defined as the ongoing assessment and identification of needs and the provision of treatment without gaps in services or supervision. Accountability is an important element of a transition plan, and case management includes coordinating the use of sanctions and incentives among the criminal justice, substance abuse treatment, and possibly other systems.Ideally, case management activities should begin in the institution before release and continue without interruption throughout the transition period and into the community. Reassessments should be conducted at various stages throughout the incarceration and community release process. These periodic assessments should form the basis for ongoing case management and service delivery.Ancillary services are needed before and after release to prepare the offender for the return to family, employment, and the community. Studies (Knight et al. 1999a ; Martin et al. 1999; Wexler et al. 1999b ) have revealed the importance of aftercare for the maintenance of treatment effects. Foremost among needs for ancillary services are drug-free housing or other living arrangements, employment, family support, transportation, education, and primary health care. Others include literacy training, HIV/AIDS education, and prosocial support networks (Belenko and Peugh 1998; Hiller et al. 1999b ). Offenders may need help learning basic life skills such as budgeting, using public transportation, and parenting. Improving clients' likelihood of obtaining a job through GED preparation, enrollment in an educational program, vocational training, or job-seeking skills classes increases their chances of success after release.This array of services reflects the multiple psychosocial needs of offenders and takes into account the likelihood that they may experience periods of relapse, requiring more intensive levels of treatment and supervision. Other needs are training to improve interpersonal skills within families and among peers and training in anger management to learn new methods for resolving conflicts. Family members should be involved whenever possible, and participation in self-help groups should be encouraged.RecidivismParole failures now account for 35 percent of all prison admissions. Two-thirds of all parolees are rearrested within 3 years (Petersilia 2000), many on technical revocations, but most rearrests occur in the first 6 months. Offenders with mental illness are especially likely to be rearrested.
- #13 Develop Discrepancy—Wepoint out discrepancies between how customers would like things to be and how they are now. When they realize that their current behaviors are not leading toward some important future goal, they become more motivated to change. Following is a possible example of pointing out a discrepancy.“You would like to be able to support your family better. At the same time, you are finding it difficult to take the steps necessary to make that happen.” (“What do you think might be going on?”) Express Empathy— We listen to customers to get an idea of their concerns and their reasons for behaving as they do. We view the world through their eyes, thinking as they think, feeling as they feel, and experiencing the world as they experience it. We put ourselves in their place. We continually ask, “If I were in their shoes, what would I be thinking? How would I be feeling? How would I be handling ambivalence about change? How would I want others to respond to me?” This is the way we want to respond to customers. When people feel understood, they are more likely to be open and share their experiences. The more customers share their experiences with us, the better we will be able to determine where they need information and support. Our ability to demonstrate empathy, i.e., to understand and feel what customers are experiencing, has a major impact on their willingness and ability to change.Amplify Ambivalence—Ambivalenceis normal. However, it can become paralyzing and cause people to remain “stuck.” We help customers acknowledge their ambivalence, discuss it with them, explore the two “sides” they are dealing with, and help them work through it. If this does not occur, long-lasting behavior change becomes less probable. Roll with Resistance: Like ambivalence, resistance is a normal behavior that should be expected when people are being asked to change. Arguing with a customer, or creating a power struggle by threatening or trying to assert control, will likely make matters worse. We encourage customers to come up with their own solutions to situations as they define them. We invite them to examine new perspectives without badgering, lecturing or imposing new ways of thinking on them. Support Self-Efficacy: A person’s belief that change is possible is an important motivator in making change. In MI, there is no “right way” to change. If a specific plan for change doesn’t work, customers can come up with other plans. However, for this to occur, they must believe that change is possible, i.e. that they are capable of making the changes necessary to improve their current situation. We engage customers in conversations to help them believe that change is possible.
- #19 Open ended questions These cannot be answered with a ‘yes’ ‘no’ or ‘five times in the past month’. Commonly most sessions commence with an open-ended question, ‘What’s been going on since we last got together?’ This type of question allows the client an opportunity to move forward and whilst closed questions undoubtedly have their place, they do not create the same opportunity. Example: “I assume, from the fact that you are here that you have something you would like to talk over. What would you like to discuss?”Affirmations There are really no better ways of building rapport with a client than offering affirmation. This is particularly relevant to clients suffering from addictions as affirmation for this group has been a historically rare occurrence. Remember that affirmation has to be commensurate with the step achieved as the client may feel that the counselor is being insincere if they are over praising them. This can lead to rapport being seriously damaged rather than built.Examples: “Thanks for coming in on time.” / “I must say, if I were in your position, I might have a hard time dealing with that amount of stress.”Reflective listening This is really the key. The best motivational advice a counselor can give to himself is to listen attentively to the client. All the information a counselor requires will come from the client, what works, what has failed them etc. However this is a directive approach. The counselor will actively guide the client by this technique; focusing more on change talk and less on non-change talk. For example “You are unsure about your readiness to change but you are aware that your drinking has damaged your relationships and your health”. The level of reflection should be varied. Keeping it at one level could lead to a feeling of moving in circles. Reflections regarding affect, particularly if the effect is unstated can be excellent motivators for example; “Your wife has left you. That appears to be giving you a lot of pain”. If that is correct the intensity of the session deepens, if wrong the client will correct you (or the client may not be ready to deal with this) and the session moves on regardless. Reflective listening maintains the movement of the interview and forward movement is what motivational interviewing is all about. Summaries Summaries are a specialized form of reflective listening and are an effective way to communicate that you have been listening by calling attention to central points and moving attention and concentration. There is no hard and fast rule as to how often you do summarize but the frequency should be quite high as there is a risk that the amount of information given may be too large to give adequate feedback. When you are about to summarize let the client know that that is what is going to occur and invite the client to correct you where he/she feels necessary. If you feel that there were points that were not clear during this period, inform the client of that when you announce your intention to summarize. Example: “So, this heart attack has left you feeling really vulnerable. It’s not dying that scares you, really. What worries you is being only half alive, living disabled or being a burden to your family.”
- #27 Precontemplation is the stage in which people are not intending to take action in the foreseeable future, usually measured as the next six months. People may be in this stage because they are uninformed or under-informed about the consequences of their behavior. Or they may have tried to change a number of times and become demoralized about their ability to change. Both groups tend to avoid reading, talking or thinking about their high risk behaviors. They are often characterized in other theories as resistant or unmotivated or as not ready for health promotion programs. The fact is traditional health promotion programs are often not designed for such individuals and are not matched to their needs.
- #28 Contemplation is the stage in which people are intending to change in the next six months. They are more aware of the pros of changing but are also acutely aware of the cons. This balance between the costs and benefits of changing can produce profound ambivalence that can keep people stuck in this stage for long periods of time. We often characterize this phenomenon as chronic contemplation or behavioral procrastination. These people are also not ready for traditional action oriented programs.
- #29 Preparation is the stage in which people are intending to take action in the immediate future, usually measured as the next month. They have typically taken some significant action in the past year. These individuals have a plan of action, such as joining a health education class, consulting a counselor, talking to their physician, buying a self-help book or relying on a self-change approach. These are the people that should be recruited for action- oriented smoking cessation, weight loss, or exercise programs.
- #30 Action is the stage in which people have made specific overt modifications in their life-styles within the past six months. Since action is observable, behavior change often has been equated with action. But in the Transtheoretical Model, Action is only one of five stages. Not all modifications of behavior count as action in this model. People must attain a criterion that scientists and professionals agree is sufficient to reduce risks for disease. In smoking, for example, the field used to count reduction in the number of cigarettes as action, or switching to low tar and nicotine cigarettes. Now the consensus is clear--only total abstinence counts. In the diet area, there is some consensus that less than 30% of calories should be consumed from fat. The Action stage is also the stage where vigilance against relapse is critical.
- #31 Maintenance is the stage in which people are working to prevent relapse but they do not apply change processes as frequently as do people in action. They are less tempted to relapse and increasingly more confident that they can continue their change.