INTRODUCTIONS /BIOS Cynthia Hoffman, MFT is a psychotherapist in private practice. She recently worked for a year as the Clinician for the Parole Re-Entry program. She has worked with severely mentally ill adults who use substances for over 14 years. She has worked in both community mental health settings and in private practice practicing Harm Reduction. She is a also a member of the Harm Reduction Therapy Centers Board of Directors. She has been practicing and teaching Harm Reduction Psychotherapy for over 14 years in both private practice and agency settings. CH

Introduction – Bios (cont) Jennifer has been working with the Harm Reduction Therapy Center for the past 9 years. She currently works as a therapist, supervisor and community programs coordinator at Sf Pretrial Diversion: Court Accountable Homeless Services and Homeless Youth Alliance on Haight Street in San Francisco. She has worked in social services for the past 20 years primarily with those clients with complex trauma and substance use issues who are homeless or marginally housed. JP

Program Descriptions - PRC The Parole Re-Entry Program (PRC) is a court based program that provided case management to parolees who had been previously unsuccessful in completion of parole. These previously incarcerated adults were eligible for the program if they had non-violent, non-sex offending and non-third strike offenses. They often did not show up for parole appointments and picked up new drug charges. PRC provided intensive case management, therapy, peer support, housing and close contact with the court. All participants would meet with the judge and other participants weekly for a check in on progress. CH

Program Descriptions - CAHS Court Accountable Homeless Services (CAHS) program, provides case management, outreach, supervision and harm reduction therapy services to homeless defendants, referred by the court, who have been charged with either felonies or misdemeanor crimes. Low threshold eligibility consists of being a homeless SF resident, the ability to provide outreach information on where they can be found in the community, and a willingness to work intensively with a case manager. Issues addressed include substance use, SSI disability, basic life skills, mental health, health care and housing referrals. JP

Who are our clients? People of color Trauma survivors Homeless or Formerly Homeless Poor Previously Incarcerated, many since childhood Psychiatrically Ill adults aged Diagnoses seen; i.e. Schizoaffective Disorder, PTSD, Major Depressive Disorder, Borderline Personality Disorder Educationally disadvantaged, unable to read and write Co-occurring Medical conditions ie. HIV, Hep C, Seizure Disorders, Diabetes, Chronic Pain from Violent Traumas, TBI’s Difficult or non-existent family support Sex Offenders Previously in Foster Care CH

Brainstorm exercise Who is here today? What challenges do you experience? What helps clients succeed? what do you personally want to change in your life? JP

Bring to mind the thing you want to change. Now know, if you don’t change that, you’re going to jail.

Types of Mandated treatment Traditional Residential Substance Abuse Treatment Group Therapy Individual therapy Anger Management Domestic Violence Groups Case Management Harm Reduction Therapy Groups CH

Substances Used Alcohol Crack Speed Heroin Cannabis Prescription Drugs: i.e. Narcotic Painkillers, Benzodiazepines Ecstasy GHB JP

Relationship History Most clients we see have a poor history of attachment to caregivers and others around them They have adversarial relationships with treatment and treatment providers. They feel rejected, uncared for, judged which makes connecting to service providers difficult. Primary relationships are often with those who also practice self-destructive behavior or are not with people at all. Their primary relationships may be with substances, criminal behavior or self destructive behavior itself. Instead of people, the primary relationship may be with the system itself, it’s predictability. JP

Attachment JP

Relationship as Treatment In treatment, it is important to provide: Consistency Acceptance Non Judgmental Collaborative experience Emotional regulation Using interactions in the therapy (rather than reviewing the past or criticizing or correcting only negative behaviors). Example of present moment/relational therapy JP

Harm Reduction Therapy Not all drug use is abuse People use drugs for reasons Incremental change is normal and motivation is fluid The work is a collaborative process model, not an outcome model Outcomes are as varied as the people seeking change Process goals Never say no to treatment – clients get to come as they are Build our skills as helpers – i.e. learn to be curious about all aspects of a person’s life Build hope for the possibly of change for both our clients and ourselves Build treatment relationship JP (and ch)

Cognitive Behavioral Therapy Years of criminal involvement, incarceration, court involvement and trauma skew how a person thinks and behaves. Cognitive behavioral therapy (CBT) is an approach that addresses dysfunctional emotions, maladaptive behaviors and cognitive processes and contents through a number of goal-oriented, explicit systematic procedures. The following guides are used by the criminal justice system for working with formerly incarcerated adults to help them make changes and successfully complete parole. Thinking for a Change (T4C) is an integrated, cognitive behavioral change program for the formerly incarcerated that includes cognitive restructuring, social skills development, and development of problem solving skills. Carey Guides CH

CBT – Thinking for a Change Thinking for a Change (T4C) is an integrated, cognitive behavioral change program for the formerly incarcerated that includes cognitive restructuring, social skills development, and development of problem solving skills. Thinking for a Change can be used in either group or individual counseling. CH

Carey Guides Research has shown that traditional methods of client supervision do not change delinquent and offending behavior or reduce recidivism. For behavior change and recidivism reduction to be possible, clients must understand the personal and environmental factors that led them to their offending behavior and teach them the skills they need in order to make positive changes in the future. The Carey Guides are designed to equip corrections professionals with the information and tools they need to support these changes among their clients The Carey Group CH

Sample Topics in Carey Guides and T4C Anger Family relationships Antisocial Peer Groups Antisocial Thinking Pro-social Behavior Interpersonal Relationships Emotion Regulation CH

Other interventions Incentives Food Housing Vouchers for food, clothing and toiletries. Peer Counseling Rest (at our site) CH

Traditional Assumptions about Substance Abusers Addiction stems from an addictive personality Clients are in denial and will resist treatment Clients will lie and manipulate Clients need to be confronted Clients must make a commitment to abstinence Clients must accept the label of alcoholic or addict Counselor is the expert JP

Changes in the Addiction Field Focus on client competencies and strengths Individualized and client centered Client ambivalence is present, acknowledged and worked with Empathy is the key to change Ultimate goal is abstinence, but the client chooses outcomes No labels Counselor is partner JP

“I’ve never had problems with drugs. I’ve had problems with the police.” --Keith Richards Keith Richards 24

Motivational Interviewing Whole package of Motivational Interviewing is complicated and there is much to learn. The spirit of MI is what’s essential. The Spirit of Motivational Interviewing with Previously Incarcerated Adults Collaboration Evocation Autonomy Perception Curiosity Ethics Treats Resistance as thinking CH

Motivational Interviewing (cont.) Principles of Motivational Interviewing Express Empathy Develop Discrepancy – Develop the discrepancy between the clients goals and their current Behavior Roll with Resistance – Avoid Arguments – Know that resistance is a form of thinking about the issue

Harm Reduction Techniques for those on Probation and Parole Safety while using: clean needles, eating and drinking before/during use Use indoors Housing Psychiatric medications to minimize symptoms Urinalysis; help clients to plan use around drug tests Developing alternative support systems (people outside of the CJS Develop alternative activities including: exercise, finding things to do outside of drug and police dominated areas Participate in Art What else have you suggested to clients? CH(JP)

Coordinating Care/Collaboration Because clients are not trusting (they have had little opportunity to trust safely), they often do not tell the whole story or give an accurate picture. We have found that coordinating care with psychiatrists, case managers, prior therapists and primary care physicians, help give us a fuller picture of what is going on with clients so that we are better able to help. It gives providers a feeling of support which allows them to better serve their clients. CH

In conclusion… PRC and CAHS clients Feel cared for. Feel able to speak their truth Have a space to examine their behaviors in a non-judgmental way Sometimes reduce their substance use Understand more clearly why they use drugs and alcohol Successfully complete probation and parole Obtain psychiatric help and medical care in the community. (including getting HIV treatment, psych meds, treatment for Diabetes etc) Get on SSI if applicable Get reunited with family