As Director of Praxis, a training and consultation project based in Massachusetts, you help addiction treatment programs meet the needs of people with substance use disorders. How can we better serve individuals involved in the justice system who are experiencing substance use disorders?
There’s a lot of area for improvement. In Massachusetts, I have a limited role in providing training to some of the houses of correction that have specific programs for people with substance use disorders. I think when substance use treatment starts in houses of correction and jail, it really needs to be continued when people leave. Overdose rates are still astronomical for people exiting criminal justice settings, even for those involved in substance use programs.
I think the most significant needs are offering comprehensive addiction treatment, both inside and outside of correctional facilities, and providing tailored supports to help people get back to work in the community. People come out of jail or prison, and there isn’t much on the menu for them to choose in terms of what parts of society are really open to them. Addressing substance use is broader than just treating addiction. It’s about creating opportunities for people coming out of the justice system to work, live, and succeed. There are many policies and organizational barriers in the community that prohibit successful reintegration for people who were formerly incarcerated.
How can the behavioral health and criminal justice systems more comprehensively address individuals with substance use disorders, no matter the types of substances they may be using?
I think successful treatment of substance use disorders is absolutely independent of the substance. Certainly, there may be more medical treatments available to help people who have opioid use disorders manage cravings (e.g., buprenorphine, methadone). There isn’t strong evidence to date for the effectiveness of medications for amphetamine addiction, though there are programs and interventions that can help. Ultimately, it has less to do with the substance and more to do with the work, training, and housing opportunities, relationships, and supports the person has when they leave prison or jail.
The severity of the disease is one factor, but the person may have other challenges, such as poor education, no job skills, or no place to live. Certainly, having a criminal background creates barriers that are hard to overcome. So, behavioral health and criminal justice systems working together have to go further than just providing access to substance use disorder treatment. They need to create opportunities for people to get their foot on the first rung of the ladder rather than additional barriers to a meaningful life.
From your perspective, why is it important to apply a trauma-informed approach when serving individuals with substance use disorders?
My ideal would be that a trauma-informed approach would become a universal design for living because I think so many of us would do much better if the world were more trauma informed. I think many people with substance use disorders have a background of trauma. If not in childhood, having an active substance use lifestyle can put you on a collision course with all kinds of traumatic events. That’s very true for people who’ve landed in criminal justice settings.
Having a trauma history keeps people out of important settings, including substance use treatment. The development of low-threshold programs may be helpful to people with substance use disorders, especially people coming out of criminal justice settings. Some of the programs we offer are not trauma informed, and they tend to elicit a lot of shame, so people avoid them.
Being trauma informed is being very mindful of the person’s experiences. Being trauma informed is extremely respectful and accommodating, like those low-threshold programs with easy access. There is a real focus on the relationship, being strengths-based, engaging, and mindful of a person’s sense of safety. The physical environment has more accurate signage and doesn’t look like a bus station. The bottom line is: have respect for the relationship you make with each person and be transparent about what’s happening. Those two things—respect and transparency—go a long way.
You advocate for people to participate in valued roles in the communities of their choice. What does this mean, and how does it apply to someone with a history of criminal justice involvement?
My background is in psychiatric rehabilitation. Its whole mission is to help people experiencing a debilitating mental illness to participate in life, rediscover their purpose and meaning, and find valued roles. These roles could be a worker or a student, a parent, a tenant, a homeowner, or even a gym member. Despite the fact that the opportunities may be more limited, there may not be as big a menu, a person still has a choice in what they value. So, it’s about helping people find living, learning, and working roles in an area they want to be.
We need to have a rich diversity of people in our community, helping people with criminal justice backgrounds succeed in our neighborhoods or workplaces and choosing what is important to them. A person with a history of criminal justice involvement may have different barriers than somebody with a serious mental illness. But, again, the approach to help navigate those barriers—sometimes by overcoming them through advocacy—is the same.
We’re all born with different choices in life, what I refer to as the things on our “menu.” We may work with others throughout our life to expand our choices to include options we didn’t have when we were born. That’s why we really need to help people with criminal justice backgrounds, serious mental illnesses, or substance use disorders—to expand their options.
How has your experience as a person in long-term recovery given you the strength to continue pressing forward in this work over the years?
It’s been a long time since I was experiencing homelessness, actively engaging in substance use, and dealing with psychiatric symptoms, but I can still remember the loneliness. I stay in contact with people I’ve worked with over the years. Seeing their recovery in the long term has been a source of strength. The strength often comes from connecting with other people rather than my own sense of accomplishment.
My personal experiences have strengthened my commitment to recovery and to helping people find their valued roles. People have to get a job they love, some education, or some other meaning and purpose in their life. I know for me, that’s helped my long-term recovery. Thankfully, my recovery wasn’t dependent on the treatment I got. The treatment wasn’t very good. In fact, the mental health treatment was pretty bad—it involved forced hospitalization and medication, and the therapy didn’t focus on trauma. The substance use treatment I received was helpful, but it hasn’t changed much in 40 years.
A lot of the mental health evidence-based practices might be helpful. But I think the criminal justice and behavioral health systems could work together to help people get the interpersonal skills they need, whether that is emotional regulation, interpersonal effectiveness, self-soothing, or monitoring stress—in my experience, none of those are really taught in any meaningful way. I think those self-management skills are what’s necessary in life, in addition to opportunities for meaningful participation in society.
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