“I see your point, and now I have a new perspective. I thank you for that.” Roberto articulated these words to Karen, his supervisor, who had met with him to discuss the reasons why it was crucial to learn new strategies to working with justice-involved individuals with mental illness. “I am glad to hear, Roberto, and now that you are on board with working with Abi, let us start discussing some tools that you will need, to do this effectively,” responded, Karen, with a smile on her face.
In a previous article entitled, New Strategies to Working with Justice Involved Individuals: 5 Reasons Why, I outlined the rationale and the related benefits for learning new strategies when working with justice-involved individuals. As Karen promised Roberto, it is now time to learn the tools to effectively do so. Below are the five principles to master when working with justice-involved individuals.
1. Use engagement strategies
In two previous articles on engagement, I described ten steps to follow to adequately engage our patients and clients. While they are useful for all patient and client populations, these steps are especially essential when working with the justice-involved individual. As I described in the first article entitled, 5 Tips to Help Engage Your Patients and Clients, when working with the justice-involved population, it is necessary to:
(1) Meet them where they are at
(2) Instill trust
(3) Include them in all decisions
(4) Establish concrete goals with clear metrics
(5) Identify barriers and problem solve
In the second article of the same series entitled, 5 Tips to Help Engage Your Patients and Clients Part II, I added that in order to properly engage, it is crucial to:
(1) Involve family members, the community, and use them as allies;(2) Use motivators;(3) Focus on the patient and client;
(4) Start the process early; an
(5) Have an overall engagement strategy around engagement.
With these ten principles of engagement, you now have your first powerful tool to effectively work with the justice-involved individual.
2. Use the Skills of effective and comprehensive mental health assessment
In a previous article series, New Strategies for Mental Health Assessment, I described principles and techniques for an effective and comprehensive mental health assessment.
(1) Establishing and maintaining safety;
(2) Starting with the end in mind;
(3) Being and remaining therapeutic;
(4) Seeking to understand; while
(5) Being and remaining collaborative, and
(6) Making them a priority, are essential principles to follow when working with the justice-involved individual.
(For the mastery of these skills, see the article entitled, Seven Principles for an Effective and Comprehensive Mental Health Assessment.) In a world where the sickest, the poorest, and the most vulnerable patient and client is forced to receive the most time constrained and rushed mental health service, making use of the principles and new strategies for effective mental health assessment is essential, especially when working with the justice-involved individual.
3. Use the skills of effective and comprehensive substance use assessment
Similar to the mental health assessment, using strategies for an effective and comprehensive substance use assessment is not simply recommended but required. As I explained in our article series, New Strategies for Substance Use Assessment, an effective and comprehensive substance use assessment will help us:
(1) better care for our patients and clients;
(2) better use our countertransference and biases for the benefit of our patients and clients; and
(3) better promote integrated substance use treatment and mental health care.
I added that an effective and comprehensive substance use assessment would help us: (1) improve our advocacy skills; (2) fight stigma; and (3) enhance clinical outcomes.
In this series of articles, I also explained that looking at
(1) pattern of use;
(2) triggers to use;
(3) explanatory model of use; and
(4) escalating factors were some of the key areas to explore for an effective substance use assessment.
Looking at (1) consequences of use; (2) comorbidities; (3) stage of change; and (4) purpose and meaning were additional areas of exploration required for an effective and comprehensive substance use assessment. In a patient population where the rate of substance use disorder is between 70% and 80%, which in turn is a precipitating factor for recidivism and violent crimes, honing and using the skills for an effective and comprehensive substance use assessment is sine qua non when working with the justice-involved individual.
(For more on this series, see New Strategies for Substance Use Assessment: 5 Reasons Why; New Strategies for Substance Use Assessment: 5 Additional Reasons Why; New Strategies for Substance Use Assessment: 5 Questions to Ask; and New Strategies for Substance Use Assessment: 5 Additional Questions to Ask).
4. Practice integrated care
Integrated care involves meeting the needs of your patient and client, and by needs, I mean physical health, mental health care, substance use treatment, and special attention to the psychosocial needs, all in an integrated manner, instead of each in isolation.
In an article, entitled, Integrating Substance Use Treatment and Mental Health Services: The How To and The 5 Steps, I outlined that (1) Ask; (2) Assess; (3) Formulate; (4) Implement; and (5) Track were the five steps to follow for an effective integration of mental health care and substance use services.
As stated above, up to 80% of our justice-involved individuals have a substance use disorder, which in turn also increases their risk for chronic physical health comorbidities, including hepatitis, other types of liver diseases, and other types of sexually transmitted diseases. Furthermore, given the fact that only 10% of our wellbeing depends on receiving care and that 90% really depends on addressing the social determinants of health, integrated care would be lacking without an emphasis on addressing the social determinants of health that, in turn, cannot be addressed in silo. Effective work with the justice-involved individual cannot happen in a silo environment, it takes a village, effective communication, and the practice of integrated care—all are essential.
5. Focus on recovery
“You saved my life and my career. I am a lawyer today because of you, and I am currently working in mental health, to help patients make the best decisions towards their recovery.” Sacha articulated these words to her former psychiatrist, Rodis, who had treated her ten years prior. At age 21, Sacha had been forced to take a break from school. She had been experiencing auditory hallucinations that were making her distracted, leading to failing her classes, and a break was deemed appropriate. She was diagnosed with Schizophrenia, but she remained determined to complete her studies, and her family was fully invested in her care. She accepted the weight gain associated with Olanzapine (Zyprexa), with the benefits of attenuating her auditory hallucinations and the paranoia so she could slowly go back to work as a waitress. Sacha later also re-enrolled in college, passed her LSAT, made it to law school, and today, she works as a “lawyer in the mental health field.” This is a success story, but not an isolated one, and it can be the story of many more of our patients and clients, including those who are justice-involved. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as, “A process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential.” Elaborating on the principles and process of recovery is beyond this article; however, it is worth mentioning that more than an outcome, recovery is a process. And as long as you are making use of the other four principles already outlined in this article, you can be sure that you are focusing on recovery, and that is an effort that is priceless.
“I see your point, and now I have a new perspective. I thank you for that.” Roberto articulated these words to Karen, her supervisor, who had met with him to discuss the reasons why it was crucial to learn new strategies to working with justice-involved individuals with mental illness. “I am glad to hear, Roberto, and now that you are on board with working with Abi, let us start discussing some tools that you will need, to do this effectively,” responded, Karen, with a smile on her face.
And so, it went. The five principles to master as part of new strategies to working with justice involved individuals:
Use engagement strategies
Use the skills of effective and comprehensive mental health assessment
Use the skills of effective and comprehensive substance use assessment
Practice integrated care
Focus on recovery
These may not all come natural to some of you, but with daily practice, proper supervision, adequate consultation, and time to reflect on the work, you will gradually and increasingly feel equipped to effectively work with this underserved and underprivileged population.
For more in this series of articles, check below!
Dr. Sidor is quadruple board certified in psychiatry, with board certification in General adult, Child and adolescent, Addiction, and Forensic, psychiatry. He also has additional training in public psychiatry, in several treatment modalities, in addition to his teaching, supervision, mentorship, coaching, and management, experience. Some of his passions are public speaking, leadership, entrepreneurship, and research, in addition to program development and project management. His overall goal is to empower all health care professionals throughout the United States and globally, towards ensuring the continuity of excellent patient care, while balancing the need to take care of themselves. Dr. Sidor is the main instructor for the SWEET Institute, and he is currently an Assistant Professor of Psychiatry at Columbia University. He is also the past-Medical Director for CASES (Center for Alternative Sentencing and employment Services), and he speaks and writes fluently in six (4) languages—French, English, Spanish, Creole, and has intermediate proficiency in Portuguese and Italian.
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