"CT-R emphasizes the importance of hope while taking it a step further, turning hope into meaningful action and internalizing what success says about a person’s identity, strength, and ability to navigate future challenges."
Returning to the community after a period of incarceration is challenging. Collateral consequences of justice involvement such as difficulty securing employment and affordable housing, challenges with accessing social and health-related resources, and disconnection from loved ones and communities contribute to the revolving door effect in which individuals cycle between the community and incarceration. Empirical studies show that this pattern is exacerbated for individuals with serious mental health conditions such as schizophrenia.1
Programs designed to collaborate with individuals who experience both serious mental health challenges and justice involvement (eg, Forensic Assertive Community Treatment, Critical Time Intervention, Prison Aftercare) are still in their relative infancy and have yet to be funded and utilized in a broad manner.2
Limitations of reentry programming, coupled with inconsistent community funding and limited resources, create a game-changing opportunity for an approach that can be applied flexibly. Recovery-oriented cognitive therapy (CT-R)3 fits this bill.
It is theory driven, empirically supported, and designed to promote recovery and resiliency for individuals with serious mental health conditions. CT-R has been successfully implemented in a variety of forensic mental health settings across the country4 and has been expertly delivered by a range of interdisciplinary providers (eg, direct care and correctional staff, clinicians, medical providers).
CT-R focuses on building connection and trust, learning and actualizing individuals’ aspirations to act toward a life of meaning, and using cognitive therapy strategies to help individuals notice and draw conclusions about success and progress.
CT-R is highly adaptable and can serve as a framework for understanding what may keep individuals stuck in a revolving door. It can be a standalone treatment or integrated into existing interactions or interventions (eg, by medical providers during appointments, by direct care staff on the milieu, or by teams during brief interactions in the community).
Cognitive-behavioral approaches are well established as the gold standard in offender treatment.5,6 CT-R is rooted in cognitive behavior therapy but it has key differences. Although negative beliefs frame the understanding of how individuals with justice involvement and mental health challenges might get stuck or give up, CT-R emphasizes strengthening of positive and resiliency beliefs that are developed by engaging in positive and meaningful activities with others (Table).
This strengthening, or guided discovery, counteracts the impact of negative beliefs and leads individuals to experience their adaptive mode, or best self, more frequently.
Particularly important for forensic settings, CT-R promotes, in a straightforward manner, each individual’s agency, giving the individual an opportunity to reestablish an identity outside their justice involvement, build hope, establish momentum, and live a personally meaningful, productive, resilient, and, ideally, crime-free life.
An Example of CT-R in Action
“James” has spent extensive time in the justice system and is now reentering the community. He has been given a diagnosis of schizophrenia and shows prominent negative symptoms as well as a prevalent suspiciousness of others.
Many in James’ shoes would feel hopeless about having the life they originally imagined for themselves. They also may struggle to meaningfully occupy time, may experience negative self-concept and defeatist beliefs about the ability to succeed, may not trust providers or the intentions of others, and may find themselves at risk of engaging in action that could lead them back to the justice system.
Empirical studies have established that poor outcomes for individuals such as James are predicted by nonengagement and disengagement with clinicians.7,8 These can be thought of as 2 intercepts in the trajectory of care in a manner analogous to the Sequential Intercept Model.9
Accordingly, first, James’ community providers need the know-how to get started with him to engage and establish trust. Next, they need to be able to keep it going by working with James in such a way that he sees the value and can carry it forward in his personal life. CT-R is expressly formulated to successfully meet both intercepts in care.
Connection. Fostering a safe connection and establishing trust with James is not a trivial matter, given that he has difficulty accessing motivation, does not expect to succeed, and is highly distrustful of the intentions of others, especially clinicians. With these negative beliefs in mind, the team begins by focusing interactions on his interests.
Although James is not initially receptive, the team persists, playing songs they think he will like or watching short videos on their phones. The breakthrough comes watching a short video on cooking. James says, “That’s not how you make chili.” The right way to cook it, James says, is “the way my mom does.” At the next contact, he greets the clinician more warmly and shares his mom’s recipe.
Over time, James and the team watch more cooking videos and James shares more recipes. The team also learns that he likes reggaeton music and knows a lot about it. During each visit, they listen to music and talk about recipes. James’ team helps him notice that he has more energy during these activities, that it is better doing things with others, and that he is highly knowledgeable and capable.
Hope. Having successfully passed the first intercept, the team moves on to the second: showing the value of their collaboration with James to help him get the life he wants.8 Building on the trust they have developed with him, James’ team members begin talking with him about his future. James shares, with considerable animation, that he has always wanted to be a chef, but his face quickly darkens. James worries he does not have the training to be successful and knows that getting a job with a criminal record can be arduous.
Noting these negative beliefs—contributors to hopelessness, days spent not doing anything meaningful, and financial stress—the clinician chooses to develop James’ aspiration of being a chef, asking him detailed questions such as “What will your days look like?” and “Where do you see yourself doing that?” Spending time enriching aspirations without a discussion of barriers or limitations is a critical aspect of invigorating hope.
Additionally, questions such as “What would be the best part about that?” and “What would it mean about you to accomplish that?” promote discovery of the underlying values and meaning, which tap into intrinsic motivation and contextualize taking challenging steps toward a desired life. James’ team learns the food he likes to make and the strengths he has as a cook, and that being a chef would tap into his values of caring for others and contributing to his community.
To help enable successful action and resilience, James’ clinicians collaborate with him to create his recovery image: a rich, vivid mental or physical picture that creates tangible reminder of his aspiration and underlying values. James’ image includes a collage of his favorite dishes arranged around Superman’s shield.
With this rich image, James can tap into the value of being a neighborhood hero contributing to the happiness of others. He can feel enthusiasm and positive emotions and bolster himself when he starts to experience hopelessness, rejection, or other negative thoughts. It is a reminder that his dream of being a chef is possible, that the work he does is worth it so that he can give to others.
Purpose. Positive action now includes pursuit of James’ aspiration. In collaboration with his clinicians, James spends his days looking for training opportunities and jobs cooking. Action toward this aspiration yields a lived sense of purpose. James’ clinicians help him notice what this pursuit says about him as a person (“he is a good person,” “he is capable of achieving his dreams,” etc).
Daily action can also tap into the values underlying aspirations. For example, what are other ways that James can show he cares for others or contribute something to individuals around him? Action toward underlying values is especially important for justice-involved individuals as aspirations such as James’ can take time to achieve and may be limited by the forensic system or conditions of community release.
James’ clinicians collaborate with him to find additional activities that tap into the same sense of value and lived purpose (eg, cooking meals for his family, writing recipes and sharing them, volunteering). He adds these to his daily schedule. James’ life space grows outward and the burden of reentry is contextualized. His days are filled with meaningful action that brings him a sense of value as a person.
As hard is it might sometimes seem, James concludes that it is worth it to complete certain justice-related and treatment requirements as these get him closer to achieving his aspirations and doing these things occupies a small piece of his life space. In this way, hope snowballs into action and occasions resilience.
Empowerment. As James makes action toward becoming a chef while also engaging in meaningful daily action—such as cooking for his family or working in a soup kitchen—his clinicians help him notice his determination, his valuable contributions, and what it says about his ability to help others during a personally difficult time.
Questions such as “What does it say about you that you accomplished this?” and “What does it say about your ability to navigate challenges?” provide James the opportunity to notice his success and resiliency.
Repeated use of this style of questioning increases his access to positive beliefs (eg, “I am a good person,” “I have value,” “I can handle challenges”). These beliefs are especially important for justice-involved individuals as they provide an empowering countervail to action that would land these individuals back in the justice system.
James no longer experiences such difficulty getting going as often and he trusts his clinicians and other individuals more—conclusions that his team helps him notice repeatedly.
On days when James’ doubts are greater or when he experiences a setback, James uses his recovery image to keep moving forward, to tap into motivation, and to contextualize why taking some risks (eg, looking for jobs despite rejection, seeking culinary training) is worth it in service of the life he wants to live.
Over time, James begins to see himself as a good, capable, helpful person rather than feeling defined by his justice involvement.
Research into community interventions for individuals with justice involvement finds that hope is an essential ingredient to community reentry success as it contributes to an overall sense of wellbeing and decreases one’s focus on mental health challenges.10
CT-R emphasizes the importance of hope while taking it a step further, turning hope into meaningful action (purpose) and internalizing what success says about a person’s identity, strength, and ability to navigate future challenges (empowerment). Connection, hope, purpose, and empowerment are essential ingredients to meaningful and sustainable community reentry. CT-R operationalizes these constructs.
Clinicians gain flexible and achievable strategies on which to base interventions in any setting so as to best collaborate with individuals reentering the community. Through positive, meaningful action, individuals begin to shift how they see themselves and feel more confident in their ability to navigate recovery while also overall reducing their likelihood of recidivism. The more individuals begin to see themselves for their strengths, the less they will experience the gravitational pull of the factors that contribute to the revolving door.
Dr Arnold is a staff psychologist at Beck Institute Center for Recovery-Oriented Cognitive Therapy, where she provides training and consultation to systems, agencies, and teams across the country in recovery-oriented cognitive therapy. Ms Pinto is a licensed social worker who received her Master of Social Work from Simmons University, where she focused her training on implementing evidence-based treatment for adults involved in the justice system and those struggling with serious mental health challenges.
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