START NOW – A Skills-Based Psychotherapy for Inmates

START NOW integrates research, theory and clinical experience. It is designed to be a strengths-based approach, focusing on an accepting and collaborative clinical style. At the same time, this approach places the primary responsibility for change on the participant. This intervention was also designed to take into account the pragmatic factors of a variety of care delivery settings, which frequently face limited treatment resources.

Originally developed for correctional environments, it has been adapted for use in other settings that face similar resource constraints and extensive need for effective, reliable, manual-guided treatment for individuals living with impairments of impulse control, emotion regulation and management of interpersonal relationships.

The underlying theme is that, while many of the people to whom we provide care present in different environments at different times in their lives, they have skills deficits that can be addressed wherever they may present.

START NOW incorporates cognitive behavioral therapy, motivational interviewing, neurocognitive modifications, trauma-sensitive care, gender-specific guidance, focusing skills and functional analysis in a highly structured, nonjudgmental approach to skills building.

• START NOW is already in use in more than a dozen state correctional systems, forensic psychiatric hospitals and community settings in the U.S. and Canada

Structure and Design

• 32 sessions divided into four skill-based units
• Twice weekly for 16 weeks (recommended) or one time per week for 32 weeks

START NOW is designed specifically for psychiatric settings:

• Concepts and language are simplified given potential cognitive or educational limitations
• Numerous images included in the participant workbook—especially useful with TBI or verbally limited participants
• Illustrative examples and coping behaviors are contextually relevant
• Detailed session-by-session facilitator manual includes numerous tips for engaging difficult-to-engage participants: e.g., shaping by reinforcing any movement toward the desired behavioral change

Therapeutic Approach:
The START NOW Skills program is an integrative model of treatment, based on several theoretical approaches. These approaches were chosen for a number of reasons: research evidence, suitability for treating individuals with behavioral disorders, and appropriateness for integration with other aspects of the planned intervention.

Cognitive behavior therapy (CBT) is the key theoretical underpinning of the START NOW approach; behavior is understood in the context of its antecedents and anticipated consequences, i.e., through “functional analysis”. Also, CBT emphasizes the primary role of understanding cognitive processes in determining both mood and behavior; thus behavioral and emotional responses are not determined simply by what happens, but by how a person interprets what happens. This overall formulation facilitates many opportunities for participants to gain increased understanding and control of their behavior, including recognizing and coping with triggers, modifying cognitions, and substituting alternate behaviors that serve similar functions. CBT involves learning and practicing new skills both within and between therapy sessions (Monti, Kadden, Rohsenow, Cooney, & Abrams, 2002).

There are positive indications for using CBT, not just with community-based populations, but with those who are institutionalized. Incarcerated or institutionalized individuals treated using targeted cognitive behavioral approaches have made significant positive changes, including: reduced depression (Wilson, 1990); reduced vengeful attitudes (Holbrook, 1997); and improved self-esteem, along with reduced anxiety and aggressive traits (Valliant & Antonowicz, 1991). Incarcerated women treated with CBT for substance use disorders and posttraumatic stress disorder (PTSD) reported high levels of client satisfaction with this intervention, and significantly reduced PTSD symptoms (Zlotnick, Najavits, Rohsenow, & Johnson, 2002).

Cognitive-behavioral therapy (CBT) has emerged as the “predominant psychological method of treating not only mental illness, but a broad spectrum of socially problematic behaviors including substance abuse, criminal conduct, and depression” (Thigpen, 2007). There has been much debate regarding the effectiveness in rehabilitating criminal offenders; however, “a consistent theme in numerous reviews of the rehabilitation literature is the positive effects of cognitive and cognitive-behavioral approaches for treating the offender population” (as cited in Wilson, Bouffard, & Mackenzie, 2005). Several meta analyses have been conducted illustrating the value of cognitive-behavioral therapy as an effective tool in reducing recidivism (Pearson, Lipton, Cleland, & Yee, 2002) and group-oriented cognitive behavioral programs for reducing criminal behavior as much as 20-30 percent compared to control groups (Wilson, Bouffard, & MacKenzie, 2005).

Typically, cognitive-restructuring, coping-skills, or problem-solving therapies have been the primary cognitive-behavioral approaches employed with individuals dealing with impulsivity, emotional instability, and interpersonal relationship disturbances. The cognitive-restructuring approach considers problematic behaviors to be a result of dysfunctional or maladaptive thought processes (Ross & Fabiano, 1985). Most cognitive-behavioral programs developed for justice-involved individuals tend to fall into the cognitive-restructuring category, focusing on cognitive deficits and distortions (Henning & Frueh, 1996), and are provided primarily in a group format.

CBT meets the criteria for an intervention that is pragmatic, because counselors trained in CBT have shown high levels of skillfulness in implementation, confidence in their ability to use the approach successfully, and satisfaction with CBT training (Morgenstern, Morgan, McCrady, Keller, & Carroll, 2001). Also, CBT is frequently conducted in group psychotherapy, which is practical given the economic limitations of many real-world settings (Morgan, Winterowd, & Ferrell, 1999).

START NOW helps participants begin to view their own actions using a CBT framework through a number of strategies:

• In-session exercises and discussions to reinforce concepts and encourage trying out new skills, including CBT procedures such as role-play, brainstorming, problem-solving, and behavior shaping.
• An “ABC system” for functional analysis of behavior (described in facilitator instructions for session 4).
• Practice exercises, in which participants are asked to complete tasks between sessions that allow them to practice new skills.