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.
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.
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.
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.
Who are our clients?
People of color
Trauma survivors
Homeless or Formerly Homeless
Previously Incarcerated, many since childhood
Psychiatrically Ill adults aged 18-70
• 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?
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
Substances Used
• Alcohol
Prescription Drugs: i.e. Narcotic Painkillers,
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
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
• 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
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.
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
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)
Traditional Assumptions about Substance
• 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
Changes in the Addiction Field
• Focus on client competencies and strengths
• Individualized and client centered
• Client ambivalence is present, acknowledged and worked
Empathy is the key to change
Ultimate goal is abstinence, but the client chooses
No labels
Counselor is partner
“I’ve never had
problems with
drugs. I’ve had
problems with the
--Keith Richards
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
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
Psychiatric medications to minimize symptoms
Urinalysis; help clients to plan use around drug tests
Developing alternative support systems (people outside of the
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.
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

Working with People on Probation and Parole from a Harm