JEVS Prolonged Exposure Expansion

Nature of the Problem

More than 25,000 adults return home to Philadelphia each year from state and local prisons, and within five years approximately two-thirds of these individuals will again become involved in the criminal justice system. To break this cycle of recidivism, it is essential to provide supports that help individuals overcome barriers to accessing education, job opportunities, public benefits, and housing. Beyond these critical supports, many returning citizens also require treatment for behavioral health, physical health, and substance abuse issues if they are to achieve stability and successfully reintegrate into society. In particular, many individuals suffer from post-traumatic stress disorder (PTSD) either as a direct result of having been imprisoned or from prior traumas, including extreme poverty, abuse, or neglect. In fact, research shows that incarceration nearly doubles an individual’s risk for PTSD. Returning citizens are less likely to receive PTSD treatment for several reasons: they may not know they need treatment; they may not seek treatment in order to address other urgent needs; and existing systems are not equipped to treat the complex nature of returning citizens PTSD. Since treating PTSD is essential to reintegrating into the community, this lack of adequate care is a serious problem.

Program Description

Prolonged Exposure (PE), a groundbreaking, evidence-based trauma treatment, is a form of cognitive behavioral therapy that helps individuals gradually approach trauma-related memories, feelings, and situations. PE is innovative because it involves ‘imaginal’ exposure to the individual’s memory of trauma, as well as real-life exposure to reminders of trauma. JEVS Prolonged Exposure Expansion is a partnership between two JEVS initiatives: our outpatient clinic and our reentry initiative with Temple University. At JEVS Outpatient Clinic, we use PE to help individuals address trauma and build stable, healthy lives. Through JEVS Reentry Initiative, we provide returning citizens with reintegration supports including a comprehensive reentry workshop, case management, and job training. These supports are necessary but not sufficient for returning citizens confronting PTSD: untreated PTSD can stymie anyone’s quest to build stability. To address this gap, we will refer 110 Reentry Initiative participants to receive PE treatment through JEVS Outpatient Clinic this year. Therapists will work with returning citizens to develop a trauma treatment plan including both PE and conventional therapies. Integrating PTSD treatment with other supportive services will decrease the risk that returning citizens will fall through the cracks of the reentry system, helping them successfully navigate the transition back to their community.

Disruption

Few empirical studies have examined the feasibility of trauma-focused treatment among returning citizens. Because Prolonged Exposure has been found to be effective in addressing a variety of secondary outcomes of PTSD in clients endorsing trauma and comorbidities, we are especially eager to expand our Prolonged Exposure program to focus on returning citizens. PE is an innovative therapy because it posits that PTSD symptoms arise as a result of cognitive and behavioral avoidance of trauma-related thoughts, activities, and situations. PE helps the client interrupt and reverse this process by obstructing cognitive and behavioral avoidance, introducing corrective information, and facilitating organization and processing of the trauma memory and associated thoughts and beliefs. This unconventional approach shows great promise to effectively serve returning citizens because it directly addresses the trauma returning citizens experience that may have led to their incarceration or as a direct result of having been imprisoned.

Leadership

JEVS Prolonged Exposure program was developed with the support and resources of the local government via a Community Behavioral Health grant: JEVS was selected as one of only a few providers to be trained to offer this treatment. As such JEVS is a pioneer, providing important leadership to the behavioral health field in Philadelphia. This innovative model has the potential to inform behavioral health efforts both within and outside of our region. Our staff are part of local organizations such as the Philadelphia Reentry Coalition, Pennsylvania Reentry Council, Philadelphia Department of Behavioral Health/Intellectual Disability Services, Philadelphia Alliance of Community Providers, and national organizations such as the Coalition on Basic Adult Education (COABE), and Just Leadership USA, and will have ample opportunities to share lessons learned via conference presentations, publications, and board memberships.

Scalability

The Prolonged Exposure Expansion has the potential to be significantly scaled both within and outside of JEVS. JEVS serves nearly 30,000 individuals per year through 30 successful programs. Given that many of adults receiving mental health services from JEVS have experienced some type of trauma and that PE has been found to be effective in addressing a wide range of traumas, we see great possibilities for other JEVS programs to similarly cross-refer participants to JEVS Outpatient Clinic to receive Prolonged Exposure therapy. Beyond JEVS, we see opportunities to scale up this model by sharing data showing the impact and positive results from this treatment with Managed Care Organizations and other agencies working with this population, such as the University of Pennsylvania Center for the Treatment and Study of Anxiety, the Philadelphia Department of Behavioral Health/Intellectual Disability Services and the Philadelphia Alliance of Community Providers, and national agencies.

Results/Outcomes

So far, the JEVS Outpatient Program has treated 7 participants with Prolonged Exposure therapy, 4 of whom have a forensic background. JEVS Outpatient Clinic administered a Post-Traumatic Stress Diagnostic Scale self-report measure (PDS5) at intake and completion. Outcomes so far are excellent: at therapy completion, all 7 participants have reduced PTSD symptoms. Outside of JEVS, evidence shows that Prolonged Exposure is highly effective, having been selected as a Model Program for national dissemination by the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Substance Abuse Prevention. As noted above, there is little empirical data on PE therapy’s effect specifically on returning citizens, but there is ample evidence suggesting that it may be particularly valuable for this population. For this reason, we believe that this initiative constitutes a new and innovative contribution to our field.