You are a clinical psychologist and an addiction researcher. Some of your research focuses on treatment for individuals with substance use disorders (SUDs) involved in the criminal justice system. What led you to this work?
People in this sector often have personal experience with substance use, but that was not my trajectory. I became interested in substance use after my undergraduate work as a chemical dependency professional trainee at one of the few publicly funded treatment centers for substance use disorder in Seattle, Washington. At this center, 70 percent of our clients were court-mandated to treatment. During treatment, many would get re-booked, often for probation violations for using substances or a new charge. I became deeply interested in that cycle of “in and out” of jail, which led me to my graduate work and research career.
It has been interesting and rewarding to work at the intersection of addiction and treatment research and the criminal legal system. Many factors can influence a person’s experience in the legal system, like race, ethnicity, and socioeconomic status, which may result in unjust outcomes.
You’ve used “policy codesign” to develop a reentry program for individuals with opioid use disorder (OUD) in jail. What is policy codesign, and why is it a promising system-planning framework?
We hear a lot of frustration about “top-down” policies. So, policy codesign builds solutions from the ground up. It brings together diverse legal system partners and community members to engage in learning conversations with each other to understand the local landscape and develop solutions that are sustainable. The groundwork in learning conversations focuses on active listening, especially to people with lived experience in the area where policy will affect them because individuals are experts in their own lives. For one project, people with lived experience included those with lived experience of substance use and legal involvement and people with lived experience as law enforcement officers. While researchers and others in the field may know “what works,” codesign melds diverse input into the process, resulting in policies that reflect what is effective in the context of a particular community.
Beyond subject-matter experts, having people with lived experience and community engagement involved in the process means they can explore creative solutions—unique to their culture and values—in the moment. For example, during one policy codesign session, a law enforcement officer talked about wanting to connect people to detox, but never being able to find beds. Because we intentionally convened a variety of stakeholders, we had the person supervising most of the region’s SUD detox beds right there in the room—they were able to connect and smooth out that referral process.
Policy codesign could be even more meaningful in rural settings where we hear the most frustrations about statewide policies that get developed out of and for more urban areas. Often, rural partners are left out of planning, which hurts buy-in and implementation down the road.
The policy codesign process can look different in urban versus rural areas. For example, in urban regions, it can be difficult to truly get all stakeholders together at the same time because there are literally hundreds and thousands of players. In contrast, while working with a rural community, an issue came up about improving crisis response for people leaving the jail. A participant texted his brother-in-law, who is the director of the jail, and he arrived 20 minutes later. Instead of just finger-pointing problems at the jail, they identified a decision-maker and brought him right into the process.
You worked on a project to improve interactions between law enforcement and people who use alcohol and drugs. Who was part of this work, and what are some key findings others may find interesting?
For this effort, we maintained a core steering committee, including University of Washington researchers and staff, people with lived/living experience of drug use and legal involvement, retired law enforcement, and multiple external partners. The regional design team members for the project included local law enforcement, people with lived/living experience of substance use and legal involvement, and service providers.
Through this work, the team found that law enforcement and people with lived experience of SUD have a lot more in common than we think. We started by exploring common ground, like who’s a parent, who’s a coach, and the personal experiences that bind us. This helped reveal shared values we could build on. Exploring these shared values built empathy, led to productive discussions about how to make change, and fostered relationships—all of these were essential to building effective policies together.
The team found that we have a lot to learn from each other. Many of the participants—service providers, researchers, and people with lived experience of SUD—gained a better understanding of and empathy for law enforcement officers and their experiences. This project was an opportunity to really hear those experiences and humanize each other.
Finally, how we connect in the process matters. In a participatory framework, we came in as a neutral third party to facilitate change. People in the process told us it was helpful to have somebody not embedded in their community to support their collaboration.
You have worked closely with justice partners to implement medication for opioid use disorder (MOUD) services in jail settings. What three strategies support the successful implementation of jail MOUD programs?
First, you must find champions within the system. System change starts by changing people. An informed champion can influence others, who then influence other staff. Then real transformation begins.
The second strategy is to learn from others who have done it before you. Do not reinvent the wheel. In convening jails, prescribers, community partners, and people with lived experience, we can mine a wealth of information about what works and what doesn’t. For instance, if a discussion reveals another jail’s workaround for storing meds, that’s important both instrumentally in building a policy, and emotionally, as in “Oh, we’re not the only jail struggling with this.” Learning from others is both strategic—as it saves time and energy—and vital to the sense of connection to other change-makers.
Third, shared decision-making promotes community ownership and, thus, sustainability. With MOUD especially, it’s vital that the community builds, accepts, and supports the policy because there can be political pushback around medications for OUD. But having jail administrators, law enforcement, people with lived experience of SUD, and other community members at the table with a sense of shared values and mission enhances the viability and effectiveness of the final product.
Your work can be difficult in terms of being exposed to stories of trauma and suffering. What are three things you do to support your resiliency and well-being, either in the office or in your free time?
I stay focused on the big picture. MOUD in jails requires big systems changes, and it is hard not to get impatient with how slowly big systems move. I remember that if we keep chipping away at the work, we can sometimes see big results. It is also helpful for me to focus on the individuals who benefit from MOUD and to remember the people that we impact by doing this work.
The second thing is getting support from people close to the issue. It is great to have colleagues who are doing the same kind of work. Last year, unfortunately, I lost a patient, and it felt very different to get support from another provider who also knew them. I get support from family, friends, and loved ones as well, but they cannot see things the way my colleagues can.
Finally, I am a huge proponent of exercise. I do not know what my mental health would be without it. I can be having a tough day, go work out, and suddenly the work feels doable and survivable. My brain can go a hundred miles a minute, so it is nice to show up at my gym, see my community, and start sweating. It is hard to perseverate when I am trying to keep a hundred-pound barbell over my head.
When I think about how hard this work gets, I also come back to a specific memory from my graduate training when I was doing motivational interviewing at the Metropolitan Detention Center in Albuquerque, New Mexico. I was passing out my flyers for new clients, and a gentleman looked up at me and said, “Thank you for being here. Most people just forget about us.”
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