Vol. #15, No. 2
Welcome to May edition of Tips and Topics. We’re glad you could join us.
David Mee-Lee M.D.
Earlier this month, I had the opportunity to present to a mixed audience of criminal justice teams and treatment providers. The focus was on engaging mandated clients into accountable, sustainable positive change to reach the goals everyone wants: increased public safety, decreased crime and safety for children and families. Because of the mix of important stakeholders there were apparent clashes in mission, attitudes, policies and procedures.
How do you marry into one coherent approach the perspectives of judges, prosecuting and defense attorneys, probation and parole personnel, law enforcement, court coordinators and case managers, treatment providers and not least of whom, clients, participants and their families?
In the process of training and talking together, there were many issues raised explicitly or implicitly in the questions, attitudes and dilemmas voiced.
Here are questions that highlight conflicting perspectives on what is “addiction” and addiction treatment……and my attempts to answer them.
Q 1. Is addiction really a disease or isn’t it just willful misconduct?
I can certainly understand the difficulty of embracing the American Society of Addiction Medicine’s (ASAM) definition: “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.”
The behavioral manifestations (and often “bad” behaviors and acts) of this brain disease are so egregious, in-your-face threatening public safety, that it can seem nothing short of willful misconduct needing punishment.
But I would encourage those doubtful about addiction as a brain disease to speak with recovering physicians, lawyers, judges, pilots and any other person who has been afflicted with addiction. Ask them about the dangerous, reckless and unfathomable things they did when in the throes of addiction. Why would a physician who has spent hundreds of thousands of dollars in medical school and countless hours of study, internship, residency training and daily practice jeopardize his license and career to get high on fentanyl, or drink before seeing patients or while on emergency call?
How does it make sense to lose family, finances, health and even face death in willful misconduct, to use a legal or illegal drug to get high, if it isn’t a brain disease which results in individuals chasing after whatever will activate the brain reward system or provide relief?
Q 2. If they don’t stop using, treatment is fine; but at some point enough is enough and you have to kick them out of drug court and lock them up?
If you just look at the behavior of a person with addiction, you may see a person who lies, cheats, breaks laws and appears to lack good moral values.
- An understandable (but counterproductive) reaction of society is to punish such antisocial behaviors and approach a person with addiction as “a bad person” to be punished.
- The productive attitude to achieve public safety and real lasting change is to “realize that good people can do very bad things, and the behaviors of addiction are understandable in the context of the alterations in brain function.”
Q 3. If you do individualized treatment, won’t participants scam the system? If we don’t treat them with all the same expectations, won’t they all try to get around the rules as much as they can?
If you think “individualized treatment” means just allowing participants to pick and choose what parts of the program they will participate in; and not have any expectation of accountability to follow a treatment plan, then I can understand your concern.
“individualized treatment” is about collaborating on a treatment plan that matches the specific needs of the participant, makes sense to the participant, and therefore has the best chance to actually work and succeed.
Treatment isn’t about rules, phases, behavior control and punishment. It is about holding a person accountable for changing their beliefs, attitudes and lifestyle such that they are:
- Better parents – if getting their children back is what they want.
- Better citizens – if getting out of jail or off probation is what they want.
- Less impulsive and out of control- if not getting arrested is what they want.
- Mentally stable, sober and in recovery – if getting housing or a job or happiness is what they want.
- Better workers or partners – if keeping a job or relationship is what they want.
Q 4. These people have criminogenic thinking and antisocial behavior. How will they change if you are soft on them in treatment? Don’t they need to know who’s the boss?
Helping people change their thinking and behavior only has lasting, sustainable results if the person is an actual participant in the process. Good treatment isn’t being “soft” on people; it is expecting good faith effort to work on thinking and behaviors that are pro-social at a pace which brings actual change, not passive compliance.
The judge, treatment court, probation and parole, and any mandating agency certainly has the power of the “boss”; and should use that power:
- Not to prescribe and define the treatment e.g., level of care, length of stay, numbers of AA meetings etc. That is outside their scope of practice.
- To enact graduated sanctions for lack of good faith effort in treatment as evidenced by passive compliance, active or passive non-adherence to individualized treatment plans. Partnership with treatment providers ensures treatment is accountable and not “soft”.
In the September 2014 edition of Tips and Topics, we covered in more detail problem- solving courts. Tips & Topics September 2014
Questions about dealing with substance use and positive drug screens
Q 1. Using illegal drugs is criminal behavior. How can we just let that go without consequences? They picked up the drug and used.
If a participant uses substances while in treatment – legal or illegal drugs – you don’t just “let that go”. Using substances for a person with addiction is not good and indicates a poor outcome in treatment just like getting suicidal is a bad outcome for a person with major depression; or a spiking high blood pressure is a poor outcome for a person with hypertension.
The “consequences” of poor outcomes is to assess what went wrong and change the treatment plan. If you believe addiction is an illness characterized by loss of control of impulses and cravings to use drugs against ones better judgment, then yes, they did pick up the drug and use….but:
- The person with severe suicidal depression also picked up the razor blade to slash their wrists; or the bottle of pills to overdose.
- The addicted smoker also lit up the cigarette to deal with the craving to use.
- The morbidly obese person ate those extra calories against their better judgment.
Q 2. If they get a positive drug screen they need more than a tap on the wrist and “treatment that is all unicorns and rainbows.” (Said one workshop participant with disgust).
Yes, using substances when you resolved not to use; or are in treatment to achieve abstinence and sobriety needs more than a tap on the wrist. It requires the participant to take responsibility to learn from what went wrong and change their treatment plan in a positive direction. If they aren’t willing to do that, then they aren’t in treatment and should be counseled about the apparent need for some kind of sanction:
- Not for having used, which is a natural vulnerability for people with addiction
- But for not doing treatment in good faith and being out of compliance with court orders or agreements to do treatment.
Q 3. I’m OK with cutting them some slack early on in treatment if they use and get a positive drug screen. But if they are further along their phases and haven’t used for months, then shouldn’t they be sanctioned for any use?
People with addiction can establish abstinence for short or long periods of time depending on a variety of factors. But just like any other chronic illness, flare-ups and reactivation of the disease process can occur at any time, regardless of the length of stability.
- The person may be triggered by a sudden loss of a relationship by death or divorce and use even if they have months and years of sobriety.
- A flare-up of co-occurring chronic pain or depression and suicidality or trauma could trigger substance use.
- The participant may have started to get overconfident after many months of abstinence and sobriety and even start thinking that maybe they don’t even have addiction. They start attending support groups less; or try having “just one drink” that then blossoms into full relapse mode.
It doesn’t mean substance use is excusable early on in treatment phases, but later use is willful misconduct needing punishment. Any substance use in addiction treatment is not a good outcome. But the approach is the same for early or later use:
- What went wrong that you picked up a drink or drug again?
- What can you learn from this bad experience and do something differently in a positive direction?
- What people, places and things can you address to decrease the chance of a future flare-up?
- Choosing to not do treatment will show up as disinterest in changing your treatment plan in a positive direction; and/or lack of follow through in active, adherent services. Then a sanction is needed.
References and Resources:
- “A Technical Assistance Guide For Drug Court Judges on Drug Court Treatment Services” – Bureau of
Justice Assistance Drug Court Technical Assistance Project. American University, School of Public Affairs, Justice Programs Office. Lead Authors: Jeffrey N. Kushner, MHRA, State Drug Court Coordinator, Montana Supreme Court; Roger H. Peters, Ph.D., University of South Florida; Caroline S. Cooper BJA Drug Court Technical Assistance Project. School of Public Affairs, American University. May 1, 2014.
- Critical Treatment Issues Webinar Series, Bureau of Justice (BJA) Drug Court Technical Assistance Project at American University Feb. 10, 2016 – May 3, 2016 https://www.youtube.com/watch?v=AuUEP52z1Xk
- Mee-Lee D, Shulman GD, Fishman MJ, Gastfriend DR, Miller MM, eds. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. 3rd ed. Carson City, NV: The Change Companies®, 2013. Application to Special Populations – People in Criminal Justice Settings
On May 22, 2017, Ford Motor changed its CEO. Mark Fields, who had been with Ford for 28 years was replaced by Jim Hackett, an outsider who had only been at Ford for about a year. (Sometimes, just because you’ve have been in the business for decades doesn’t mean you have the most innovative ideas.)
Ford Executive Chairman, Bill Ford, said the “switch” was aimed at remaking Ford’s:
- Legendary hierarchical culture
- Expediting decision-making
- Pursuing a cohesive vision for the future
- Improving day-to-day operations
(USA Today, May 23, 2017 Money section page 2B)
What could justice teams and treatment providers take from these aims as they create more effective partnerships for public safety and lasting positive change?
- Facilitating accountable pro-social thinking and behavior can’t be a top down, hierarchical court mandate or a provider’s push for treatment compliance.
- When a flare-up of drug use destabilizes a participant’s treatment progress, good treatment and court decision-making must rise above a knee jerk sanction or suspension from treatment.
- All stakeholders must come together to pursue a cohesive vision for the future of criminal justice reform and improved treatment outcomes that serve public safety and recovery oriented systems of care.
- Communication between court teams and treatment teams must improve beyond cookie-cutter treatment compliance reports to meaningful progress reports on whether the participant is actually changing and growing.
The article quoted AutoPacific analyst Dave Sullivan: “Any time you go to a company like this, the culture is not gonna change overnight. It’s been set in stone for a hundred years.”
It hasn’t been 100 years since Drug Courts started. But it feels like there is still a lot of stone. However if you resonate with any of the thoughts for a new direction, the stone is breaking down and the culture is already changing.
STUMP THE SHRINK
Here is a question from a Mental Health Specialist at the Department of Corrections in Oregon:
Q: “I am assessing an individual who is non-compliant with their probation/parole and has missed UAs (drug urinalysis) in addition to many other noncompliance issues, but has not admitted to using substances. I have always been taught that we do not consider a missed UA to be a positive UA when diagnosing and/or determining appropriate level of care (LOC). Would the American Society of Addiction Medicine (ASAM) agree with this?”
The issue is less about the technicality of designating a missed UA to be coded as a “positive” UA result. Rather, the focus should be on assessing the individual’s Dimension 4, Readiness to Change. If the client is missing urine testing and other treatment meetings and strategies, the first consideration is to determine whether the client is even interested in treatment and whether s/he thinks there is an addiction problem needing treatment.
If s/he is ambivalent or not interested in attending, and there are no unstable problems needing containment and structure, then any treatment should focus on motivational enhancement that could be done in an outpatient Level 1 setting.
If there is instability threatening safety or their ability to access services, then the assessment and placement would be based on the needs of those issues, not just on missing drug testing.
In summary, the level of care placement depends on what issues, in which dimensions need services, the dose and intensity of which can only safely be delivered in which level of care? In that sense missing drug testing is indicative of broader issues rather than just legalistically considering that miss as a “positive” UA.