Vol. #15, No. 3
David Mee-Lee M.D.
This is the fifteenth year of publishing Tips and Topics (TNT). It is always gratifying and meaningful when people tell me how much they appreciate receiving it. About three years ago, one of TNT’s readers introduced himself to me and has gone way beyond just being a reader of TNT. I introduced Izaak Williams to you in the November 2014 edition of TNT. In there, he summarized a paper he had written which was prompted by my writing on graduation ceremonies, which had appeared in a 2011 TNT edition.
If you missed his paper entitled “Drug Treatment Graduation Ceremonies: It’s Time to Put This Long-Cherished Tradition to Rest,” here is a link to that paper:
This June, Izaak published another paper as principal author. I was a co-author, along with two others. This new one built on Izaak’s previous paper and expanded into graduations in Drug Courts. I will get to that in a minute.
Before that, here is some backdrop. Below is part of an exchange between Izaak and myself about: * how he came to be on the TNT mailing list in the first place and what resonated with him to read them so extensively?
Izaak Williams: “Years ago I was working on the frontlines of an outpatient addiction service, when my well-regarded Interim supervisor and colleague forwarded me their edition of Tips & Topics (If I may digress into a brief aside, I do not believe it coincidence that my professional relationship with these two former colleagues, who were both eager and avid readers of Tips and Topics at the time, would years later blossom into a personal friendship). As an addiction counselor, I was gradually becoming aware that there were areas of addiction treatment that needed improvement. Tips & Topics seemed to articulate a set of values and beliefs that really resonated with me. Since then I have used Tips & Topics as a bedrock to form a foundation upon which to build addiction services. Tips & Topics has become a prevailing medium to both highlight and inspire changes in treatment programs and to help fundamentally shift anachronistic paradigms. With Tips & Topics, I have drawn on the 14 years of Archives to address a variety of core initiatives that could very well make addiction treatment a better quality system in terms of its integrity, efficacy and effectiveness.”
Izaak L. Williams, Hawaii State Certified Substance Abuse Counselor (CSAC), was selected in the 2014 cohort of emerging leaders by the Center for Substance Abuse Treatment’s(CSAT’s) Behavioral Health Leadership Development Program. He can be reached at: email@example.com.
Rethink Drug Court graduation ceremonies; consider a possible alternative approach
“Rethinking Court-Sanctioned Reintegration Processes: Redemption Rituals as an Alternative to the Drug Court Graduation” was published this month in the Howard Journal of Crime and Justice.
Here are some highlights:
- On Drug Court (DC) graduation day, participants receive a certificate signifying completion of treatment for their substance use disorders and compliance with DC requirements. Having satisfied the conditions of DC by staying drug free and not engaging in criminal behavior, graduation signifies successful compliance.
- Graduation ceremonies can, however, create the perception among DC participants and families that graduation represents the end of treatment, and that little, or no further support will be necessary to prepare DC participants for their future.
- This article offers an alternative perspective. It explores what it means to graduate from DC, and how DC graduation might be reconfigured and reoriented to preserve validation and accomplishment, while guarding against the impression of a cure.
- Our conceptual framework is grounded in both re-integrative shaming theory, as well as the idea of redemption rituals. The latter is a form of ceremony to facilitate the offender re-entry process. In this approach, the offender is “shamed” by their community by being held accountable for their actions, but also provided with the support to enable them to make the changes necessary for successful reintegration.
- Redemption ceremonies feature reward and celebration, evoke positive emotion, and involve the public. However, in contrast with conventional graduation ceremonies, redemption rituals are intended to be restorative in their outcomes.
- Redemption ceremonies offer alternative meanings and symbolism for graduation from DC. These represent much more than just a participant’s compliance with court orders, treatment programming, and drug testing expectations.
- Redemption ceremonies emphasize a number of key factors: achievement, coordination of care, status elevation, and moral inclusion.
- “Achievement“: refers to long-term positive changes in the behavior of DC graduates rather than just compliance with program requirements of abstinence; promotes sustainable change and treatment matching.
- “Coordination of care“: ensures that the overall care provided is sufficiently comprehensive and coordinated to address the diverse and specific needs of individuals pre/post-graduation. Major differences in the characteristics and needs of DC participants means that there needs to be coordinated, integrated services from a variety of providers.
- “Status elevation“: involves effectively elevating the status of DC graduates so they can be fully accepted by, and integrated into, the social community without ongoing stigma and discrimination.
- “Moral inclusion“: addresses the process of welcoming the DC participant as a full member of a moral community rather than as a stigmatized person; it highlights the role of community acceptance in promoting sustainable change among DC graduates.
“Redemption entails identifying clients who are doing time versus doing treatment and change, and ensuring that adequate treatment resources are made available to successfully engage the former category of participants in an ongoing process that requires more than the DC phase from which they have now graduated.” (Page 263)
How to access the full article:
I am not permitted to post the full paper, but here’s the link to the Abstract: http://onlinelibrary.wiley.com/doi/10.1111/hojo.12203/full
If you want to read the whole paper you can contact me at firstname.lastname@example.org. I can “transmit individual copies of this PDF to colleagues upon their specific request provided no fee is charged, and further-provided that there is no systematic distribution of the Contribution, e.g. posting on a listserv, website or automated delivery.”
Consider the underlying assumptions, attitudes and practices driving the structure and naming of Discharge Categories.
Back in 2005 (February and March editions of TNT), I wrote about Discharge categories and the hidden philosophy, values and attitudes underlying many agencies’ categories.
Now 12 years later, Izaak and I formalized an article named:
“Co-participative Adherence: The Reconstruction of Discharge Categories in the Treatment of Substance Use Disorders”. It was just published this month online in Alcoholism Treatment Quarterly (ATQ).
Here are some highlights:
- Every program and agency has a variety of discharge categories classifying whether a client was successfully discharged or not.
- We suggested that a “moral-choice-compliance” (MCC) model of addiction and treatment underpins current discharge categories.
- Many providers advocate a “disease model of addiction”, but actually practice from the perspective of an MCC model. That model embraces practices and policies that sees substance use as willful misconduct, a moral problem where clients choose to pick up a drink or drug and therefore:
- Should have “consequences” for their use
- Be suspended from treatment for the day until sober
- Be discharged from residential care and sometimes banned from reapplying for treatment until 30 days have passed
- Be removed from mixing with other clients lest they trigger use for others.
- Rather than conducting treatment in recovery-oriented systems of care that values client empowerment, each client is expected to comply with treatment recommendations. Treatment progress is then measured by the client’s quality of compliance with program rules and counselor recommendations. Non-compliance can be met with “loss of privileges”, set back a level in a phase-based program; and even Administrative Discharge or Discharged for Non-compliance.
- To contrast a compliance, program-driven philosophy implied in the MCC model,we suggested a “coparticipative adherence” model to drive discharge terminology.
- Such a model values client autonomy in the administrative and clinical program systems. Clients participate and collaborate on goals and treatment plans, and participate in self-fueled adherence and committed effort in treatment. Coparticipative adherence thus facilitates a self change process rather than program-driven change.
- We offered contrasting and alternative discharge categories based on a “coparticipative adherence” model.
Here’s link to the Abstract:
How to download the full article:
- There are a limited number of free downloads at these two links to see the full paper:
- Check the Addiction Professional website around the middle of July to read Gary Enos’ online cover story of a Williams – Mee-Lee interview about this paper. For 30 days once that Addiction Professional article is posted, you can access the link for a free copy of the article https://www.addictionpro.com
Williams IL, Mee-Lee D, Gallagher JR, Irwin K (2017): “Rethinking Court-Sanctioned Reintegration Processes: Redemption Rituals as an Alternative to the Drug Court Graduation” The Howard Journal of Crime and Justice. Volume 56, Issue 2 June 2017 Pages 244-267.
Williams IL, Mee-Lee D (2017): “Co-participative Adherence: The Reconstruction of Discharge Categories in the Treatment of Substance Use Disorders” Alcoholism Treatment Quarterly. Vol. 35, Issue 3, June 2017 Pages: 279-297. Published online: 16 Jun 2017, Pages 1-19
Here are a few Skills tips to help rethink graduation ceremonies and promote sustainable self-change in the people we serve.
How to move from graduation to commencement ceremonies.
- In the March 2011 edition of TNT, I suggested we develop RCA – the Reflection, Celebration and Anticipation ceremony.
- Some drug courts and treatment courts have literally shifted terminology from “graduation” to “commencement” ceremonies. This encourages viewing recovery as a process just started, not completed.
- Talk to clients and participants in terms of having done an important “piece of work” in their treatment process, which is to be appreciated and honored. However, it is just a “piece” of the process of recovery, if sustainable change is to be achieved.
- Pay attention to clients who are just going through the motions of treatment. Make sure you don’t give the impression that just complying with rules and regulations will bring lasting results. I was reviewing with a care manager about her client who was eager to know what his drug court graduation date was going to be.
Why was it important to him to know the exact date?
He wanted to plan his wedding date after graduation. That way he could drink alcohol at his wedding without fear of consequences from drug court. His drug court graduation date was pushed back, so he promptly changed his wedding date to a later date. You can see where his priorities were.
How to enhance “coparticipative adherence”
What was the rationale behind coining the term “coparticipative adherence”?
The term emphasizes the true meaning of “adherence”; this encompasses collaboration, client empowerment for shared decision-making, and client choice in treatment decisions affecting their life. It isn’t an exercise in political correctness to replace “compliance” with “adherence”.
- Is the client actually a co-partner in defining overall and specific goals in their treatment? If you feel like you are doing more work than the client, then something has gone wrong with the co-partnering process.
- Are they actively participating in treatment or passively going along with treatment? If you feel like you are doing all the talking and making all the arguments (e.g. why attending self/mutual help groups is important; why medication adherence is necessary; why staying away from those friends is advisable) then your client is watching treatment, not doing it.
- Is your client adhering to the treatment plan – clinging to, steadfast, sticking to it – with the same energy and commitment they had in their active addiction days. If they knew they could have whatever drugs, whatever quantity, so long as they met their dealer promptly at 4 PM, how many of your clients would say “I don’t think I can make it at 4 PM. How about 5 PM? Or feel a little flu coming on, can I go next week?” However when it comes to treatment, if your client can’t seem to make it to appointments until 15 minutes late or not even show up or call, their adherence quotient is low.
Finally, if your client is not adhering, don’t look at the pathology of the client and think about Discharging them for Non-Compliance. Take a look first at the treatment plan and how well -or not- you have engaged the client. It may well be your treatment plan not a coparticipative plan.
Because I travel so much, I notice the hospitality and travel industries continually innovating to be more and more customer-friendly.
For example, renting a car?
- If you are enrolled in a loyalty program, you can bypass the lines at the rental counter and go straight to your car in space A9.
- How can you be sure A9 is your car? Either you receive a text or email telling you what car to look for in what space, or, their TV monitor lists your name and car space.
- What if you don’t like the assigned car and want to choose yourself? Some companies allow you to choose any car in your rental rate category. Since we are a Toyota RAV-4, Prius family, it’s nice to select a car with familiar dials and settings.
How about hotels?
- Many hotels now have phone apps. This enables you to check in ahead of time. When you arrive at the hotel, you simply pick up your key and go to your room.
- In a few hotels it is possible to even bypass the key-pickup-process and use your smartphone to enter your room. I haven’t tried that yet.
- Checking out is just as easy. Before leaving the room, just review your emailed bill, check out on your phone or laptop. You can now bypass the front desk.
Then there’s Uber
- As soon as I type in my destination in the Uber app I love seeing the price, how many minutes my ride is away, the driver’s name, car brand and license plate number. Now I know what to look out for.
- How great is it to be able to track the car’s path on the map and exactly how many minutes s/he is away, so there is no confusion who and where your ride is?
- Have you tried Uber (or Lyft)? When you do, I think you’ll see, like me, that you’d never choose to use a taxicab again.
Healthcare and addiction and mental health treatment all serve people too. Yet, I have to think hard to churn out m/any bullet points of innovation:
- I do like the easy access to my medical record online where I can make an appointment, ask my doctor a question, check my lab test results all without being placed on a phone hold.
However there are a lot of “unfriendly” practices which come to mind:
- When I visit the doctor’s office, I am handed a clipboard with a request to update any changes to my medical history. However the form is a brand new form as if I am a brand new patient.
Why not offer me a printout of my current history, then I can indicate any updates or changes on that ‘existing information’ form?
- Often an anxious person or family member is given an intake appointment in 2 days, 2 weeks and even 2 months.
Why not establish and offer an orientation, service-overview group available in 2 hours? If no one turns up, the leader can do paperwork. If 10 people show up, engagement and support can start that day.
- We still offer care and treatment services only in face to face appointments.
Why not provide phone apps, online education, treatment sessions, disease management, chat groups and support networks in the privacy of the person’s own home by phone or online?
Of course, innovations are already happening in healthcare. Practices and policies are indeed becoming “friendlier”. But maybe we could pick up the pace! Surely people’s health and well-being are just as important as renting a car, booking a hotel room or catching a ride.