What to do with poor outcomes: ACCEPT; my top 10 “Unvarnished Truths”
Welcome to the start of the 17th year of Tips and Topics (TNT). Most of you were not a reader from Day 1 when I started writing TNT, April 2003. If you were, please write and let me know.
In SAVVY, I’m introducing an acronym to help think through what to do when a client, patient or participant is not doing well in treatment – ACCEPT © David Mee-Lee 2019.
In SKILLS, what is a poor outcome for your client in addiction treatment?
In SOUL, whether you are thinking about retirement or not, “21 Unvarnished Truths about Retirement” is a worthwhile list from which I highlight my favorites.
When treatment is not going well for patients in the treatment of any disorder (diabetes, asthma, schizophrenia, major depression, bipolar disorder etc.) every healthcare professional usually follows the same sequence:
- Evaluate what is going wrong with the current treatment plan
- Identify with the patient what needs to change or be added to the treatment
- Continue treatment with the new adjusted treatment plan and track the outcome.
But when it comes to addiction treatment, somehow this usual sequence often does not apply. What happens all too frequently is that the client is “punished” in some way:
- Sanctions for breaking rules
- Suspension or discharge from treatment
- Consequences for non compliance
- Loss of privileges and set back a phase in treatment
- A behavioral contract, which if broken, results in discharge
Instead of seeing substance use, poor attendance or angry outbursts as poor outcomes in addiction treatment to be assessed and treated, such behaviors are seen as willful misconduct requiring consequences.
To treat addiction like other diseases, here’s what to do with poor outcomes – ACCEPT (© David Mee-Lee 2019)
A ssess what is and is not working in the treatment plan
C hange the treatment plan to address those identified problems or priorities
C heck the treatment contract if the participant is reluctant to modify treatment plan
E xpect effort in a positive direction – “do treatment” not “do time”
P olicies that permit mistakes and honesty; not zero tolerance
T rack outcomes in real time – functional change (attitudes, thoughts, behaviors) not compliance with a program.
That’s the overview of ACCEPT and here is more detail:
- Were the strategies in the treatment plan too difficult to do? Did the participant even do them?
- What were the circumstances that surrounded the substance use, or angry outburst, or missed appointment?
- Were the interventions in the treatment plan good strategies, but not as effective as expected?
- Did we miss anything that is now flaring up and affecting success e.g, unaddressed trauma or chronic pain?
- Collaborate with the participant to change the treatment plan to address whatever was discovered in the ASSESS part e.g., Did you identify together certain people, places and things that led to substance use? What is the participant willing and able to change in the treatment plan?
- Change goals or strategies in the treatment plan in a positive direction e.g, avoid at least one friend who triggers use even if the participant is not willing to give up all friends; practice nonviolent ways to deal with anger in a role play in group; attend just one self help/mutual help group if not open to 90 meetings in 90 days?
- Changing the treatment plan is a learning opportunity to be embraced, not a consequence to be enforced.
- If you are doing more work than the client e.g., pushing AA/NA attendance; urging the client to change friends or get a sponsor; pushing a relapse prevention plan while they watch you passively, then check whether the participant is actually interested in treatment or just going through the motions.
- The participant should be as active in figuring out changes in the treatment plan as you are.
- If the participant is putting in a good faith effort to work on the new treatment plan, treatment continues.
- If the participant is passively following your lead in treatment plan changes, that is “doing time” not “doing treatment and change”.
- When you have policies that are zero tolerance, this does not permit participants to be open and honest about mistakes, substance urges and actual use; and pushes illicit use by themselves and others underground.
- Participants are then more focused on “snitching” and antisocial, criminogenic behavior to scam the system than on learning how to take responsibility to protect their environment from drug using and other triggers.
- Track whether participants are actually working on attitudes, thoughts and behavior that have contributed to problems in relationships, employment, child care, public safety or school.
- If participants aren’t able to explain what attitudes, thoughts and behaviors they are working on, then they are most likely sitting in treatment groups thinking that complying with program rules is treatment. This assumes you have worked on a person-centered, individualized treatment plan.
Too many addiction treatment professionals view substance use while in treatment, disinterest in AA and other self/mutual help meetings, impulse problems or poor attendance as behavior problems to deal with rather than as outcomes to be treated.
Identify what a poor outcome is for your client in addiction treatment
1. If a client is working towards sustained abstinence and sobriety, using substances and getting a positive urine drug test is not a good outcome.
2. If a client is working to establish a positive recovery support network through self help and mutual help groups like Alcoholics Anonymous or SMART Recovery, then not going to meetings or going, but sitting passively up the back or smoking outside the meeting room the whole time is not a good outcome.
3. If a client signed themselves into treatment, but sits in group staring out the window, counting the minutes until a smoke break, that is not a good outcome.
If the goals for abstinence, meetings and active group participation are
your goals, not the client’s focus, then the first step is to abandon those
recovery goals and work with what is important to the client.
- For a client not interested in recovery, the focus may be controlled substance use, no meetings and to get out of treatment as soon as possible.
Such a client needs a discovery plan – help them discover a connection between substance use, impulse control and hanging with using friends and the “bad” things happening to them – doing more time in jail; having their children taken away; losing a job or relationship.
So a poor outcome for the discovery plan client is different from a person interested in recovery:
1. If a client is trying to prove that they can cut back or stop using any time they want, then any substance use over the amount or quantity that the client agreed to do, is not a good outcome.
2. If a client agrees to go to at least one meeting/week, then missing a meeting the whole week is not a good outcome.
3. If a client doesn’t know their treatment plan, then that is not a good outcome. (Of course you can’t blame the client if you did a cookie-cutter, generic plan instead of an individualized, collaborative treatment plan.)
Whatever the current focus of treatment, whether recovery or discovery, when treatment is not working and the client is not achieving the outcomes agreed upon, then that is the time to ACCEPT. © David Mee-Lee 2019
I don’t plan to totally “retire” and hang out the “Gone Fishin'” sign. But I am putting more spaces in my schedule to do more travel and leisure. As I read Look’s 21 Truths, it was evident that these weren’t just relevant to retirement, but pearls about life for everyone.
Jonathan Look quoted Hunter S. Thompson: “Life should not be a journey to the grave with the intention of arriving safely in a pretty and well-preserved body, but rather to skid in broadside in a cloud of smoke, thoroughly used up, totally worn out, and loudly proclaiming “Wow! What a Ride!”
You can read the whole list, but here are my top 10 favorites out of the 21 Unvarnished Truths. I’ll keep the same numbering of the article so you can compare them with your top 10:
2. Be curious. See both sides. Stubbornness is not strength. When given new information, strong people develop and evolve their opinions. We can grow when we can admit we are wrong. Your life stagnates when you are wrong, but you refuse to admit it.
4. You don’t have to wait for an apology to forgive. We have all been wronged at one time or another. Waiting for an apology from someone who may never give offer one is a waste of life. Who cares? Hell, if this is a gray area and it’s possible the other person is waiting for an apology from you, apologize first. What does it matter? Life is too precious to play those kind of games.
7. Ambition can be a killer. I hate to break it to you, but you aren’t going to be Number One in everything you do. Breathe, and be satisfied, with the act of living today. Don’t let blind ambition cause you to lose sight of what is important. Savour all of life’s moments, even the bad ones, because you only get so many and you may wish you had paid more attention.
8. Your aspirations mean nothing. Well, they mean nothing if you don’t make an effort to realize them. Take action to get the things you want.
9. Stop complaining. Most people don’t care about your problems; some are happy you have them. Complaining only serves to keep negatives at the center of your life.
11. You can’t make people happy. You can listen. You can be kind. You can smile. You can respect. You can offer assistance. You can contribute tools. But people are responsible for their own happiness (see No. 9).
13. You are responsible. You may not be at fault for what happens, but you get to choose how you respond to everything. Yes, everything. Your response to anything is a choice. You are response-able.
16. Your bucket list is crap. Putting things on a bucket list can be just another way of deferring your aspirations. Sure, go ahead and make a list but remember: life goes on while you are making plans. Lists are useless unless we utilize them.
18. Time is your most valuable asset. You only get so much, and that is it. You can’t horde it. You can’t get it back. You can’t turn back the clock. The best you can do is to start investing your time wisely.
20. In the end, we are all dead. Make that phone call or send an email to let someone know you are thinking of him or her. Better yet, go visit. Mend fences, hug, show appreciation, be kind to people. Don’t be complacent; you never know when the people you thought would be there forever will be gone.
What are your top 10 “Unvarnished Truths”?