December 2022 – Vol. #20, No. 9

The story of the Judge and the Grieving Team; What does “going high” mean (keep an open mind on these excerpts).

In SAVVY, STUMP THE SHRINK and SKILLS,  this is the story of the Judge and the grieving Treatment Court team. Relapse and a deadly overdose is sad at any time for anyone with addiction. But it is all themore stinging when the participant has been in long-term recovery and then relapses and dies.

In SOUL, I feel sad, confused, and sometimes hopeless about the way we deal with our political differences. But keep an open mind to review what solutions Michelle Obama offers when she explains what “going high” means.

savvy, stump the shrink, and skills

Last month a judge from Pennsylvania sent this simple but heartfelt request to me:

Subject: Grieving as a Treatment Court Team

Message: Do you have any recommendations – readings, processes, tips etc. – for a team grieving the loss of a graduate to overdose? I’ve attended sessions on grief at conferences and read articles/books on thesubject, but I don’t want to merely say “read this, it might help.”

Of course it piqued my interest to know what was the backstory of this grieving Treatment Court team. So I wrote back:

Tip 1

In addition to processing the grief, the death of a participant is an opportunity to identify any learning lessons that can help future participants.

My response:

One thing I would say is to have the team use this not just to grieve the loss of someone with addiction, but to see if there is anything that can be learned from this tragedy to prevent such losses and help future participants.

  • For example, was the “graduate” linked to any ongoing services for continued care of his or her addiction? It is not unusual for a person with addiction to think that when they “graduate” that they are done with treatment. But addiction is an ongoing, potentially chronic illness that isn’t cured when they graduate from a program. Flare-ups happen for this deadly disease and death is a real possibility if there is no ongoing addiction treatment and monitoring.
  • Was the participant involved in any ongoing recovery, self/mutual help support groups like Narcotics Anonymous or SMART Recovery? If not, then again, they are very vulnerable to a flare-up and death. 
  • Even if they were connected with mutual help groups, do you know if they were still going to meetings and active; or had their attendance fallen off?
  • Were there any co-occurring mental or physical health needs like trauma or chronic pain treatment and were they connected to mental or physical health treatment as unstable signs and symptoms can trigger a flare-up too?

Let me know if you have answers to any of these questions. A review of questions like this can help theteam see that some good can come of this death to help others, even though you lost this particular participant.

(I was thinking that the Court participant had just recently “graduated” the Treatment Court program and that is why the team was so sad. I thought that it could be an opportunity to seize the moment while thefacts were still fresh, to use this loss for some good once they had processed some of their grief).

But there was more to the story than just a recent graduation, flare-up and death that helped explain why the Team’s grief was especially acute.

More from the Judge:

I was planning to get back to you after processing the memorial service, which was Friday afternoon. In short, It may not be the best fact scenario for a “what we could have done” because this is someone who graduated almost 7 years.

As such, no metric for relapse or recidivism that I know of would tell us we should have done “x, y or z.” But then, no metric is necessary for feeling like we should have done just that. Nor, is there a metric for grieving.

Let me discuss this with the Team at our meeting tomorrow. Obviously, there is a lot more to the story.

My Response:

Thanks for that update. You are right that with the participant’s having graduated 7 years ago, it is a bit hard to reconstruct the “could haves” “should haves” “might haves” etc. I think it is a constructive vignette that will help raise questions and suggestions to others facing similar concerns, relapses, deaths and grieving.

It sounds like you have a very caring team under your leadership to have kept contact with a participant after 7 years. I should say that addiction is a deadly disease as you know and that a relapse and death at anytime is part of the curse of any chronic addiction, mental health and physical health disease.

(I was impressed that the Team had kept contact with this participant for 7 years and I was about to find out more of the story, which helped explain why the Team was so affected by the loss of this Treatment Court participant.)

Tip 2

Recovery in addiction is wonderful to witness and celebrate with participants. But this makes relapse and death all the more stinging. 

The Judge explains:

Dr. Mee-Lee,

Caitlin (not her real name) entered Treatment Court on July 12, 2014, on a third DUI (drugs and alcohol) that would have landed her in state prison for at least a year. She was actively using marijuana and 150-300 mg of OxyContin a day. She had never been in treatment and was recommended for a long-term women and children’s program. She was discharged unsuccessfully in late November due to some allegations of her or another participant drinking or possessing a beer. It was as much of an issue with theprovider so we did not pile on the sanctions.

From that point on her program was mostly unremarkable. Caitlin’s biggest problem was forgetfulness – missing tests and curfew calls. She never tested positive and once she changed her phone’s lock screen to a picture of her Probation Officer, Katie (not her real name), she never missed a test or a call. She started back at college mid-program and by graduation on July 16, 2016, she had almost finished and was focused on becoming a nurse. Happily, she became an Registered Nurse about 2 years after graduating. During that time, Caitlin came back to court regularly to visit and give us updates. She continued to help those in recovery and we recognized her for that service in 2019 with an award we give to alumni.  

Caitlin maintained contact with Katie over the years, until probably the last several months of her life. About 2 years ago, she and her husband got Medical Marijuana cards, which led to a positive test and the loss of her job in a local hospital. She was placed on probation by the State Board of Nursing. I won’t blame everything on medical marijuana, but it probably didn’t help her recovery any more than it did her career. She gave birth to her third child about 7 months ago and I think that’s when things went south fast, perhaps with pain issues (the family would like to say it was kidney stone-related). Regardless, Katie hadn’t heard from her for a few months when she got the call – another damn fentanyl overdose.

Tip 3

The Judge is the leader of the Team. His or her measure of caring, compassion and competence sets the tone for the effectiveness of Team members and the success of Treatment Court participants.

Note how the Judge talks about his grief for this participate who “graduated” seven years ago:

I cannot speak for the other team members in attendance, but the memorial service was somewhat cathartic for me. It was difficult to see her 15-year-old, who used to come to court on occasion, but even harder to see the toddler and infant who have no idea what just happened to them. The pastor said, “life is truly and harshly unfair, but God is not.” To the extent we need some spiritual basis to deal with our lives and our addictions, that will help me deal with the grief … for a while.

Programmatically, there was no recidivism, only a relapse, years down the road, and had it not involved fentanyl, she might still be with us. Of course, the fact that no criminological measure of success would blame our program for Caitlin’s death is not helpful. With every termination or overdose, and fortunately there have been only a few of the latter, there is a sense that we should have done more. Katie (who has been back in the treatment field for a year) is probably struggling the most. She is the one who knew Caitlin the best and Caitlin called her “my angel.”

Now, I’ll reread David Kessler’s book on the 6th stage of grief and see if I can find some meaning in Caitlin’s death. I gave the book to the Team last year so I guess I need to take my own medicine.

 You be the “judge” of this Judge. Does that sound like caring, compassion and competence to you? It surely does to me.

My response:

Thanks so much Judge, for this. It is so sad when we see people doing well in recovery and then relapse. Even worse when it leads to death, so I understand how you and the team is impacted.

I guess it’s just a reminder that addiction is a deadly disease and like other chronic illnesses, cannot be perfectly cured.

soul

I feel sad, confused, and sometimes hopeless about the way we deal with our political differences – demonization of the “other side”; death threats and actual violence; fixed in our information bubbles, unwilling to hear or understand any counter opinions and views.

With the Midterm elections over, it seems we have already started the next cycle of polarized politics and divisiveness. Most of the time I avoid reading about and listening to all the opinions, arguments and political machinations. I am not a news junkie fascinated by the latest conspiracy theories, declarations of doom on the right and left and who is fighting whom.

But I do vote and want to be aware enough to know what’s happening in my world and the world. So I do want to find solutions to healing the divisiveness that is too easy to take for granted as the new (or is it old) normal.

In SOUL this month, I am taking a risk – not to discuss this topic – but to draw on Michelle Obama to offer some solutions. The risk is for you to have a knee-jerk reaction depending on which side of the political divide you sit. If you are on one side, you might not want to read anything more because of the word “Obama”. If you are on the other side, you might just assume that what she says is worthwhile.

I share excerpts because her article dropped into my TIME Magazine lap, and as I read her essay, Michelle Obama: Yes, We Still Need to ‘Go High’ When Everything Is Terrible it helped me feel more hopeful. She gave direction on what to do with our hurt and rage, our worst impulses, and power.

Stay open and consider Michelle Obama’s solutions whether your hurt and rage is about:

  • the threat to the life of an unborn child or restricting the right for a woman to choose what she does with her body and health
  • the right to marry only a person of the opposite gender or to marry any person you choose
  • giving the government less or more control and regulation over your life and resources.

Here are some excerpts

Of all the questions I get asked, there’s one that comes up more often and more predictably than any other. Nearly every time I talk to an interviewer or sit down with a new group of people, I can basically count on someone raising it, while others lean in to listen.

What does it really mean to go high?

All I was doing, really, was sharing a convenient bit of shorthand…..to remind ourselves to hang on to our integrity when we saw others losing theirs.

Going high is like drawing a line in the sand, a boundary we can make visible and then consider. Which side of this do I want to be on? It’s a reminder to pause and be thoughtful.

And yet the problem with any simple motto, I suppose, is that it can be easier to remember and repeat than to put into active daily practice.

These days, when people ask me to explain what it means to go high, I sometimes sense a slightly less polite question riding on its back side, tinged by a natural skepticism, a feeling brewed by weariness and arriving when our efforts seem fruitless and our tests don’t end: But wait, have you seen the world lately? How much worse can things get? Where is the energy to fight?

Are we still supposed to be going high?

My answer is yes. We need to keep trying to go high. Operating with integrity matters. It will matter forever. It is a tool. 

At the same time, though, I want to be clear: Going high is something you do rather than merely feel. It’s not some call to be complacent and wait around for change, or to sit on the sidelines as others struggle. It is not about accepting the conditions of oppression or letting cruelty and power go unchallenged. The notion of going high shouldn’t raise any questions about whether we are obligated to fight for more fairness, decency, and justice in this world; rather, it’s about how we fight, how we go about trying to solve the problems we encounter, and how we sustain ourselves long enough to be effective rather than burn out. There are some who see this as an unfair and ineffective compromise, an extension of respectability politics, in which we conform to rather than challenge the rules in order to get by. Why, people rightly wonder, do we need to try to be so reasonable all the time?

I can see how some think that reason leaves no room for rage. I understand the perception that going high means that you somehow remove yourself and remain unbothered by all that might otherwise gall and provoke you.

But it’s not that at all.

But where was my actual power? I knew it didn’t reside in my hurt and rage, at least as they existed in raw forms. My power lay in whatever I could manage to do with that hurt and rage, where I could take it. It hinged on whether or not I could elevate those feelings into something that would become harder for others to write off, which was a clear message, a call to action, and a result I was willing to work for.

That’s what going high is for me. It’s about taking an abstract and usually upsetting feeling and working to convert it into some sort of actionable plan, to move through the raw stuff and in the direction of a larger solution.

I want to be clear that this is a process, and not always a quick one. It can take time and patience. It’s okay to sit and stew for a while, to live inside the agitation caused by injustice or fear or grief, or to express your pain. It’s okay to grant yourself the space you need to recover or heal. For me, going high usually involves taking a pause before I react. It is a form of self-control, a line laid between our best and worst impulses. Going high is about resisting the temptation to participate in shallow fury and corrosive contempt and instead figuring out how to respond with a clear voice to whatever is shallow and corrosive around you. It’s what happens when you take a reaction and mature it into a response.

Because here’s the thing: Emotions are not plans. They don’t solve problems or right any wrongs. You can feel them—you will feel them, inevitably—but be careful about letting them guide you. Rage can be a dirty windshield. Hurt is like a broken steering wheel. Disappointment will only ride, sulking and unhelpful, in theback seat. If you don’t do something constructive with them, they’ll take you straight into a ditch.

My power has always hinged on my ability to keep myself out of the ditch.

(Adapted from the book The Light We Carry: Overcoming in Uncertain Times by Michelle Obama. Copyright © 2022 by Michelle Obama. Published by Crown, an imprint of Random House, a division of Penguin Random House LLC. All rights reserved.)

I have a request:

I just excerpted from Michelle Obama’s adaptation from her book “The Light We Carry: Overcoming in Uncertain Times”. But if you have an essay or book adaptation from your favorite opinion leader(s) on theRight of the political divide who offers solutions, please link me to them. I am looking for solutions, not to perpetuate our divisiveness. I know as much about our differences as I care to know. I want solutions and I don’t care where the solutions come from. 

until next time

Thank-you for joining us this month. See you in 2023. Happy New Year and may you have a year of health and well-being.

David

November 2022

Dr. Ken Minkoff on “Welcoming” and “Skills-based learning” when serving people with complex needs; 70th birthday and 50th wedding anniversary and Thanksgiving week

In SAVVY, guest writer and psychiatrist, Ken Minkoff, M.D., highlights the importance of designing services expecting to see people with co-occurring mental health, substance use and other complex needs. But most importantly, organizing ourselves and services in a welcoming manner in everything we do.

In SKILLS, Dr. Minkoff addresses another important principle in helping people with complex needs, what he calls “Adequately supported, adequately rewarded, skills based learning for each condition.” As simple as you may think this needs to be, it needs to be even simpler!!!!

In SOUL, I reflect on what would have been my wife’s 70th birthday, our 50th wedding anniversary. Thanksgiving Day is an opportunity for pain or joy.  I choose to make it a week of Thanks and Giving.

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October 2022

Clients who don’t want inpatient treatment – What to do; Individualized, accountable care; Right turns on red.

In SAVVY, STUMP THE SHRINK and SKILLS, Amber asks a couple of questions about what to do when clients are recommended for inpatient treatment but decline and only want outpatient services. This edition explores how to meet the client where they are at, but also hold them accountable to the outcomes of whatever plan they agree to work on, even in outpatient services.

In SOUL, I am grateful for the “Right turn on red” law and ponder why we can’t have an “everybody wins” attitude to lots of challenges and problems.

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September 2022

Brief But Spectacular take on telling the whole story; Solutions Journalism; COVID and Things are always working out for me.

Welcome to the September edition of Tips and Topics from Australia.

In SAVVY, watch David Bornstein make the case for Solutions Journalism to activate people to be powerful players in a participatory democracy.

In SKILLS, be part of telling the whole story, not just focusing on the problems. “It is as if your parents were always criticizing you about what you were doing wrong and never letting you know where you have possibilities to grow.”

In SOUL, I have adopted more robustly the attitude of “Things are always working out for me”. A number of events on my Aussie trip would seem to contradict that. But as I reflect on the events midway through my trip, and my week of COVID, I’m sticking with my story.

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August 2022

Jaclyn’s story about a mother and son in her own words – Applying the therapeutic alliance to any relationship; What is ‘young’ anyway?

In SAVVY, SKILLS, SHARING STORIES & SOLUTIONS, I depart a little from our usual format to let you enjoy and learn from a mother’s story about how she applied the principles and practices of the therapeutic alliance to restore her relationship with her son. Not only did it rebuild the relationship but it empowered Leo to reach his full potential.

In SOUL, I am choosing to focus more on the joy of living than on my biological age. Even though I hit 73 this month, I don’t feel anywhere near that. How about you?

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July 2022

How smart are you about SMART Recovery and its Family & Friends Program? Wisdom on coming together from social media

In SAVVY, we all know about AA and other 12-Step programs. But Joe Gerstein, Founding President of SMART Recovery, gives us an update on this complementary alternative community mutual assistance organization started in 1994.

In SKILLS, Joe explains how SMART Recovery runs and what skills and goals are the focus; as well as how the Family and Friends Program is integrated with CRAFT [Community Reinforcement And Family Training].

In SOUL, I share some of my favorite quotes and images from social media that helped me think about how to come together in an era of division and information bubbles.

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June 2022

Helping families with addiction – Residential treatment is not the gold standard; Intervention, Tough Love or CRAFT?; Exercise training is hard work. How do those athletes do it?

In SAVVY, STUMP THE SHRINK and SKILLS, I share a colleague’s request for recommendations for a residential program on behalf of a family affected by addiction. The family wanted their son in long-term residential treatment. But is residential treatment the gold standard? We have to use the whole continuum of care to give long-term, life long addiction treatment if necessary.

What should be done for a son who the parents are financially supporting and who doesn’t follow through with treatment?

In SOUL, I recently started strength and core exercise training. Better late than never, but it is hard. I have a new found admiration for all those athletes who workout everyday to reach their peak performance

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May 2022

Pandemic Parenting: Do you have Parental Burnout?; Strategies to help with Parental Burnout; 13 million pounds of discarded soap.

In SAVVY, an online survey of 1,285 working parents was conducted between January 2021 and April 2021. Earlier in May, the researchers from Ohio State University published their report, Pandemic Parenting: Examining the Epidemic of Working Parental Burnout and Strategies to Help.

In SKILLS, after describing what Parental Burnout is, the report went on to provide some strategies to help parents deal with burnout. So whether you are a parent yourself, or helping parents cope, the report has strategies for you.

In SOUL, In 2008, Shawn Seipler was staying at a hotel in Minneapolis and wondered what happens to all the unused hotel room soap? This got me thinking about what would be the ‘wasted hotel soap’ of the healthcare industry? What better systems could we build that could save as many lives as 13 million pounds of discarded soap?

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April 2022

My three career bridge-building targets; Where to start in helping people change; 50 years for Elon Musk and me.

Welcome to the start of my 20th year of writing Tips and Topics. The first edition was published April 2003.

In SAVVY, this edition of Tips & Topics begins the 20th year of publication. I look back at what I’ve written before in three areas of bridge-building: Addiction as an illness – the general public and health care in general; Addiction and mental health – Co-Occurring Disorders; Justice and Treatment teams.

In SKILLS, it requires skillful bridge-building to attract people into lasting, accountable change, and cross the bridge from expecting compliance to treatment to collaborating in person-centered care planning: Start with what the person is at Action for, not what you are at Action for; Hold the participant accountable to their goal and track their engagement, good faith effort and outcomes.

In SOUL, this year is 50 years since I graduated from medical school and started my career. See my ASAM Educator of the Year award photo and video bio. Elon Musk is 50 years old. I’ve had a good career, but find out what drives Elon and what someone who was one year old when I started my career has achieved.

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March 2022

What to report to Probation and CPS; Dilemmas about drug testing; Client-centered doesn’t mean client anarchy; Win, lose and win

In SAVVY, SKILLS and STUMP THE SHRINK, treatment providers can be confused about their role when clients are referred by Probation, Child Protective Services and other mandating agencies. Focus on improved function and skills, not compliance with assignments and phases in a pre-determined program. How to be “client-centered”.

In SOUL, increasingly I make no distinction between ‘wins’ and ‘losses’. A ‘win’ is an opportunity to discern what works and what doesn’t; and a ‘loss’ is an opportunity to discern what works and doesn’t.

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February 2022

What I didn’t know about growing up Black in America; I thought I pulled myself up by my bootstraps, but….; the 3 year anniversary of losing my wife.

In SAVVY, I learnt a lot from three African American young people. I was aware of some of their experiences but others were totally new to me. Rethinking the terms “microaggressions” and “cultural competence”.


In SKILLS, being person-centered and focused on the individual in their social context addresses siloed initiatives and projects. I thought I pulled myself up by my own bootstraps. But a look at my generational history exposed the myth of meritocracy.

In SOUL, it is three years since the sudden loss of my wife. Current thoughts on my process in Work, Love and Play.

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January 2022

Could you learn something from Buddha? Check out some of his quotes and how to apply them; Using joy to focus on where to put my energy.

In SAVVY and SKILLS, Suzan Dalia shares Quotes by Buddha that will change the way you think….if you apply them. She suggests some ways to apply them.


In SOUL, anything or anyone who doesn’t bring joy to your life; and doesn’t think you are a joy in their life, doesn’t deserve your time or energy.

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