TIPS & TOPICS
Volume 5, No.7
In this issue
— Until Next Time
Welcome to the November edition; and if you are in the USA, Happy Thanksgiving. We’re glad you join us every month. But if you find yourself with too much e-mail, and want to unsubscribe, you can do that at the links at the end of this newsletter.
Earlier this month, I presented a workshop on motivational enhancement strategies for people with co-occurring mental and substance-related disorders. Frequently those clients are mandated for treatment, so we were discussing the interaction between mental health, addiction treatment and criminal justice perspectives.
- Maintain the boundaries between criminal justice and clinical work; between “doing time” and “doing treatment”
The three fields of criminal justice, addiction and mental health are all actively involved in the treatment planning process and delivery of services for mandated clients with co-occurring disorders. How do we make a difference without working at cross purposes? How do we support and augment our impact on a client to produce healthy results? It is essential we understand and respect each field’s background, mission, jurisdiction, expertise and experience.
We must advocate for each field’s distinct roles and responsibilities while simultaneously respecting the unique mission of each other’s field. Where do we draw the line? When do we refer clients to the other arena? How do we collaborate? What systems should be in place to impact the lives of our clients and society at large?
While each field is separate, we all work for the same purpose: to restore an individual to productivity, responsibility and wellness. Our joint intent and mission is to minimize, and hopefully eliminate addiction, mental illness and legal recidivism.
Here are some polarized perspectives and their implications that work against integrated services:
–> Mental health professionals not trained in addiction treatment run the risk of viewing all substance use problems as a symptom of an underlying mental health problem – e.g. a person’s compulsive disorder, or low self esteem, or poor self-care, or intrapsychic or interpersonal conflicts etc. If the client would just work through those mental/emotional issues, then the substance problems would take care of themselves! For those who think this way, the following 3 D’s are important:
Remember that addiction illness can be deadly. Consider addiction in the differential diagnosis of any mental health presentation. Ask questions to screen and diagnose.
There are at least three aspects of denial:
–> conscious lying to give family, friends or others what they want to hear, or to protect oneself from nagging, sanctions or external consequences of substance use.
–> the amnesia of blackouts where some will deny their behavior, not due to lying, but because they were in a blackout and don’t have any recall due to the organic effects of the substance.
–> unconscious survival mechanism where an individual person protects himself from the pain of owning the reality that drinking or drugging is causing his physical, mental, social and spiritual problems. There is major internal conflict over accepting this self-defeating behavior. To resolve this, survival mechanisms kick in. They range from minimization, rationalization, externalization to projection of blame. Combined they make up “denial.”
As a helper, beware of pinning your professional self-esteem to whether a client does well or not in treatment. If/when a client relapses, it is easy to blame the client so your clinical integrity and skills are not threatened. The professional challenge is to balance 2 equally important priorities:
(1) To create a healthy distance and detachment to allow you to accept the client for whatever mistakes were made.
(2) At the same time, to hold both yourself and the client accountable for anything that was not done which led to a poor outcome. Did you miss a co-occurring disorder? Fail to engage the client in a collaborative plan? Did you even ask the questions to identify a co-occurring disorder? But also, what did the client not do that they agreed to do? Did they take their medication faithfully; or attend recovery groups actively as they agreed?
–> Addiction professionals untrained in mental health have the opposite risk. They view mental health problems as a symptom of an underlying addiction problem e.g., the anxiety is really alcohol or benzodiazepine withdrawal; the depression is just cocaine crash; the suicidal feelings will pass when the detox is over. The danger here is that mental health disorders might not be addressed. For addiction counselors who think this way, the 3 P’s are important:
Not all mental health problems are symptoms of addiction and withdrawal. Consider a possible co-occurring mental disorder in the differential diagnosis. Ask the screening questions to identify any mental health problems.
Not every medication automatically causes drug-seeking behavior or an addiction relapse. Not only can psychotropic medication be necessary to stabilize a co-occurring mental disorder, but it can often prevent both a psychiatric and an addiction relapse. An unstable mental disorder is bad for mental health recovery as well as addiction recovery.
It is easy to be impatient, to want the quick answer or psychiatric evaluation to diagnose a co-occurring disorder. Some clients have long histories, multiple diagnoses and medications. There is no easy answer. Time may be needed. You may need to process considerable history data, family and collateral information. You may need to move forward with assessment and treatment with some uncertainty, based on a provisional diagnosis and hypothesis. This may take weeks and months to evaluate.
–> Criminal justice professionals – judges, probation and parole officers- untrained in addiction and mental health run the risk of thinking that everything can be dealt with from a criminal justice model. Mandated treatment is viewed as a criminal justice intervention – e.g. mandate the client to a particular addiction treatment level of care for a fixed length of stay. The parallel is ordering an offender to jail for a term of three months.
“Doing time” gets equated with “doing treatment.” Clinicians declare they cannot provide individualized treatment because they must comply with court orders for a particular program, level of care and length of stay. For everyone involved with mandated clients who thinks this way, the 3 C’s are important:
Criminal justice rightly ensures that offenders take the consequences of their illegal behavior. However if the court agrees the offender’s behavior was largely caused by addiction and/or mental illness, they provide an alternative. The offender, as well as the public, is really best served by treatment, rather than punishment. Clinicians must remember their job is to provide treatment, not custody nor enforcement of consequences.
An offender is required to act in accordance with court orders, rules and regulations, and criminal justice personnel should expect compliance. Clinicians, however, provide treatment where the focus is not on compliance to court orders. They assess whether there’s a disorder in need of treatment. If there is, a clinician sets an expectation for adherence to treatment, not compliance with just “doing time” in a treatment place.
The criminal justice system aims to control, if not eliminate, illegal acts that threaten the public; this control is appropriate for the courts. Clinicians and programs aim at attracting people into recovery; they center their work around collaborative treatment plans with the client actively engaged in this process. The only time clinicians are required to control a client is if the client is in imminent danger of harm to self or others. As soon as that imminent danger is stabilized, treatment resumes with collaboration and client empowerment, not consequences, compliance and control.
- From the beginning focus on adherence to treatment, not compliance with court orders or other mandates.
It is easy to view the client as having to be in treatment because that is how the client views it. For them, their biggest problem is having to come to treatment, not working on problems and recovery. You can feed into that “victim” position and convey: “I know you don’t want to be here, but you have to be, so you might as well try to get something out of it.” This immediately reinforces the idea that the client had no choice, and that “doing their time” here in treatment is acceptable to you versus committing themselves to working actively on their issues in treatment.
In previous TIPS and TOPICS (TNT) editions, I suggested an opening greeting to a mandated or coerced clients to the effect of: “Thank-you for choosing to work with me. What is the most important thing you want that made you decide to come to treatment?”
“Choose to work with you? I didn’t choose to work with you. They made me come” the client may say.
You can read the rest of this dialogue at these links:
January 2004 edition
December 2006 edition
- Balance the unique addiction, mental health and criminal justice needs of clients.
Blind spots exist due to different educational backgrounds and experiences. Consider whether you are emphasizing one or two areas of a client’s needs to the neglect of other areas. Watch for blurring of the boundaries between the mission/needs of the mandating referral source and those of the clinical treatment team.
–> Do you identify with mental health professionals who need to remember the 3 D’s?
–> Do you really take substance-related disorders seriously? Assess for and intervene with any substance problems?
–> Are you someone quite comfortable and skilled with addiction issues, but identify with counselors who need to remember the 3 P’s?
–> Do you have policies and procedures which exclude clients who are taking certain medications such as benzodiazepines or prescribed opiates?
–> Have you ever felt like (or even said) you can’t do individualized, motivational enhancement work with clients because the court mandates total abstinence and sanctions for any drug relapse?
–> Do you develop treatment plans more focused on compliance with the orders of the court, child protection or the employer than on assessment of the client’s stage of change and specific multidimensional needs?
Finding the right balance between all stakeholders is necessary to help people make lasting change.
TIME magazine’s very latest December 3, 2007 edition contains a brief report on General David Petraeus (p.24). Apparently Petraeus and 14 other Army generals have been asked to do something unprecedented: to review the files of about 20,000 colonels, and look for about 40 worthy of promotion. What’s new about this? These generals are changing how promotions are made because the ways in which modern wars are fought have changed.
What caught my eye in the Time article was that today’s new battles use counterinsurgency skills which “rely on persuasion and security as much as on coercion and combat”.
“Persuasion” involves attracting people into recovery, providing hope for something better, relief from pain and turmoil. “Security” is about helping people feel safe and empowered, free to make their own choices and chart their own daily activities and future dreams.
“Coercion” focuses on compliance, doing time, control and consequences. That is appropriate in a criminal justice approach. “Combat” is about disempowering others, fighting with their resistance and subduing them into submission.
It is time to move in new directions, away from conventional methods suited to the “cold war” days. We have much more knowledge about how people change and how to attract people into recovery. With what we know, it is our responsibility to create healing treatment environments where people feel secure and safe to be honest about relapse, and not have to lie for fear of sanctions or being kicked out. Treatment is all about persuasion and attraction; not coercion, control and combating resistance.
If the Army realizes there are new lessons for a new generation of soldiers, surely treatment can do the same. And incidentally, persuasion and security works a lot better than coercion and combat in your personal life as well.
Until Next Time
See you soon again for the December issue. We’ll get that out before heading to Australia for a bit of summer Down Under.