Hard questions in the interface between Treatment and Justice Teams; Scripts on what to say to participants; What’s your Olympic Game?

In SAVVY, I preview a couple of hard questions that New Hampshire Chief Justice Tina Nadeau and I will discuss in the final General Session of RISE21, the National Association of Drug Court Professionals annual conference at the Gaylord National Resort and Convention Center in National Harbor, Maryland.   

In SKILLS, to help convert a clinical principle or policy and procedure into actual words to say to a client, I give some “scripts” of what to say to orient participants in Drug Court; and what to say about positive drug screens.

In SOUL, I have two connections to the Olympic Games and get into the spirit of the Games with my lifelong friends inventing new Olympic games.

savvy

On August 18, New Hampshire Chief Justice Tina Nadeau and I will present together for the final General Session of RISE21, “the world’s preeminent conference on addiction, mental health, and justice reform.”

This annual NADCP (National Association of Drug Court Professionals) gathering will this year be at the Gaylord National Resort and Convention Center in National Harbor, Maryland August 15-18, 2021.

It will be my first “live” and in person conference since COVID-19 grounded us all.  That in itself is exciting or scary depending on my mood that day.

What is exciting is the opportunity to look at some of the hard questions that arise when marrying the perspectives of the justice team with the treatment team in Drug and other Treatment Courts.

In this edition of Tips and Topics, I’ll preview a couple of those questions and give you a glimpse of my responses.

Tip 1

Treatment’s job is to ensure treatment adherence.  The Court’s job is to ensure good treatment is happening and “enforce consequences” if the participant is not participating.

Question:

You have talked about the clinician’s job is to ensure the client adheres to treatment, but what about the court’s obligation to enforce consequences for non-compliant behavior?

My response:

• If there is “non-compliant behavior” like poor attendance at treatment groups; substance use or continued socializing with drinking/drugging friends, treatment’s first response is to see that behavior as a poor treatment outcome and immediately assess what has gone wrong and improve the treatment plan with the participant.
• The court’s obligation is to ensure that competent and knowledgeable treatment providers are available and that the participant is doing that treatment with personal responsibility and in good faith.
• If the participant is learning from mistakes and actively involved in improving their treatment plan and outcomes, the court has met its obligation.
• If the participant is just “doing time” and not “doing treatment and change”, then the court’s obligation is to enforce consequences for lack of good faith effort. It is not the court’s obligation to enforce consequences for flare-ups and signs and symptoms of the participant’s addiction.



Tip 2 

The best outcomes come when there is a solid therapeutic alliance between the participant of Treatment Court and the treatment provider and the justice team.

Question:

You recommend empowering the client to collaborate with a treatment plan, but what about clients who want to avoid the hard work of treatment and who reject evidence-based treatment recommendations?  

My response:

• A therapeutic alliance like a three-legged stool, comprises agreement on goals; agreement on methods and strategies within a trusting, mutually respectful relationship (Miller & Rollnick (2013): Motivational Interviewing – Helping People Change p. 39.)
• Over 4 decades of research documents the importance of the therapeutic alliance in what works in treatment. But also common sense in any arena points to the importance of being on the same page together in a trusting, safe relationship to be effective.
• The treatment plan is just the written expression of the therapeutic alliance, so we collaborate to agree on the goals and methods in the treatment plan. A trusting relationship will mean participants feel safe to be honest about what they want to do or not. 
• If your goal and methods are for the participant to do the hard work of staying away from all antisocial friends and to make new friends at Alcoholics Anonymous (AA), they won’t want to do that if they like their friends and hate AA.  Or if you think they should take medication and they are fearful of medication, they will reject it.
• The way to help people make lasting, accountable self change is to start where they are at concerning any “hard work” you think needs to be done. You may well be right that the participant needs to do the hard work of making new friends. But they think they can still hang out with substance-using friends and say “no” to temptations and cravings to use.
• Treatment is about discovering that their methods aren’t working and to keep them engaged in treatment long enough to work through stages of change towards real, lasting change.
• That’s what I call a “Discovery, Dropout Prevention” plan. The participant will need to “discover” that s/he can’t hang out with those friends and remain abstinent.  It may be obvious to you, but not to them. If they could see and do the hard work from day one of treatment, they wouldn’t need treatment to help them change attitudes, beliefs and behaviors that have gotten them into trouble.

skills

In the May 2018 edition of Tips and Topics (TNT),  to help convert a clinical principle or policy and procedure into actual words to say to a client, I gave some “scripts” of what to say in different situations.  Here are a couple of those from that TNT edition.

Tip 1

What to Say to Orient Participants to a Drug or Treatment Court

In justice transformation, Drug and other Treatment Courts are seeing the value of treatment to reach the goals we all want – safety for the public and children and families and decreased crime and costs. Here’s one way to orient treatment court participants:

“Thank-you for choosing to enter Drug Court. The reason you have been given the opportunity to get treatment rather than be incarcerated is that you have addiction related to your charges. We believe if you receive addiction treatment and establish recovery, this will not only be good for your life, but society will benefit from increased public safety, decreased crime; and spending resources on treatment rather than incarceration, which is much more expensive.

But you are accountable for doing treatment, not time; for working on changing your attitudes, thinking and behavior, not just complying with a program and graduating.”

Treatment providers’ responsibility is to keep the court informed about the participant’s level of active engagement, not just passive compliance with attendance and positive or negative drug screens; on whether the participant is actually changing in attitudes, thinking and behavior which advances public safety.

Tip 2

What to Say about Positive Drug Screens

In treatment programs and treatment court programs, many still have policies and procedures mandating abstinence as a condition for treatment and expect perfection in abstinence as a condition for staying in treatment.

But how is it useful to suspend, discharge or sanction a person for a flare-up of their signs and symptoms of addiction when that is the very time they need the help to make sure their addiction doesn’t spiral out of control even further?

Here’s what to say:

“In addiction treatment, it’s not OK to use any unauthorized substance. But if this didn’t happen and everyone had perfect control over using, they wouldn’t have addiction and wouldn’t need treatment. You can learn skills and use supports to never have to use again, so it is not inevitable you will have a flare-up and use.

However if it happens to you or anyone else in treatment with you, it is your responsibility for your safety and your fellow participants to immediately address any attitudes, thinking or behavior building up to any substance use; or any actual use. Reach out to a team member,  just like you would if experiencing a heart attack or feeling suicidal. They will then work with you to find out what went wrong and how to improve your treatment plan to prevent another flare-up.

If substance use happens in a residential setting, there will be a community meeting ASAP to help anyone who used with you.  If you or anyone else is not interested in finding what went wrong and  changing your treatment plan in a positive direction, you have the right to choose no further treatment. You can then take the legal consequences of your criminal charges.”

When treatment programs and treatment courts have zero tolerance policies, substance use, or even building up to a drink or drug (BUDD-ing), goes underground.

• Participants in the program become more focused on snitching and covering up actual or potential drug use than on keeping their environment safe from drug use for their own well-being, as well as for the treatment community they are in.
• Criminogenic thinking and antisocial behavior is thus encouraged.
• If jails and prisons can’t keep drugs out – with all the cameras and correctional officers supervision – how can treatment programs keep a milieu safe without the help and responsibility of all participants?
• Learning how to take responsibility to prevent use or catch drug use early is what treatment is all about.
• Clients and participants are just as responsible as the staff to keep themselves and the program safe.

soul

I have two connections to the Olympic Games:

• My son-in-law is working on the tech team filming Olympic surfing, which is the first time surfing has officially become an Olympic sport.  He is at Tsurigasaki Surfing Beach on the Chiba coastline, about 40 miles southeast of Tokyo.
• On July 21, Brisbane, the capital of the State of Queensland, Australia was officially announced as host of the 2032 Olympics.  Brisbane is my hometown where I was born, raised and graduated Medical School.

That’s a bit of trivia that won’t rock your boat, but thought I’d share it to get into the Olympic spirit.  I’ve written before about my CHEMM-ites group in the SOUL section of the November 2020 edition of Tips and Topics.  We stay in touch via a WhatsApp group that was inspired by the isolation of COVID-19. This group of lifetime friends is getting into the Olympic spirit too, by teasing each other with mythical “Olympic” sports.

Wayne got us going: 

“I want all of us to nominate a sport you think you could win Gold.”



• David, would you be good at Jumping to Conclusions?”
• Bronwyn, what about Paddling up the Creek without a Paddle?  
• Geoff, you would be excellent at Dodging Washing Up.  
• Nonie, you could try Carrying on Too Far.  
• Carolyn, start training for Pushing your Luck. 
• I am claiming gold for Leading up the Garden Path. Enjoy your Olympic training, Wayne.

I tried my hand at naming a sport:

• Running Behind I offered
• Kicking Back was my next

“You got it,” Wayne said. “You could waste a whole day thinking of games.  Be careful it could be contagious.”

It was a little contagious as Robyn tried her hand at the game-naming:

• Running late (although I had already claimed that as Running Behind”)
• Jumping Over the Moon

What would you be good at?  – Herding cats, Walking it Back, Surfing the Web…….