Two STUMP THE SHRINK questions on passive compliance and substance use while in treatment; customer-focused and friendly
Welcome to the October edition of Tips and Topics (TNT). This edition combines SAVVY and SKILLS to address two STUMP THE SHRINK questions that encompass several relevant attitude, knowledge and skills issues.
savvy, skills, and stump the shrink
Whether you work in Drug Courts or not, these questions address how to deal with clients’ passive compliance in treatment programs; and substance use while in treatment.
TIP 1
When assessment-based, outcomes-driven, individualized treatment plans are used it prevents clients from skating through programs and “graduating”
STUMP THE SHRINK #1
Here’s Lanier’s question:
Dr. Mee-Lee,
I have emailed you multiple times, been in Tips and Topics and have been in Drug Courts for over 4 years, following your trainings and whatnot because, well, you’re awesome. (DML: I hesitated leaving this part of the message in, but what a nice compliment) I just left the conference and thought of a question I should have asked you: there is a lot of conversation about doing time vs. treatment and compliance vs. adherence. How do you address (with the help of the court) a client who is not adhering but complying perfectly?
They aren’t doing anything wrong but you know they aren’t invested in their treatment or recovery. There isn’t really anything to point to in terms of sanctions, it feels like one of those situations in which “he isn’t ready”. However, he moves along in the program (albeit slowly). (Abiding by the treatment plan he made because his goals are not use – which he isn’t – and show up to everything – which he is).
Are we doing him (and the rest of the group) a disservice by allowing this to continue after a certain amount of time or do we have to just “roll with it” so to speak and allow him to “graduate and drink at his wedding” because we just can’t control everyone? What is the best treatment response thinking of this type of client as well the rest of the group who (maybe) is trying.
I sort of feel like I know what you might say and in the past I just let them be uninterested and in compliance but I can’t force adherence or recovery onto anyone so they graduate then go back to using.
Thanks for the guidance, once again. I’ll probably be emailing again as I think of scenarios. (I was a treatment provider for another court and recently moved into the coordinator position at a new court but I have no treatment people at the table so I have to be both roles).
Lanier Meeks Yi, MA, MA, NCC, LPC
Fairfax County Drug Court Coordinator
Fairfax/Falls Church Community Services Board | 4110 Chain Bridge Road; Room 314.5, Fairfax, VA 22030
703.246.4454 Behavioral Health Main Line | 703.246.3238 Desk | 571.595.5218 Cell | 703.653.7178 Fax
My Response:
Hi Lanier:
Here are some thoughts in no particular order:
1. Usually the focus in treatment courts is on participants complying with predetermined phases and expectations like abstinence, doing random drug testing, attending all prescribed activities including getting attendance checked off at AA meetings and complying with court orders and community supervision with probation etc.
2. What this means then is that participants can go through the motions of doing all of what they have been told to do to graduate; and be in what looks like perfect compliance and then “complete drug court”. Many people with addiction can hold it together if under sufficient scrutiny and structure to be abstinent while being watched closely (many others can’t, even when closely supervised as their addiction may be so severe).
3. The focus in treatment courts should be on what attitudes, thoughts and behaviors is the participant working on in treatment such that public safety will be enhanced; their physical, emotional, mental, spiritual and social life will improve; and their commitment to ongoing recovery is achieved. When this is the focus, participants can’t just sit and go through the motions doing time and compliance anymore.
4. Yes, you can’t force adherence and recovery. You can somewhat force compliance and “doing time”, but that doesn’t automatically equate to lasting accountable change. That is why people can graduate drug court, but be using within a week of graduation. It is also why there are high dropout and non-completion rates.
5. Good treatment and good multidisciplinary court teams should be focused on #3 and if so, it will become clear very quickly if participants are taking responsibility for “doing treatment and change” at a pace that honors their stages of change and taking responsibility to change their lives to improve public safety and decrease crime.
Hope this helps, but let me know if not.
David
Lanier’s Response:
This is sort of what I imagined you would say, and it is what I try to practice; however, if “showing up” is a proximal goal for them but it’s the only thing they identified on the treatment plan, it feels lackluster, and not like we are doing anything to help this person. If the participant just has “showing up” as the “goal” for their treatment plan, then it appears as though they are complying id “showing up is not difficult for them.
My Response to this section:
You are correct that a proximal goal of the program is to “show up”. But I don’t think just “showing up” should be a “treatment plan” goal. If that is a treatment plan goal, that is not individualized to the participant’s assessment. That is a basic program goal that applies to all participants and by definition is not an individualized treatment plan based on the assessment of the person. If you make “just showing up” a treatment plan goal, then yes, as you say, that is a lackluster goal and an incomplete goal for most participants. That is just a compliance goal that doesn’t translate necessarily into real change in attitude, thoughts or behaviors.
There may be some participants who are so severe and unstable, that just “showing up” would indeed be an assessment-based treatment goal individualized to that person’s current severity.
Lanier:
Would it be helpful to urge one of the goals to be related to attitudes, thoughts, and behaviors and encourage something more challenging? Or would that be too leading because then I am imposing my thoughts on their treatment?
My Response:
I agree that the treatment plan problem/priorities should be individualized to match that particular participant’s attitudes, thoughts or behaviors that threaten the public safety, safety for children and families or contribute to repeated crimes or legal problems. That is not imposing your thoughts on their treatment, that is raising the issues that an assessment identifies as to what is causing the person to be arrested and told what to do with their life.
If they want people off their back; to do less time; to get their kids back; or whatever their goal is, then helping them identify how they shoot themselves in the foot is not imposing anything. It is helping them get what they want.
If they don’t see what they are thinking and doing that gets them locked up, then how can they empower themselves to break the old patterns that get them arrested? In an assessment, we point out those attitudes, thoughts and behaviors that don’t serve them well. If they disagree or don’t think it is a problem, then they need a “discovery, dropout prevention” plan, which is still an accountable plan for which they are responsible to work on. That is not a lackluster plan, nor a compliance “just showing up” plan. That is a specific plan that they have to work on from Day 1.
Lanier:
I also have some concerns for the what it looks like to all the other participants when they see someone sliding along, making bogus goals, when others choose to challenge themselves in their goals and work hard. But at the end of the day they all graduate regardless of how hard they worked on challenging goals, because they just complied with program goals.
My Response:
There should be no “bogus goals” like just showing up; or attend all prescribed activities; or get the AA meeting attendance checked off; or giving urine for drug screens. These are just program goals, not treatment plan goals. Every participant should have goals individualized to their stage of change. If they are not working on these either as “recovery” goals or “discovery” goals, then they are not doing treatment and a sanction can be considered.
Lanier:
I’ve had many participants in the past ask me about participants who are just sliding along, and I’ve always told them that not everyone’s treatment looks the same and not everyone responds to the same treatment the same way or puts in the same amount of effort. So I have encouraged them to look at what they are doing to help themselves and their future and know that their work will go further if they are putting effort into it. (That’s the provider in me, it’s not about the program, its about the individual).
My Response:
If assessment-based, individualized and outcomes-driven treatment plans are being done, this issue of seeing participants skate through and graduate won’t happen anymore.
TIP 2
Assess flare-ups in addiction treatment, like substance use and positive drug screens, to identify what to change in participants’ treatment plan to enhance sobriety and recovery. If the participant is working in good faith in a positive direction, there’s no need to sanction or discharge.
STUMP THE SHRINK #2
Here’s Ashlee’s question:
Hey Dr. Mee-Lee,
I listened to you at the most recent National Association of Drug Court Professionals (NADCP) conference in Washington, D.C. I learned a lot and you’ve helped me so much. I am the treatment representative for my Drug Court (Northern Hills Drug Court) in Sturgis, SD.
My question is that we recently discovered that a group of our participants are using Kratom. Their sanction was community service and treatment adjustments. Today I held our first pre-treatment group (to address continued use, pre-contemplation and contemplation) to try and motivate change. To my surprise my clients cried, yelled and really got honest with me for the first time about Kratom.
One girl shared about how it helps her with her eating disorder, another has degenerative bone disease and it helps with pain, a few others who were daily IV heroin users shared it helps with their cravings and they have been able to not use other more harmful substances. I truly found them in continued use and pre-contemplation today.
My question is, I believe that if I develop (with them collaboratively) individualized treatment plans, we can make a plan for them to wean off and get off of it it completely so they are in compliance with the rules of Drug Court.
I am so proud of them for their honesty and willingness to get real about where they are at. I don’t want to see them get sanctioned for admitting continued use of Kratom and I want my team to support me to get them on board with choosing to get off for their internal reasons and not the external reasons of the court.
I know this weaning off won’t happen overnight but over a few weeks. As long as my clients are adhering to treatment and their individualized plans can I really ask my team to let me work with them without interfering with sanctions?
I realize that my Kratom clients will have to report zero days clean in court to the judge but my hope is that she allows me to work to move them out of pre-contemplation and continued use so that choice is partially made by them and not made for them. I would so appreciate any suggestions or thoughts on this situation.
Thank you for your time and work.
AshLee Pray BS, ACT
Compass Point
1807 Williams St.
Sturgis, SD 57785
My Response:
Hi AshLee:
This is an important question and you are certainly on the right track to want to respond to this clinically and in a treatment way, not a punitive and sanction manner. The participants’ Kratom use is:
- For some, part of their addiction cravings and impulses
- For others, it may be that, but also complicated, as they said, by eating disorder, or pain from degenerative bone disease.
When participants are telling us that they need help for cravings, eating disorders, pain or whatever keeps their use active, that is an indication that their addiction, co-occurring mental health and physical health problems are unstable and need help in addition to the addiction cravings and triggers.
As you heard me say, poor outcomes and flare-ups need assessment of what needs to be done to give participants the best chance to achieve abstinence, sobriety and recovery. That is what treatment is for and if they could immediately overcome cravings to use and control mental health and physical health problems without using, they wouldn’t have addiction needing Drug Court help.
So this means developing a good working and collaborative relationship with the Court team and everyone from the judge to attorneys to court coordinator to probation and parole and law enforcement and try to help them see that this is a treatment issue not a willful misconduct and sanction issue.
Yes, sanction for lack of good faith effort in treatment and if participants are not willing to learn other methods of dealing with eating disorder or pain or cravings other than to use Kratom or anything else addictive. If participants are not changing their treatment plan in a positive direction, they would not be in compliance with court orders to do treatment, which they originally agreed to.
But if they are trying as hard as they can to learn new ways to deal with cravings, pain and mental health problems with the help of your treatment and any other pain specialists or mental health and physical health resources, then they are doing treatment. The focus should be, as you say, on the individualized, collaboratively developed treatment plan to which you can hold them accountable to work on towards abstinence and sobriety. This is what you are ready and wanting to advocate for with the rest of the court team.
So see if you can raise this approach with the team; reassuring them that you are not being soft on drug use or just turning a blind eye, but that you are actually holding them more accountable to change their treatment plans in a positive direction to work on other methods to deal with cravings, pain and eating disorders rather than just use drugs like Kratom.
Thanks for working on this in a new direction rather than just sanctioning them, which can push honesty about use underground instead of the open sharing of their “pain” in all its forms (cravings, physical and mental issues etc.).
All the best,
David
soul
I have been flying United Airlines as exclusively as possible for over 25 years because frequent flyer and customer loyalty programs really work…..or at least they have for me. I like all those perks of free first class upgrades, free food even when I am in Economy, extra legroom in Economy Plus and lifetime membership in the United Club in airports (and more).
I’ve stuck with United through the lean and mean times; lousy food; sparse airport clubs with poor food compared to other airline clubs; and grumpy, demoralized flight attendants. It was about earning and using those frequent flyer miles and points for free trips, not blind loyalty to a company.
I’ve noticed over the past year however, that customer service has been improving at United. I won’t bore you with details except to give you one recent example. When I boarded the plane, I notice this aircraft was one that had the individual TV screen in each seat. I was pleased because even though I missed a free upgrade seat, I was going to get to watch live TV on a long transcontinental flight.
Alas, when I settled into my seat, every TV screen around me was working well except mine. Two flight attendants later, no luck. No live TV tonight. However one of the flight attendants said he would see what he could do for me. It was a nice promise, but I was skeptical and didn’t get my hopes up.
Nothing happened for most of the flight and I had given up on his promise to see what he could do for me. Not long before preparing to land, I got a message telling me I had a $175 credit towards a future flight. $175 for the trouble of missing live TV for the flight. That was a generous peace offering.
I walked back to personally thank the flight attendant and to ask if they were now empowered to use their discretion about what would soothe the customer. He said “We are empowered to do whatever will make it right for the customer”. I was impressed. That credit certificate melted away my frustration; and was so much more effective and satisfying than just giving me the complaint website and tell me to lodge my frustration.
How ready are you and your organization to “make it right for the customer”; to engage and attract them into real and lasting change and recovery?
I looked back and realized I must have a thing for customer-friendliness. If you wish, check out these past editions and the issues they raised.
November 2004 – SAVVY –Promote a customer-focused culture in your treatment program or practice:
July- August 2008 – SOUL – Five rules that were posted at McDonalds to remind the workers about customer service:
June 2017 – SOUL – Innovating to be more and more customer-friendly.
December 2018 – SOUL – I was amazed. What customer service! What efficiency! What responsiveness!
January 2017 – SAVVY and SKILLS – Keep the person (the patient, client, consumer, customer) at the center of all systems and clinical change; and what is of value for them.