TIPS & TOPICS
Volume 3, No.5
September 2005

In this issue
– SAVVY
– SKILLS
– SOUL
– STUMP THE SHRINK
– Until Next Time

A significant number of new readers are joining us this month, so welcome to you. Thanks too, to all of you who have been with TIPS and TOPICS for many months and even years. I appreciate the many comments and messages of appreciation you send me.

SAVVY

This month I spoke at a couple of conferences to audiences I don’t usually get to address. While in most workshops there are always a few people who work in drug courts, mental health courts or criminal justice settings, the audience for these conferences was comprised fully of judges, lawyers, probation and parole officers and clinicians who assess, treat and case manage court-involved clients. Sometimes when people discover I am a psychiatrist, they jokingly ask whether I am psychoanalyzing them. It was my turn to wonder if I was being judged, interrogated or scrutinized for arguments to which they might object, overrule or appeal. But it turned out to be informative for them and me too. In preparing for my presentations and in listening to theirs, here is some SAVVY on mental health and drug courts. It is a rare treatment program these days that does not have any court-mandated clients.

Tips:

• Notice what contributes to good outcomes in mental health courts and drug courts.

Before sharing what I found in the research literature, here are a few brief history facts:

–> 1989 – First drug court established in Miami, Florida.
–> 1980 to 1992 – the proportion of mentally ill persons in jail increased by 154%.
(Travis J (1997): “The mentally ill offender: viewing crime and justice through a different lens.”
Presented at a meeting of the National Association of State Forensic Mental Health Directors, Annapolis, MD – www.ojp.usdoj.gov/nij/speeches.htm)
–>1997 – First mental health court established in Broward County, Florida.

You can see that drug courts have been around for just over 15 years, while mental health courts are less than 10 years old—still quite a young movement with lots to learn. But so far drug courts have demonstrated positive outcomes of lower re-arrest rates, reduced substance abuse and criminal behavior, and significant savings in taxpayers’ money. Mental health courts have had similar results with decreased use of county jail slots.

Here are a few findings on what works to achieve good outcomes in mental health and drug courts:

1.  Enhanced collaboration among all agencies – team approach to screening and evaluation, crisis intervention, short-term treatment that includes suicide prevention, case management, counseling, psycho-tropic medication and community integration.

2.  Increased awareness of the needs of substance- using clients in the criminal justice system.

3.  Build strong collaborations – improved coordination and continuity of care.

4.  Maintain good communication.

5.  Recognize competing interests in developing procedures for drug and mental health courts.

6.  Increase drug court participation, treatment retention and completion rates.

7.  Judicial supervision of community-based treatment.

8.  Identification and referral shortly after arrest.

9.  Regular hearings to monitor treatment progress and adherence.

10.  Series of graduated sanctions – mental health courts use various creative methods of disposition of criminal charges to mandate adherence to community treatment. In contrast, drug courts commonly use jail and other sanctions for nonadherence. Mental health courts rarely or occasionally use jail for sanctions.

11.  Mandatory drug testing.

12.  Assurance of existing appropriate treatment slots.

Reference for points 1-5:

Wolfe EL, Guydish J, Woods W, Tajima B (2004): “Perspectives on the drug court model across systems: a process evaluation” J. Psychoactive Drugs 36(3): 379- 86

Reference for point 6:

Fielding JE, Tye G, Ogawa PL, Imam IJ, Long AM (2002): “Los Angeles County drug court programs: initial results” J Subst Abuse Treat. 23(3): 217-24.

Reference for points 7-10:

Griffin PA, Steadman HJ, Petrila J. (2002) The use of criminal charges and sanctions in mental health courts. Psychiatr Serv. 2002 Oct; 53(10):1285- 9.

Reference for points 11-12:

Steadman HJ, Davidson S, Brown C (2001): “Mental Health Courts: Their Promise and Unanswered Questions” Psychiatric Services 52(4): 457-458.

Even if you are not directly involved in a mental health or drug court, the principles of good collaboration, communication, participation and treatment retention, community-based treatment, regular monitoring of adherence and accountability; and finally assuring access to needed services are all, in and of themselves, methods for success for all disorders in behavioral health.

• Compare how drug and mental health courts work with offenders and contrast that with traditional courts.

Arizona held their first conference on Mental Health Courts in Phoenix in September: “Judicial Efficiency and Therapeutic Jurisprudence: Strategic Utilization of Mental Health Courts”. Not only was I able to teach some judges and others; but they were able to teach me too. Here is how Judge Carmen Dolny, a mental health court judge in Pima County Justice Court, Arizona outlined succinctly but comprehensively her top 10 comparisons on how mental health courts work with offenders:

I was impressed, informed and more savvy about how a good mental health court and judge should work. More from Judge Carmen later.

SKILLS

Here are suggestions to address challenges in working with the mandated client- whether mandated by the court, the employer, a child protection worker for example.

Tips:

• Be assertive to advocate for the most effective clinical approach with a mandated client. As a clinician you are not the right arm of the law, the employer, the judge or child protection worker.

(I’ve heard comments like these from clinicians who act like they have no clinical decision-making power:” She has to commit to total abstinence because that’s what Child Protective Services wants.” or “We can’t do outpatient treatment because the judge ordered residential treatment.”)

In the January 2004 edition of TIPS and TOPICS, I suggested when you have a client mandated for treatment that you resist the impulse to immediately set out the rules and regulations with which they must comply. We are engaging them to do treatment, not do time. I further highlighted how we could meet the needs of all stakeholders- including the client- if we started to join with referral sources to dialogue about the following five areas.

If you have a chance to talk directly with judges, lawyers, probation and parole officers and child protection workers, here is what you can advocate for as you collaborate and communicate. You can say something like this:

*** Common purpose and mission
“We are all interested in public safety, accountability and responsibility, and safety of children. But if approximately half of the participants in drug courts resume drug and alcohol use within 12 months of admission to drug court and approximately 10-15% resume illegal activities,* we have to work together to find the most effective methods as a team. There are some good outcomes, but we have room for improvement and need each other.”

*** Common language of multidimensional assessment and of stage of change
“If collaboration and communication improves outcomes, how could we find a common language of assessment and treatment matching? I understand that our assessments and recommendations can be unclear sometimes and maybe even look the same for many clients. But what if we could use the common language of a multidimensional, person-centered, comprehensive assessment like the six dimensions of the Patient Placement Criteria of the American Society of Addiction Medicine (ASAM PPC-2R)? And also, could we agree on some models to assess readiness to change? This way we are not setting a person up for failure by expecting them to work on recovery when they don’t even think they have a problem. They first need to discover, and own for themselves, that they have a substance use problem, a parenting problem, an anger or domestic violence problem or whatever it might be.”

*** Consensus philosophy of addressing readiness to change
“Since we know that offenders who complete the drug court program are less likely to have further arrests versus non-completers of drug court, would you judge (employer or child protection worker) be willing to mandate assessment and treatment adherence rather than mandate a particular treatment, level of care and length of stay? If so I could develop with the client a more accountable plan matched to his/her stage of readiness to change and increase retention and meaningful participation. This would allow me to have them examine their ambivalence more specifically. We could address their reluctance to change at a pace aimed at keeping them accountable, but a pace which would discourage their tendency to just wait us all out, and basically do time in the program.”

*** Consensus on how to combine resources and leverage to effect change, responsibility and accountability
“A successful outcome and lasting change is much more than dealing with the substance use, or anger or abuse problem, or the psychosis or depression. It will need us all to pull together and pool resources. Community re-integration involves housing, transportation, child care, vocational, educational, financial and family work just to name a few needs. How might we work collaboratively as an interdisciplinary team to piece together a mix of services that will sustain community re- integration?”

*** Communication and conflict resolution
“I know we have what looks like competing interests and expectations. But as I said before, we have to find a way to reach consensus and a common team approach since that is the most likely chance we will have of facilitating lasting change. And we both want the same successful outcomes anyway. So I have no problem with conflict as that tells me we are all assertively advocating for what we believe in. But we do need to find an effective communication and conflict resolution process so we are not working at cross purposes.”

* Reference:
Marlowe DB, Festinger DS, Dugosh KL, Lee PA. (2005) Are judicial status hearings a “key component” of drug court? Six and twelve months outcomes. Drug Alcohol Depend. 2005 Aug 1; 79(2):145-55. Epub 2005 Mar 4.

Treatment Research Institute at the University of Pennsylvania School of Medicine, 600 Public Ledger Building, 150 South Independence Mall West, Philadelphia, PA 19106-3475, USA.
Marlowe@Tresearch.org

• Working with mandated clients has its challenges, but have fun with it.

“Have fun” may seem flippant and I certainly don’t mean make fun of people. What I’m talking about is Judge Dolny’s advice on how to work with offenders. She recommended to HAVE FUN:

H – Help by providing Hope and Healing
A – Appreciate even small successes; Appreciate everyone – probation officers, providers, case managers
V – Validate each person and Value them as people too, not just as an offender
E – Encourage and Empower the clients and team members in what they do

F – Facilitate change through collaborative treatment and communication
U – Understand the hardships that many clients have based on past history, but also present obstacles
N – Non-judgmental and Non-adversarial – collaboration will enhance success, not confrontation

Actually these principles apply to our work with all people, not just clients mandated to a drug or mental health court.

• Tune into the common needs of all people. It enhances empathy, engagement and collaboration.

When clinicians more highly value so-called “internal” motivation versus “external” motivation, it misses the opportunity to understand that all motivations for a person seeking treatment are “internal”. Said another way, even if clients come mandated for treatment, they still have common needs, which join us all together. For example, coming to treatment to stay out of jail, or to get their kids back; or to keep their job or relationship are all very “internal” motivations.

-> Why would a person want to stay out of jail?
A:To have freedom to pursue their own desires; autonomy and independence to come and go as one pleases. Is there anyone you know who does not want freedom, autonomy and independence?

->Why would a person want to get their children back?
A:To be reunited as a family; to love and be loved by one’s own flesh and blood; to nurture and shape a new life. Is there anyone you know who does not want to have a loving family, and to love and be loved?

-> Why would a person want to keep their job?
A: To earn an income for food, shelter and financial security; to have discretionary income to buy material goods or travel or to vacation. Is there anyone you know who does not want financial security, relaxation and vacations, and maybe a new digital TV or a car or a home?

Tuning into the common needs of all clients (mandated or not) joins us with clients in such a way as to enhance trust, alliance-building and accountable treatment.

SOUL

It is hard not to be transfixed by the red and orange swirl of that hurricane formation churning its way to destruction, devastation and depression for all in its path. The non-stop TV, internet and radio coverage has kept those of us not in Louisiana, Mississippi, Alabama, Florida and Texas more informed in real time than ever before. There are so many stories of loss. There’s the police officer who retired 3 weeks before Hurricane Katrina hit. He had bought a boat to travel the seas. He now has no boat and no home. He does have a job, which is more than many of his fellow storm victims.
I was pondering what it would be like to suddenly lose every material thing you have. I was speaking at a conference in Baltimore at the time New Orleans flooded. In the audience were staff and some consumers from a treatment program in New Orleans. The consumers had won an essay competition to attend the conference. These attendees had no homes nor treatment program to which to return.

Twice, in Australia and Boston, our home was threatened by flood waters. Twice, the water came within a foot of the floor boards, and then receded. Heavy rain not hurricanes brought the water, so we didn’t have to rush from our home deciding what was important to us to take.

When I was in Medical School, my parents didn’t have time to decide what to take when our home burnt down. In the hot dry Aussie weather, a spark from the washing machine ignited some dry cleaning fluid. In minutes, my parents had their lives but just the clothes on their backs. Gone were all their wedding photos, baby pictures, clothes, furniture etc. I was a thousand miles away on summer break. I saw our house burning and my father interviewed on TV.

It is not a cliché to say that as long as you have your family and no one is hurt the rest are just things. But there are some things more important than others – things that are irreplaceable. So what would you take if you had to evacuate and flee? What do you value most? What would you take with you if you thought your house might not be there when the storm passed?

We faced that situation one time when living in Hawaii. There was a tsunami warning after an earthquake in Japan. Our house was one block from the ocean. We had time only to load up our minivan with the kids and a few priorities, and go to higher ground. Remembering the fire in my parents’ home, we gathered up photos, audiotapes and videotapes of the kids through all their development thus far. Besides important documents like passports and legal papers, that was it.

As we’ve watched Hurricane Rita and déjà vu with New Orleans, those practical and philosophical questions surface again: What is most important to you? What would you take with you if you thought you might never see your home again?

STUMP THE SHRINK

This month I received two similar questions that stumped me a bit since it is not an area I had researched much before. That didn’t stop me from sprouting my opinion.

Question:

1. “We are considering utilizing the existing State Legislation (that currently is not being implemented), related to involuntary treatment for persons impaired by chronic alcoholism. This mirrors the involuntary commitment for mentally impaired individuals, the Lanterman-Petris-Short Act here in California. In looking into the utilization of this intervention, I am looking to find literature that describes “best practice” models for the treatment of chronic inebriants. Anything related to treatment models that may include the use of involuntary holds, and/or locked treatment facilities, would be helpful as well. Our work with the chronic street homeless, particularly the chronic public inebriant, is driving our consideration for more drastic treatment interventions for assisting this population gain better quality of life and health.”

David Nakanishi, MPH, LCSW
San Francisco Department of Public Health
Community Programs

2. “I was interested if you felt there is a place for involuntary treatment of addicted persons. I know presently enforced treatment occurs via criminal orders but actually wonder if that leaves things a little too late for some and focuses only on one aspect community risk. The persons I am most interested in are ones who have some form of disability i.e. alcohol related brain injury, mental illness and often both. The evidence I can gather at present appears mixed as to efficacy and I wondered if you had experience or personal beliefs.”

Mark Powell
Australia

Answer:

I have not carefully studied this issue for persons impaired with chronic alcoholism.

I have some familiarity with outpatient commitment for severe and persistent mental illness to mandate treatment. Of course there has always been involuntary commitment for inpatient treatment for those who are imminently in danger to self or others.

There does seem to be some success with outpatient commitment and expectation for treatment. For addicted persons, I think a version of that would be effective too. But my own clinical opinion is to work on any leverage and incentives that would be available to “raise the bottom” before focusing all efforts on this client who is still in very early stages of change.

I have more interest in the efficacy of motivational enhancement strategies, motivational interviewing, focus on the alliance and engagement. If the person is close to being incompetent because of brain injury or severe mental illness, then those would be other reasons to look at involuntary commitment. However if a person is in an early stage of readiness, I would rather have clinicians work with the system around them to create incentives to get what they want- e.g., I’ll look at my substance use because I really want to get independent housing; or keep my benefits; or stay out of jail etc.

David

Until Next Time

I hope you found something that will make a difference in your daily work. Thanks for reading— see you in October.
David