Welcome to the May edition. You may notice something different about this month’s edition. Tips and Topics will now be housed on The Change Companies' website. If you click on the Resources tab and scroll down, you’ll see Tips and Topics. You can search the archives of over 21 years of content. If you type in tipsntopics.com, you will be re-directed to Tips and Topics’ new home.

I have had a productive and treasured collaboration with The Change Companies (TCC) for many years. Reconnecting Tips and Topics with TCC promises to expand the effectiveness of that collaboration...stay tuned!

In SAVVY, I highlight two of four presentations I will be doing at RISE24 in Anaheim, CA May 22-25, 2024: “Now What? A Deep Dive on Standard V and the Challenge of Putting Treatment and Recovery Management Into Practice” and “Trauma, Sobriety and Treatment Court Compliance – Finding the Balance in Behavior Change” with Leah Elsbernd.

In SKILLS, a few highlights from the other two presentations: “Skill-Building for
Treatment and Justice Teams – How to Quickly Develop an Alliance to Help People
Change” and “A Judge and Psychiatrist Unpack How to Move from Compliance to
Lasting Change: Attitudes and Practical Tips for Justice and Treatment Teams”.

In SOUL, I’m moving from my house and our home of 25 years to a new downsized, comfortable and brand new house. It’s a time of reflection, de-cluttering and change.

Although I am 99% retired, this month, I will speak at the only conference I am committed to that “brings together public health and public safety leaders working to expand treatment for people with substance use and mental health disorders who are involved in the justice system.” RISE24 will be in Anaheim, California, May 22-25.

It will be a busy time where I will present on four topics to a conference that attracts 7,000 attendees. It is an excellent forum for me to reach a wide variety of justice and treatment teams to advance person-centered, outcomes-driven services for participants in treatment courts. Since most of you will not be attending the conference, I am sharing some highlights from my presentations this year.

Tip 1: Trauma, Sobriety and Treatment Court Compliance - Finding the Balance in Behavior Change.

Even when a participant expresses full readiness to change their thoughts, attitudes, feelings and behaviors, it is often still very difficult to change. This is especially true if a person has suffered through chronic and/or acute trauma, Adverse Childhood Experiences (ACEs), abuse, neglect, and/or childhood development challenges.

• Most of the high-risk, high need participants we serve in treatment courts have
  had many of these experiences.

• However, participants and professionals alike are often not aware of the impacts
  that these past traumatic life experiences are continuing to have on participants’
  behavior, their involvement with the criminal legal system, and on their attempts
  to establish sobriety and mental health stability.

Treatment courts expect compliance with a variety of behavior expectations including:

• Abstinence

• Honesty

• Attendance

• Vulnerable participation

But they often don’t understand how much of a struggle complying with these
behaviors can be for participants who have experienced significant amounts of trauma.
Justice and treatment teams need to understand:

• The role of trauma in the development of substance use and mental disorders.

• How to expand treatment court practitioners’ understanding of how trauma affects participant engagement, treatment, and recovery.

• The role of psychotherapy, other evidence-based trauma treatment modalities, and personal tools that can help participants process past trauma, so they can achieve more control of their behaviors, in support of sustained sobriety and recovery.

• How to balance exploring past trauma and recovering from self-defeating patterns with compliance with program requirements and expectations for behavior change, in the early phase of treatment court and in later phases. Leah Elsbernd is a Statewide Treatment Court Coordinator who focuses on coordinating training and education for over seven hundred multi-disciplinary professionals. She and I will co-present this important topic.

Tip 2: The Challenge of Putting Treatment and Recovery Management Into Practice

All Rise (formally the National Association of Drug Court Professionals, NADCP) published the second edition of the Adult Treatment Court Best Practice Standards, Part 1, Standards I-VI in 2023.

Standard V: Substance Use, Mental Health, and Trauma Treatment and Recovery Management provides treatment courts with a blueprint for better outcomes in treatment and recovery. Person-centered, outcome-driven treatment helps participants change and grow in recovery.

But how do we apply the principles contained in this standard to the unique and specific situations that commonly arise in our treatment court programs?

Here are a couple of the frequently asked questions by the treatment court field about real-world scenarios and how to apply the Practice Standards. I give a brief response here upon which I will expand in the General Session on May 23, 2024.

1. Standard V mentions outcomes several times, including client outcomes and program outcomes. Do you have any recommendations or suggestions how a treatment agency might measure and share outcomes?

The answer to this question actually draws on at least three of the Best Practices in Standard V: A. Treatment Decision Making; B. Collaborative, Person-Centered Treatment Planning and E. Evidence-Based Counseling.

Under A. Treatment Decision Making “Treatment court requirements that impact or alter treatment conditions are predicated on a valid clinical assessment and recommendations from qualified treatment professionals.”

• In other words, the treatment court team is one team of justice and treatment
  professionals who all want the same outcomes: real, lasting and sustained
  behavior change that fosters long-term recovery and increases public safety.

• There may appear to be “client outcomes” versus “program outcomes”. But
  person-centered services start where the client is at and engages them in a self-
  change process. With person-centered, accountable outcomes-driven teamwork,
  client and program outcomes can come together for lasting prosocial change.

The client may not initially want long-term recovery as an outcome. They may just want everyone to get off their back. That’s where B. Collaborative, Person-Centered Treatment Planning and E. Evidence-Based Counseling come in.

• Start with where the participant is at in a collaborative, person-centered treatment plan using evidence-based counseling like cognitive behavior therapy (CBT) and motivational interviewing (MI) and enhancement therapy (MET).

In the Commentary section of B. Collaborative, Person-Centered Treatment Planning, Treatment Goals: “Treatment court participants do not always share staff’s views about treatment goals, especially during the early phases of the program. Some participants may prefer to reduce or control their substance use rather than pursue total abstinence, others may deny an apparently pressing need for mental health treatment, and still others may prefer to receive vocational assistance in lieu of counseling or therapy. The treatment court model is ideally suited to address such situations. Team members serve different but complementary functions in both supporting participants’ treatment preferences and ensuring adequate behavioral change to protect participant welfare and public safety.”

• These “complementary functions” allow the treatment counseling to start with participants’ preferences but holds them accountable to public safety. Law enforcement and justice personnel will not “get off your back and leave you alone” if you are still driving drunk, breaking laws, behaving dangerously and threatening the safety of yourself and others.

2. Our treatment court requires an inpatient stay for everyone who enters the program, even though the treatment provider may recommend an outpatient level of care based on assessment. Do you have any research that I can use to help the team understand how this can be harmful to the client.

The answer to this question draws on at least another three of the Best Practices in Standard V: C. Continuum of Care; F. Treatment Duration and Dosage and G. Recovery Management Services.

In the Commentary under C. Continuum of Care, this issue is directly addressed: “Some treatment courts may arbitrarily and imprudently begin all participants in the same level of care or may taper down the level of care routinely as participants advance through the successive phases of the program. The research reviewed above demonstrates clearly that such practices are unjustified by clinical necessity and cost. Participants should not be assigned to a level of care without first confirming through a standardized assessment that their clinical needs warrant that level of care. Moreover, treatment care levels should not be tied to the treatment court’s programmatic phase structure. Phase advancement should be based on the achievement of proximal or attainable goals (e.g., resolving unstable housing or initiating abstinence) and not on the level or modality of care that is required to achieve or maintain these goals (see Standard IV, Incentives, Sanctions, and Service Adjustments).

• There is nothing in the Standards or Best Practices that requires that everyone start in a pre-determined set level of care, just as we don’t start everyone with Major Depression or Diabetes in a hospital for a certain length of stay.

• If a treatment court requires that everyone starts at a certain level of care and/or for a pre-determined duration, they are focused on compliance with a programmatic model.

• The focus needs to be on outcomes and indicators of lasting change not program compliance. How has this participant changed in their thoughts, actions, attitudes and behavior such that they are no longer a threat to public safety and are on a solid path to recovery?

In the Commentary under F. Treatment Duration and Dosage, “Studies of treatment duration and dosage have thus far been confined mostly to adult drug courts, mental health courts, and traditional substance use treatment programs. Comparable information is unavailable, unfortunately, for many other types of treatment courts. The success of adult drug courts has been shown to be attributable, in part, to the fact that they significantly increase participant retention in substance use treatment (Gottfredson et al., 2007; Lindquist et al., 2009). The longer participants remain in drug court and the more sessions they attend, the better their outcomes (Banks & Gottfredson, 2003; Gottfredson et al., 2007, 2008; Peters et al., 2001; Shaffer, 2011;
Taxman & Bouffard, 2005).”

• Because change is a very individualized process, and because change takes practice and sustained effort, retaining participants in treatment is necessary, but not sufficient for change to happen.

Under G. Recovery Management Services: “Throughout participants’ enrollment in treatment court, staff work to connect them with recovery support services and recovery networks in their community to enhance and extend the benefits of professionally delivered services.”

In the Commentary under G. Recovery Management Services: “Recovery management services that have been demonstrated to improve outcomes in treatment courts and traditional substance use or mental health treatment programs include pairing participants with peer recovery specialists, engaging participants with mutual peer support groups, and conducting brief post-treatment recovery checkups. Assigning benefits navigators to help participants access needed services and resolve access barriers has also been shown to improve outcomes in traditional substance use, mental health, and criminal justice programs (e.g.,Guyer et al., 2019; SAMHSA, 2019) but has not been examined in treatment courts. Finally, recovery management services that link participants with abstinence-supportive housing, education, or employment are described in Standard VI, Complementary Services and Recovery Capital.

• Connecting participants to recovery management services starts while the person is in treatment and within the structure and support of the treatment court.

• Recovery management services are not “aftercare” to which a person is referred upon “graduation” from the treatment court program. These services are essential supplements to professional services that accompany the ongoing addiction and mental health services in the treatment court program and beyond.

SKILLS

Tip 1: How to Quickly Develop an Alliance to Help People Change - Skill-Building for Treatment and Justice Teams

Anyone who works with helping people change knows the importance of the alliance and relationship. Whether you are a treatment provider or a justice team member, the ability to develop an alliance and an empathic connection with the participant often determines whether they engage in a self-change process.

I could have named this presentation “How to develop a working alliance in ten minutes or less.” I’m not diminishing the complexity of the participants, nor dismissing the work of alliance-building as a simplistic, easy-to-do, short process. But I am challenging you to not go to the other extreme, which is represented by:

• “Oh it takes weeks, months and even years to build an alliance.”

• “When people call who are mandated to get into treatment, you can’t build an alliance with them. They just want to stay out of jail or get probation off their back.”
  

In any beginning exchange with a participant, it is imperative to tune in quickly in the first minute or two: What is most important to the person that prompted them to reach out or keep an appointment?

Here is an example on a call with a Mandated Client:

Interviewer (I): “Thank-you for calling, what is the most important thing you want that made you decide to call today?”

Caller (C): “My probation officer (PO) told me to call to get an appointment with an
addiction treatment program?”

I: “Oh so does he think you have an addiction problem?”

C: “Well that’s what he thinks and what I have to do.”

I: “But what do you think? I’m more interested in whether you think you have an addiction problem which needs treatment, not just what your PO thinks.”

C: “Well I don’t think it’s really a problem but I have to go to treatment otherwise I could go back to jail because they found something in my urine drug test.”

I: “So what is most important to you – to work on an addiction problem or not go back to jail and get off probation?”

C: “Not go back to jail.”

I: “So how about I find somewhere for you to go that will help you stay out of jail and help you prove to your PO that you don’t have an addiction problem. Or, if by chance, you do find out you have an addiction problem, demonstrate you are treating it so you won’t get arrested again?”

The Working Alliance:

• Now you have just agreed on a goal: Stay out of jail.

• Agreed on strategies and methods: See someone who can work on that goal and prove you don’t have a problem or if you do, that you won’t get arrested again to have to go back to jail.

• The context: A brief telephone call where you have bonded on helping the client get what is most important to him.

Whether you are working in a “call center”, work in law enforcement or justice services, see clients in an outpatient or residential setting, it is the same process - especially if the person is calling at the urging of a family member, a supervisor or PO, or a child protective services worker.

Tip 2: How to Move from Compliance to Lasting Change: Attitudes and Practical Tips for Justice and Treatment Teams

For a couple of years at the RISE conference, now retired New Hampshire Chief Justice Tina Nadeau and I have offered practical tips for moving from an only compliance focus in treatment courts to engaging participants in lasting change.

Judge Nadeau shares Why and How she shifted her attitudes and participant interactions to better engage them in lasting change. Through case examples and challenging questions from the audience, both Judge Nadeau and I demonstrate how to shift attitudes and practices to achieve improved outcomes.

Here are a couple of examples of questions we have addressed:

1. We often hear from teams that some clients are “manipulative.” I know you’ve said that means someone isn’t skilled at asking for what they want or persuading people to meet their needs, and collaborate with them to reach their goals. Here is an example: A participant who was avoiding residential treatment agreed time and again to go. Every time he showed up for the assessment, he would indicate he had suicidal ideation, so they would not take him. He was referred to the ER where he would deny he was suicidal.

Response:
In a Treatment Court compliance culture, the participant agrees to go to residential treatment. But his repeated behavior of “suicidal ideation” ensures that he is not accepted for residential treatment. It is clear he agrees to do to residential treatment but really doesn’t want to go.

In a Treatment Court that is focused on enhancing lasting change, a collaborative, person-centered treatment planning process would allow for the participant to have a choice of treatment and personal goals. Engage the participant in shared decision-making and what are his preferences around level of care and treatment goals. This will prevent the need for the participant to invoke “suicidal ideation” and encourage collaboration rather than insincere compliance.

2. Let’s talk about honesty. We tell participants we can’t help them when they are dishonest. We know it’s hard, but we also know it’s something they can do even though they are actively using. When treatment repeatedly has conversations around barriers to honesty, but after a period of time the individual doesn’t indicate their willingness to be honest, how can you continue to work with them?

Response:
An important assessment question before launching into sanctions or discharge is to determine if the participant is unwilling to be honest or is unable to be honest. Even people who do not suffer from addiction may tell “white lies” to avoid rejection, punishment or embarrassment e.g., “Sorry we can’t make it to your dinner party, we have other plans”. The truth is you don’t like them very much and certainly not the other dinner guests invited. Or “Officer, really? I was going 15 miles over the speed limit? I would have sworn it was only 5 miles over even if that.” The truth is you know you were speeding but are hoping that your lies will avoid or lower your fine.

Consider then the person with addiction who often had to lie on a daily basis in order to keep their job, relationship or self dignity. They couldn’t be honest that they were late for work because they were hungover. It was the car accident and traffic. They couldn’t tell their partner that they forgot the important dinner date because they were drinking at the bar and lost track of time. It was the boss who made them work overtime in a work crisis and that’s why they lost track of time.

Every day, it was a survival technique to lie and not be honest. Then they enter treatment court and we expect them to turn on a dime and undo 10 to 15 years of survival strategies to be honest with people they hardly know and certainly don’t trust. Add to that the fear that if they are honest about being late, substance use or disagreement over level of care that they then could be sanctioned and punished.

Bottom line: Dishonesty, like suicidal ideation, substance use, difficulty attending sessions and any other behavior for which we expect compliance first needs to be assessed to identify anything that needs treatment not sanctions.

SOUL

This month, I’ve been moving....moving from the house that was our home for 25 years. This was the house that:
Saw our three children move through their teen years to college and out into the world.

• My wife of 46 years beautified and cared for until her passing over 5 years ago.

• Was my office address when I started DML Training and Consulting doing full time training and consulting from home.

• Grounded me as the only place I have lived the longest in my life – one third of my years in the same house, same address.

The list could go on. You get the picture. A lot of memories, emotions, life events and milestones. But it is time to downsize and unleash resources that can better be used by my children now, not when I am dead. (I’m planning on another 20 or more years!)

So every day this month, I have been filling my Toyota Prius to the brim with boxes, clothes, furniture, kitchen utensils, bedsheets and towels to truck over to the brand new house 20 minutes away. It is an excruciating de-cluttering and downsizing process. I have to resist several times a day: “I better keep this. You never know if I might need it one day.” The problem is I had forgotten I even had it and haven’t used it in 15 years.

How do I feel, you may ask. I’m feeling great and loving the new place. I’ll feel even better when a buyer closes the deal and begins to make my old house their new home. Sure, there are some sad tinges as I survey the bare rooms and can “hear” the laughter, crying, arguing, music-making and clanging of the kitchen mealtimes.

But it’s a new day, a new chapter, a new beginning of sorts. I’m de-cluttering and moving “stuff” to the new home....and I’m de-cluttering and moving my emotions to a new place as well.

UNTIL NEXT TIME

Thanks for joining us this month. See you in late June.

David