Vol. 10, No. 11
Welcome to the February edition of Tips and Topics. We are approaching the tenth anniversary of Tips and Topics in April, so check out SOUL of this edition for a special request I have of you.
David Mee-Lee M.D.
In 1976, I was still in my specialty psychiatric training in the Boston area. I completed two rotations, which had a long-lasting impact on me.
–> One was a weekly visit to a traditional Synanon-style therapeutic community (TC) with its attacking, confrontive peer group therapy. The “no language barred” style seemed like every second sentence was “f… you this” and “f…you that.” There was the belief that personal humiliation was needed in order to receive the well-meaning feedback from ones’ peers. Clients in the TC were made to wear signs around their neck saying such things as “I’m stupid” or “I’m arrogant”. People were sometimes made to clean the floor with a toothbrush, or shave their head for some infraction of the rules.
Perhaps back then, I was naïve about the ravages of heroin use and other drug street addiction and its effects on hardening the defenses of the addicted. However I still believe the attacking counseling style was abusive, guilt-enhancing, and an affront to each client’s personal dignity.
–> My second training opportunity was on the Behavior Therapy Unit (BTU). Here there was no confrontive yelling or humiliating techniques, just the initial defining Behavioral Analysis. This determined what rewards and reinforcers would be constructed to modify the client’s specified target behaviors in the BTU’s token economy system of behavior modification.
So what has this got to do with treatment programs in 2013? 1976 was last century!
We’ve come a long way from the attacking, “no language barred,” confrontive Therapeutic Community model. There are not many pure behavior therapy token economies left either. However… many modified strands of those original models shape current residential programs, especially in adolescent and criminal justice treatment.
In therapeutic communities, especially in criminal justice treatment settings, a predominant belief is: The way to arrest addiction is through retraining the individual’s thinking, to make better decisions on using drugs. This approach relies almost exclusively upon behavioral theories and techniques, versus any other theoretical model.
Of those earlier models, note what features have been modified and are being used in today’s therapeutic communities.
Milieu therapy: “Patients are encouraged to take responsibility for themselves and the others within the unit.” (Wikipedia) This typifies therapeutic communities, where trust is built through an attitude of ‘we are all in this together ‘to help each other. Peer support and confrontation are central to milieu therapy.
This milieu therapy approach still seems to apply today in most programs.
Heavy confrontation and verbal attacks, with a good dose of profanity and humiliation, were not uncommon in the old TC model.
Counselors and peers no longer verbally attack and humiliate clients. Usually there is a “no profanity allowed” and no “drug talk” war stories approach. However a central part of the treatment culture is for peers and counselors to issue corrective reminders of rule violations or unacceptable behavior, sometimes called “pull-ups” or “write ups”. There are various consequences, which affect a client’s movement through phases of the program. These write-ups can delay “graduation” and treatment completion. Confrontation and Encounter groups still continue in some therapeutic communities.
In the past in some programs, clients were expected to do significant unpaid work for the program.
Unpaid work for the program is no longer allowed. However there is still a value put on physical health, activity and work. There is still an emphasis on sharing chores and maintaining clean, tidy, and orderly living spaces.
Traditional therapeutic communities emphasized separation from clients’ old lives and environment and entering into the safe community of the program for long periods.
Today there is less of that in terms of length of stay and degree of isolation from the “outside” world. Some elements of previous methods still do remain though: limited phone calls, limited contact with friends and family; earning of privileges for passes and outings based on behavior and compliance with rules and regulations; restriction of family visits.
Both Then & Now
Compliance with program goals, rules and norms remains a major focus of treatment. Clients’ status, level or phase in the program is based upon their accomplishments within the therapeutic community.
- They must complete various therapeutic tasks and assignments common to all clients.
- They must demonstrate a quality and degree of participation in the groups and therapeutic milieu.
- They must show changes in attitudes and behaviors. Movement through treatment is based on compliance with program tasks and responsibilities and the individual’s adherence to rules and norms.
- This is reinforced by the use of contingencies (privileges, learning experiences, earned incentives, and sanctions.)
Both Then & Now
The tradition of peer role models remains part of the therapeutic process. Clients are expected to demonstrate consistent compliance with rules; supportiveness to peers and staff; leadership skills and a positive, no “drug talk” war stories attitude. Self-help and mutual-help group sessions remain central to a “people helping people,” “all in this together” culture of healing and wellness.
There is much from the past to be valued. Effective, relevant elements from past models should be continued but modified for today’s programs. Even so, some unintended negative consequences work against change that is positive, lasting and accountable.
Overemphasis on compliance to program rules, norms and assignments overshadows a person-centered, assessment-based, outcomes-driven approach. Lasting change is then compromised.
How do we integrate individualized and tailored treatment plans into a therapeutic community, preserving all that is good, but modifying elements of past models?
SKILLS will begin to address this challenge.
Warren K, Hiance D, Doogan N, De Leon G, Phillips G (2013): “Verbal feedback in therapeutic communities: pull-ups and reciprocated pull-ups as predictors of graduation”Journal of Substance Abuse Treatment Vol. 44, Issue 4 , Pages 361-368, April 2013.
So if the research on integrated and collaborative care is compelling, why are some -perhaps many- physicians, clinicians and counselors suspicious and even antagonistic to these changes in health care?
There are aspects of modified Therapeutic Communities that work against outcomes-driven individualized treatment:
—> Because a therapeutic community approach relies almost exclusively upon behavioral and social learning models and techniques, other evidence-based practices do not mesh well.
- How does a program integrate Motivational Interviewing and Stages of change work if all clients are expected to do the same clinical assignments regardless of their stage and readiness to embrace recovery?
- How do you use Integrated Dual Disorders Treatment for a person with a mood disorder, if there are sanctions or write-ups when there is an emotional outburst?
- How do you decide if one client gets psychotropic medication for their mood swings and behavior, while another peer is confronted and gets a write-up?
—> A client may not be progressing well. Mental health issues with more complex treatment needs may not be responsive to behavioral methods.
- In a therapeutic community, all clients are expected to comply with certain universal tasks and meet behavioral expectations. How does a program deal with more complex clients incapable of doing these at the same pace as others, or who may even be incapable of compliance?
- How do counselors individualize expectations for particular clients in a treatment culture that relies on peer confrontation where everyone is expected to comply?
- How do you individualize treatment without peers feeling that “if he doesn’t have to do it, why do I?” and upset that a peer is receiving special treatment and exceptions from the rules and norms?
Review these dilemmas in Therapeutic Communities. Consider these solutions to move to individualized treatment.
1. Early Phase/Level Expectation
In order to achieve and maintain the first level in the program, one task to complete is to list 10 costs and benefits of substance use in your life.
What if a client is at Action for completing probation, but at Precontemplation about substance use and sees nothing wrong with his/her use? In order to get through the program and get off probation s/he will comply with the task- to talk about the costs of substance use. But how is this promoting honesty?
A Solution to Individualize Treatment:
Ask your client to share: “What brings you here? ” “What do you want to get from the program?” This could be done in an individual session or in a “What do I want?” group where the group leader helps each client state honestly why they came to treatment. “I want to get off probation, but I don’t have a drug problem, it wasn’t even my stuff.” Or “I just want to get my kids back and don’t have a parenting or alcohol problem.”
2. Behavioral Infractions
Because of an angry exchange with staff, the client was written up with an LOP (Loss of Privileges); and required to write a 1,000 word essay on managing anger.
When there are structured policies and procedures for certain behavioral infractions -e.g. LOP and 1,000-word essay, it is easy to avoid an individual assessment of the outburst and to tailor the treatment response. Yet a more tailored treatment response may actually be needed and clinically indicated. For example, a client may learn better by role-playing in group an angry situation rather than writing an essay. Another example: A client may be angry after an upsetting phone call with his wife. Counseling on how to plan for a family meeting is what is needed, not writing an essay. Another example: If the patient’s medication is not stabilized, that may be the priority, not an essay.
A Solution to Individualize Treatment:
Train staff on how to de-escalate behavior. Train them how to assess, with the client (at the time of the behavior) what is going on and what the communication difficulty is about. Focus then on helping the client to express negative emotions in ways that are effective in getting their needs met. This can involve cognitive behavioral therapy (CBT) and TC methods of “learning experiences”. Thus the emphasis is on treatment and change, not on write-ups and consequences for behavioral infractions.
3. Evaluating Progress in Treatment
With a levels system, movement through the program is measured by compliance with program tasks. By contrast, individualized treatment evaluates progress by how well the client improves in the problems identified in the assessment. In some systems, clients even wear color labels to indicate what level they are at. Such a culture and mindset is too focused on levels and tasks, not on each person’s specific treatment plan.
A “levels” system directs the client’s attention to compliance to tasks. But we want their energy directed toward resolving their unique combination of obstacles to their recovery. We work with them to apply their personal strengths, skills and resources to advance recovery.
Check where your client’s attention is by asking: “Tell me about your treatment plan and what you want to get out of group today to advance your treatment plan? I am asking about your treatment plan, not what level you are in the program, nor what you have to do to avoid loss of privileges or to move to the next level.”
A Solution to Individualize Treatment:
Consider eliminating color tags or other labeling mechanisms used to identify the phase a client is at in the program. Develop new clinical skills to gradually replace any old methods of a TC model that no longer promote individualized, outcomes-driven treatment. Focus clients and staff on evaluating client function, stages of change, and progress of assessment-based goals, not program-driven tasks and goals.
4. Late Phase/Level Expectation
In order to achieve and maintain a more advanced level in the program, a client generally must demonstrate certain skills: leadership in groups, show leadership by following rules, helping staff voluntarily, aiding in maintaining order in group, and providing honest feedback.
Clinical example: The client is the oldest of three children of alcoholic parents. He was always the “hero” who rescued his younger siblings, putting aside his own needs. In the program he takes on a role almost like junior assistant counselor, more focused on giving feedback to others than on getting in touch with his own needs. What if his individualized treatment plan needs for him to NOT be a leader; NOT be always helping others and giving them feedback?
A Solution to Individualize Treatment:
Consider changing the program culture to one where:
- Each client is the one most familiar with, and responsible for the success of their treatment plan.
- Each person then shares that plan with peers. He/she uses the therapeutic community as a safe and supportive place to take responsibility for trying out new ways of thinking, being, behaving and relating.
- Each person indicates what help they need each day, perhaps a role play to handle anger better, or feedback on how to ask for help- whatever is in their particular treatment plan.
- Progress through treatment is based on outcomes of the tailored treatment plan rather than compliance with program milestones and levels.
Perhaps you are someone involved in a TC model. What is your level of interest in changing your program…or not?!
If you are not involved in a TC model, what can you do to raise consciousness about these issues for your colleagues in such programs? Many have been set on the road to recovery in therapeutic communities, so how do we preserve all that is good? How do we modify what would make them even better?
“No single treatment is appropriate for everyone. Matching treatment settings, interventions, and services to an individual’s particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace and society.” – Principle No. 2 in National Institute on Drug Abuse: Principles of drug addiction treatment: a research-based guide (NIH Publ No 09-4180). Rockville, MD: National Institute on Drug Abuse, 2009.
In April, Tips and Topics (TNT) is having a birthday, turning ten years old. I’m not usually one for big anniversary celebrations. But ten years of monthly newsletters emailed to over 8,000 addresses is no small feat. And those addresses didn’t come from some purchased mailing list either. Workshop attendees, colleagues and friends of participants signed up voluntarily over the past decade.
But this is February, so why am I talking about an April edition tenth anniversary?
Tips and Topics has been my gift to you. To help celebrate, I thought I would ask a gift of you.
No, I’m not asking for money donations or an engraved plaque. It would be fun (and informative to me) to hear what you appreciate about Tips and Topics. You can even slip in a suggestion or two on what you would like to see more of, less of, or different from what we have presented to you each month.
In the tenth anniversary edition, we’ll publish some of your “appreciation gifts” to celebrate together. Now maybe all you have time to do is shoot back an e-mail that says “Great job!” or “Love getting TNT every month” (I am assuming you’ll spare me any hate mail for the April edition). On the other hand, if you can take a little more time and effort to express appreciation, check out SKILLS in the March 2010 edition where you are guided through a more powerful way to express appreciation in your life.
Perhaps there was a particular edition of a SAVVY, SKILLS, SOUL or STUMP THE SHRINK section especially meaningful or memorable for you. Please tell me what it was and in which edition. (You can see all ten years of TNT at The Change Companies www.changecompanies.net and click on Blogs.)
Thank-you for reading TNT. And to the many of you who have already taken the time to write and express appreciation over the years, thanks. Over the next month, I look forward to hearing from you, if you are moved to write something for the 10 year celebration of Tips and Topics.
P.S. Let me know how you want to be identified or not.
If you haven’t yet read the new third edition of Motivational Interviewing (2013), you can get the “movie” first. It didn’t win an Academy Award, but maybe next year!
Drs. William R. Miller, Theresa B. Moyers and Stephen Rollnick walk you through the concepts and practice of Motivational Interviewing.
It is based on the revised and updated Motivational Interviewing, 3rd Edition (2013) by Drs. William R. Miller and Stephen Rollnick. The video provides over 6 hours of material, introduces the new four-process method of Motivational Interviewing, and includes downloadable resources. (Available in 2-DVD set, streaming Web version, or a bundle that includes both formats).
- Discussion with the authors
- Interview demonstrations with annotated transcripts
- Detailed menu of topics
- Interview commentary
Until next time
I am glad you could join us this month. See you in late March.