Vol.12, No. 8
Welcome to the November edition of Tips and Topics (TNT). For all in the USA, a Happy Thanksgiving!
David Mee-Lee M.D.
The emails and verbal appreciations are gratifying. This month however, one reader, Izaak Williams, went much further than simply read and digest a previous edition.In the March 2011 edition, I wrote in SKILLS about the sometimes negative, unintended consequences of “graduation” ceremonies in residential treatment.
Izaak researched the topic and wrote his version in a peer reviewed paper entitled “Drug Treatment Graduation Ceremonies: It’s Time to Put This Long-Cherished Tradition to Rest” He even received permission to allow you free access to the whole paper at this link:
So I asked Izaak Williams to summarize his paper for the November edition. Here is how he did that (with some minor edits from me.)
Are Graduation Ceremonies a Therapeutic Celebration or Hollowed Concept? You Be the Judge
1. Where did substance use treatment graduation ceremonies originate?
The history of this tradition finds its roots in “early 19th century treatment institutions. It was the practice in the Keeley Leagues (KL) – (for example, the patient-led recovery mutual aid fellowship within the Keeley Institutes) for the person leaving treatment to recount their experience, receive the best wishes and guidance of other KL patients before KL members walked the departing patient to the train station in Dwight, Illinois. The function of this ritual was to reaffirm commitment to sobriety, cement the bonds of fellowship, and form a bridge between the institutional group and the Keeley League meetings in one’s own home” (Personal Correspondence, W. White, November 6, 2014).
2. What’s wrong with using the term graduation or commencement?
Just about any dictionary definition of “graduation” or “commencement” spells out the notion of “wholeness” that refers to completion of everything needed or required. When we talk about graduation in the education system the discussion shifts to prerequisites and credits towards a degree program—requirements that are clearly articulated.
For example, asking a high school or college student if he or she will graduate would invite the student to talk about how many credits they’ve completed or what classes they plan to take in the near future in order to graduate or commence. Moreover, while the meaning of commencement in the dictionary may refer to “a beginning”, this very same definition is often qualified with cross-reference to graduation. In other words, to start anew or “begin” one must first completely finish (high school or college degree program).
With this in mind, how does one commence or graduate from a substance use disorder?
Why might it not be such a Good Idea to Graduate Treatment Participants?
Here are Izaak’s thoughts on how graduations appear to affect participants:
- There can be an overblown sense of confidence about their prospects of not returning to use. This reinforces a willpower stance toward addiction. It seems to foster a particular relationship with their drug of necessity which directly contributes to continued drug use or relapse.
- For some clients who tend to reward or celebrate with drug use, a festive celebration with entertainment value may trigger a drug craving in order to enhance the fun.
- It may foster the false belief that “cure” has occurred and that treatment support or ongoing mutual aid is no longer needed or will ever be required.
- Treatment participants may be working on repairs or making amends while relationally cutoff from loved ones. If loved ones are not invited or refuse to participate in graduation, this can provoke client distress, anxiety, and other not-so-good feelings and negative emotions.
- Returning to treatment after graduating would seem to provoke a sense of stigma in light of embarrassment and disappointment of having to face treatment staff and possibly other peer clients who celebrated with them.
3. What is the future for graduation ceremonies?
There are many ongoing changes in drug treatment industry standards in light of the Affordable Care Act (ACA) and Mental Health Parity and Addictions Equity Act (MHPAEA)(2008). In the future, the existence of graduation ceremonies will hinge on the availability of empirical evidence to support it as a therapeutic practice. This is because traditional stand-alone addiction treatment programs which perpetuate this tradition mostly aim at targeting drug use on the basis of stabilization. This is an acute care model; it’s not sophisticated enough to be effective for chronic disease management. One emerging model of care is the patient-centered “medical home” or “Patient-Centered Primary Care Home Program” (PCPCHP) (see: http://www.oregon.gov/oha/pcpch/Pages/index.aspx for patient-centered primary care programs). In short order, here are but a few of the key standout words characterizing this model: comprehensive, integrated, coordinated, continuous, patient and family centered, collaboration.
As treatment industry standards encourage collaborative plans of intervention that are holistic and promote wellness, the future of both acute care model and graduation ceremony is bleak. This is because both appear antithetical to the new standards of care conforming to the medical model of drug addiction promoted by ACA and MHPAEA.
4. Is there another way of thinking about Graduation Ceremonies?
- One suggestion is that the word “graduation” and its substitute or euphemism-“commencement”— be avoided in program speak. This would then permit the notion of continuum of care transition to creep into thought rather than “end of treatment”, “completion”, or “graduation.”
- Perhaps the proverbial graduation ceremony performed in a grand ballroom could be scaled down to a more individualized patient-centered setting-an intimate meeting- between the treatment team, client, family members, sponsor, and friends willing to offer ongoing support. This forum would provide a structured opportunity to talk safely and formulate support roles. Add to this: the possibility of clarifying misconceptions about addiction dynamics and facilitating ongoing treatment recovery processes.
- As David Mee-Lee suggests, this could be called the Reflection, Celebration, and Anticipation (RCA) (seehttp://www.tipsntopics.com/2011/03/march-2011-tips-topics) stage. At its very essence, what this entails is establishing a road map to help patients and his/her support system see where they are now and where they are headed in treatment recovery. This might be called a ”life in recovery transition day” centered on the sharing of a solid, longitudinal, community-based Continuing Care Recovery Plan (CCRP) in supporting further stages of recovery.
In closing, Izaak indicated that Thomas McGovern, editor of the Journal of Alcoholism Treatment Quarterly invites comments in response to the article entitled “DrugTreatment Graduation Ceremonies: It’s Time to Put This Long-Cherished Tradition to Rest” (Vol. 32 issue 4). “We welcome critique and criticism to stimulate further dialogue, compel critical thinking, and encourage empirical scrutiny of substance use disorder treatment graduation ceremonies.”
Izaak L. Williams, Hawaii State Certified Substance Abuse Counselor (CSAC), was selected in the 2014 cohort of emerging leaders by the Center for Substance Abuse Treatment’s(CSAT’s) Behavioral Health Leadership Development Program. He can be reached at: firstname.lastname@example.org
Williams, Isaak L (2014): “Drug Treatment Graduation Ceremonies: It’s Time to Put This Long-Cherished Tradition to Rest” Alcoholism Treatment Quarterly Volume 32, Issue 4, pages 445-457
Published online: 06 Oct 2014http://www.tandfonline.com/doi/full/10.1080/07347324.2014.952995
In April of 2011, theBoard of the American Society of Addiction Medicine unanimously adopted a new definition of addiction. There is a “short version” (shown below), as well as a “long version” definition (available at http://www.asam.org/for-the-public/definition-of-addiction), which serves as more of a description of the condition.
Short version: “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.”
Izaak provided what he called “Stimulus” questions for you to think about. Reflect on these to see how you view graduation ceremonies in the context of your definition of addiction. I responded with a few thoughts his questions stimulated for me.
Consider the following “Stimulus Questions” about Graduation Ceremonies
How do graduation ceremonies provide mutual support and aid drug addiction treatment and recovery for participants?
It is always a joy to see people change (if they have) in attitude, thinking and behavior from the beginning of an episode of care to their transfer or discharge. Celebrating these changes creates a sense of accomplishment that too many clients and patients have rarely experienced in their lives. However, on the path of life-long recovery, their episode of care is just one step; it is a beginning not an ending. For many clients, families and mandating agencies “graduation” sounds like cure, as if a broken leg is now fully healed and ready for weight-bearing. It may seem that the term “commencement” might be a better word, to signify a beginning process, except in people’s minds this word is still associated with graduation ceremonies.
Many families have suffered for years from the effects of addiction in their lives and their loved one. Finally, after treatment, the family finds it wonderful to have their son, daughter, father, mother or partner back. They get back the loved one they haven’t experienced for years, due to the ravages of addiction. But I have seen so many families disappointed and hurt by expectations of “treatment completion and graduation.” They thought this would finally be the miracle.
When families think of addiction treatment as finding the best program (like researching a world expert surgeon, cancer center, miracle medication or procedure) “graduation” offers false hope. They need to understand addiction requires continuing recovery and care. Flare-ups and acute exacerbations of this ongoing disease are common, just like asthma, diabetes, hypertension, bipolar disorder or panic disorder. Families are in need of recovery help as much as their loved one. “Graduation” sends the wrong message.
What values and perceptions about the nature of addiction are you expressing when you have graduation ceremonies?
Are such values and messages consistent with what the research says about addiction?
Obviously I view addiction and treatment as an ongoing process of recovery; it needs to be viewed as chronic disease management in a flexible continuum of care. The ASAM Criteria has set out the criteria for how to do chronic disease management since 1991. Ponder your definition of addiction. How consistently do you walk the talk about addiction – its nature and its treatment.
Does participation in graduation lead to better recovery outcome?
Do “graduates” find it easier to maintain their therapeutic gains?
Whether you are for or against “graduation”, we are most often speaking from tradition, personal life and work experience, and clinical opinion. The research evidence is slim to nothing. This would be a worthy research focus for an up and coming scientist in the field.
How does graduation ease the transition from treatment to longitudinal recovery care management in the community?
Unfortunately, I believe the unintended negative consequences outweigh the understandable advantages of joyful celebration. I wonder, as Izaak Williams’ paper suggests, whether “It’s Time to Put This Long-Cherished Tradition to Rest”.
I am pretty good at saving money. My father was frugal and I have been socialized to be the bread-winner and provide the best I can for my family. But when it comes to saving time, it’s a different matter. Somehow, I just never seem to have enough time.
Now before I go on further, let me acknowledge that this SOUL was inspired by reading Scott Provence’s “Time Robbers” in his weekly stories about superheroes and behavior change. Scott is Vice President of Product Development at The Change Companies and in his blog, Superhero is learning about the science of self-help. You’ll be entertained and educated by the antics Superhero gets up to. You can see the November 3, 2014 story I’m referring to at the website Scott calls “I’ll Save You (and other lies)”. Check out the Archives and subscribe there too if you want.
“Time Robbers” started me thinking about parallels between money and time, and the language we use:
- We save money to spend later. We save time by taking a shortcut on a road trip.
- We spend a lot of money on what is important to us. We spend a lot of time on what is important to us.
- We can waste money on ill-founded schemes or trivial pursuits. We can waste time on ill-founded schemes or trivial pursuits.
- If you don’t watch out to keep your money safe, it can get stolen. If you don’t watch out for how life flies by, you may find on your deathbed that time can also be stolen.
- We can be generous or stingy with our money. We can be generous or stingy with our time.
- If you manage your budget well, you can have extra money. If you manage your schedule well, you can have extra time on your hands when you arrive early for an appointment.
- You can worry about how much money you have and stress yourself out. You can worry about how much time you have left in life and stress yourself out.
- Some people just never seem to enough money. Some people (looking in the mirror) just never seem to have enough time!
Well this could go on endlessly. What I realized is that I need to look at what works so well for me in having enough money, then apply the same skills to having enough time.
Here’s what I came up with for starters:
1. I set my priorities between retirement savings, living expenses, charity, travel and vacation.
2. I watch what I spend for quality and value.
3. I check my bank account and credit card accounts frequently to make sure expenditures and savings are in balance.
I do all that well.
Now for time, it is the same three principles:
1. What are my priorities between work, love and play?
2. How can I be more conscious about spending quality time with people, places and things of value?
3. How can I regularly check that all is in balance?
I’m sure my wife willbe happy to keep my feet to the fire on how I spend my time. I can see NewYear’s Resolutions gradually taking shape.
Until next time
Thanks for joining us this month. See you again in late December.