Doing Time or Doing Treatment: Moving Beyond Program Phases to Real Lasting Change

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Bartholomew Carter
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1 Doing Time or Doing Treatment: Moving Beyond Program Phases to Real Lasting Change BJA Drug Court Technical Assistance Project at American University March 14, 2016 David Mee-Lee, M.D. Chief Editor, The ASAM Criteria Senior Fellow, Justice Programs Office (JPO) American University Washington, DC Senior Vice President, The Change Companies Carson City, NV Davis, CA

2 A Word About Terminology Treatment Compliance vs Adherence Webster s Dictionary defines: comply : to act in accordance with another s wishes, or with rules and regulations adhere : to cling, cleave (to be steadfast, hold fast), stick fast

3 Criminal Justice s View of Presenting Problem and Solution 3 C s Consequences Compliance Control

4 Court Teams and Treatment Providers Working Together - Need to Promote: Common purpose and mission public safety, sustainable change to decrease legal recidivism & crime Common language of assessment of stage of change Consensus philosophy of addressing readiness to change Consensus on how to combine resources and leverage to effect change, responsibility and accountability - judges to mandate assessment and treatment adherence; not a particular level of care, length of stay and/or specific treatment strategies or services e.g., AA; sponsor; meds. Communication and conflict resolution

5 Example of a Phasing System Protocol In general, there are four (4) phases of treatment through which all participants must progress. All clients enter the Drug Court program in Phase 1 Often the phases are structured in terms of time frames and tasks rather than achievement of functional milestones Such phases, without functional milestones, too easily promote compliance Doing Time vs. adherence Doing Treatment and Change

6 Example of a Phasing System Protocol (cont.) This example presented not as an ideal system, but rather to illustrate where compliance (highlighted in yellow) is promoted; and/or ambiguous about functional change e.g., participating may be passive attendance only Words highlighted in yellow italics indicate where adherence and functional improvement is promoted Compliance with court orders is appropriate and consistent with a criminal justice mission Adherence with treatment plans allows individualized treatment and a focus on sustainable change

7 Phase 1 - ORIENTATION GOALS Screening and Assessment Referrals to service(s) based on individual needs Placement in community based treatment Identification of treatment barriers Discontinue drug/alcohol use as evidenced by negative urinalysis EXPECTATIONS Weekly or Bi-weekly court appearances, to be determined by assessment Enter into substance abuse treatment Compliance with all other court orders/adherence to treatment plan Urinalysis testing three times per week or at random

8 Phase 1 - ORIENTATION When participant is compliant with all court appearances and treatment recommendations, is participating in substance abuse treatment, has completed any sanctions imposed and provides negative urinalysis for minimum of one consecutive month, participant is eligible for advancement into Phase 2.

9 GOALS Phase 2 - CHANGE Continued abstinence and recovery Enrollment and participation in other ancillary services Identify home group for NA/AA meetings (if required to attend) Attend NA/AA meetings regularly (if required to attend) Maintain negative urinalysis EXPECTATIONS Once per month court appearances Engagement in Substance Abuse treatment Continued urinalysis testing Begin additional ancillary services Attendance of NA/AA meetings (if required to attend). Identify a home group, attend frequently, and begin to identify with a sponsor

10 Phase 2 - CHANGE When participant is in Phase 2, it is expected that he/she expresses and demonstrates commitment to treatment services. Participant must be compliant with all court appearances and treatment recommendations, be actively participating in substance abuse treatment, participating in 12 step Fellowship meetings (if required to attend), complying with ancillary services if referred or recommended by Court and/or treatment provider), have completed any sanctions imposed and provided negative urinalysis for minimum of two consecutive month in order to become eligible for advancement to Phase 3.

11 GOALS Phase 3 - CHALLENGE Continued abstinence and recovery Educational and/or Vocational training (if needed) Successful progression in treatment If required to attend NA/AA meetings- obtain a sponsor and begin working the steps No further criminal involvement Develop an aftercare plan Identification of community supports EXPECTATIONS Court appearances every days Continued urinalysis testing as ordered Continued involvement with NA/AA meetings (if required to attend) Behaviors consistent with recovery lifestyle (including no more arrests)

12 Phase 3 - CHALLENGE When participant is compliant with all court appearances and treatment recommendations, is participating in substance abuse treatment, remains involved with NA/AA meetings (if required), remains compliant with all ancillary services, has completed any sanctions imposed, avoids further involvement with the criminal justice system, and provides negative urinalysis for minimum of three consecutive months, participant is eligible for advancement into Phase 4.

13 GOALS Phase 4 -SELF-SUFFICIENCY Continued abstinence and recovery Reintegration into the community No positive urinalysis Maintain stable housing Maintain stable employment or enrollment in school Involvement with NA/AA meetings, if required to attend Not engaging in criminal activity Utilization of resources and support systems EXPECTATIONS Court appearance scheduled every days Continued urinalysis testing as ordered Maintain stable housing Maintain stable employment or enrollment in school Completion of all court conditions Recommendation from treatment team that participant is ready to graduate Participant has gained insight into their addiction and able to manage their recovery

14 Phase 4 -SELF-SUFFICIENCY In order for participant to graduate from Drug Court, participant must remain sanction-free and drug-free for four consecutive months while in self-sufficiency phase. Treatment team must be in agreement that participant has successfully completed all requirements and is maintaining a life conducive to his/her recovery.

15 The ASAM Criteria Multidimensional Assessment 1. Acute Intoxication and/or Withdrawal Potential 2. Biomedical conditions and complications 3. Emotional/Behavioral/Cognitive conditions and complications 4. Readiness to change 5. Relapse/Continued Use/Continued Problem potential 6. Recovery Environment The ASAM Criteria pp

16 Another Example of a Phases Protocol The phases for participants identified in Track 1: High Risk/ High Need are highly structured and last minimum of twelve (12) months; length of time varies depending upon individual progress. Each phase consists of specific requirements for transition into next phase This example illustrates an attempt to increase wording to promote individualized treatment adherence, change and functional milestones (highlighted in yellow italics) not just compliance. Needs improvement - work in progress Compliance language still embedded and highlighted in yellow

17 Phase 1: Orientation Objectives Intake, Needs assessment, and Orientation; Establish abstinence and substance disorder/addiction treatment; Formulate a treatment case plan with treatment provider and identify personal goals. Length of Phase Minimum of two (2) months or earlier, in collaboration with treatment provider, if functional change achieved

18 Requirements Phase 1: Orientation Complete screening and assessment with Drug Court representative Placement in a community based treatment program. Participation in formulating an individualized (based on the priorities and needs in the six ASAM Criteria assessment dimensions). treatment plan with provider. Identification of treatment goals in conjunction with treatment plan Abstain from alcohol and illicit drugs as well as unapproved over the counter medications.

19 Requirements Phase 1: Orientation (cont.) Attend court hearings on a bi-weekly basis for the first 30 days and monthly thereafter, unless the Court deems more frequent contact is warranted. Attend all scheduled appointments related to program. Begin development of meaningful (Dim. 6, Recovery Environment e.g., AA/NA; church or synagogue; faith or cultural community etc.) support network which participant will be invested (Dim. 4, Readiness to Change e.g., Preparation and Action stage of change) in and utilize (Dim. 6 e.g., actual attendance with ability to related people with whom s/he identifies; names and numbers; home group etc.)

20 Residential Phase 1: Orientation If participant meets criteria for inpatient treatment, all internal requirements of treatment program must be met. Random testing as deemed necessary by treatment provider. While in residential, defendant need only report to Court one time per month unless problem behavior occurs. It is recommended inpatient treatment should be min. of 90 days or earlier if treatment provider verifies stable progress and improvement such that participant can safely transfer to less intensive treatment.

21 Outpatient Phase 1: Orientation Participate in group therapy minimum of 3 times per week; participate in individual therapy minimum of once per week or as deemed necessary by the provider (based on demonstrated functional improvement in treatment plan progress). Submit to random urinalysis testing as ordered by Court (if there is not a random system set up, participant must submit to testing three times per week to include alcohol testing with one of the alcohol tests consisting of random ETG test).

22 Advancement In-Patient Advancement to Phase 2 is once discharged from treatment or when permitted by treatment to leave the facility for job search. Out-Patient Negative drug tests for 30 consecutive days Consistent attendance at program; actively and meaningfully (Dim. 4, Readiness to Change e.g., participant knows their treatment plan and is doing it) participating in substance use disorder/addiction treatment with no unexcused absences for 30 days Completion of any sanctions imposed for lack of meaningful, good faith participation in treatment during Phase 1.

23 Phase 2: Change Objectives Obtain tools to live drug-free lifestyle, demonstrating functional improvement in problems that threaten public safety or increase legal recidivism and crime. Actively address issues related to personal and family needs and develop strategies to meet those needs. Participant is encouraged to involve his/her family in the process. Identification of treatment barriers. Length of Phase Minimum of three (3) months or earlier, in collaboration with treatment provider, if functional change achieved

24 Requirements Phase 2: Change Follow and update treatment plan with provider. Abstain from alcohol and illicit drugs as well as unapproved over the counter medications. Attend court hearings on a monthly basis or as ordered by Court Keep all appointments related to program. Identification of support group and attend 12-Step or other support group in collaboration with treatment provider who assesses that this is part of the individualized treatment plan (Dim. 6, Recovery Environment). Involvement of family/support system in treatment to include family therapy as deemed necessary by the provider and family psychoeducational groups, as needed and if feasible. Continue to develop a prosocial support network. Sign up for evidenced-based parenting classes if referred by Court.

25 Phase 2: Change Residential If treatment provider feels participant is ready (based on demonstrated functional improvement in treatment plan progress) to be stepped down into a lower level of care, a discharge plan must be completed and presented to the Court. Participant must attend 90 meetings in 90 days upon discharge from residential, and obtain a sponsor; or an equivalently effective recovery support system as agreed upon between the court, participant and treatment provider. (Dim.6) Outpatient Participate in group therapy minimum of twice per week; participate in individual therapy weekly or as deemed necessary by the treatment provider (based on demonstrated treatment plan progress). Submit to random urinalysis testing as ordered by Court (if there is not random system set up, participant must submit to testing 3 times/wk to include alcohol testing with 1 of tests consisting of random ETG).

26 Advancement In-Patient Participant may not advance beyond Phase 1 or Phase 2 while in residential treatment. Participant will be monitored for minimum of six (6) months following residential treatment or longer, in collaboration with treatment provider, if lack of functional improvement and treatment progress warrant Out-Patient Negative drug tests for 60 consecutive days Consistent attendance and demonstrating functional improvement in problems that threatened public safety or increase legal recidivism and crime with no unexcused absences from services for 60 days Must be engaged in recovery network, such as 12-step NA/AA Adherence with individualized treatment plan and demonstrating functional improvement; Beginning to internalize a sober lifestyle Completion of any sanction imposed for lack of meaningful, good faith participation in treatment during Phase 2.

27 Phase 3: Challenge Objectives Focus on relapse prevention and identification of coping strategies. Continue involvement of support system in recovery process. Reintegration into the community with evidence that the participant has developed prosocial peer and leisure activities. Length of Phase Minimum of four (4) months OR earlier if the treatment provider verifies stable progress and improvement such that the participant can safely transfer to less intensive treatment AND the participant has completed all phase advancement requirements in this phase.

28 Requirements Phase 3: Challenge Follow and update treatment plan with provider. Abstain from alcohol and illicit drugs as well as unapproved over the counter medications. Attend court hearings every days or as ordered by the court. Keep all scheduled appointments related to the program. Obtain or maintain employment or enrollment in educational program unless this requirement is waived by the Court. Identification of support group: attend 12-Step or other support group in collaboration with treatment provider who assesses that this is part of the individualized treatment plan (Assess Dim.6). Submit to random urinalysis testing as ordered by the Court (if there is not a random system set up, participant must submit to testing three times per week- to include alcohol testing.)

29 Advancement Negative drug tests for consecutive 90 days within Phase 3. Consistent attendance and demonstrating functional improvement in problems that threatened public safety or increased legal recidivism and crime (review all six ASAM Criteria dimensions e.g, Dim. 2, chronic pain; Dim. 3 COD or impulsivity; Dim. 4 stage of change; Dim.5 coping skills to not use; Dim. 6 friends, family, work, $$), with no unexcused absences for 60 days. Must have a sponsor or continue to be engaged in a meaningful support network (Dim. 6). Employed and /or meeting educational goals unless this requirement was waived by the Court. Adherence with individualized treatment plan. Completion of any sanction imposed during Phase 3.

30 Residential Advancement These participants should continue to actively and meaningfully participate in group therapy sessions a minimum of twice per week and individual therapy at least twice per month or as deemed necessary by provider. If participant was previously in residential treatment, he/she may still be attending daily NA/AA meetings (90/90). These participants should be actively and meaningfully working the Steps; or an equivalently effective recovery support system as agreed upon between the court, participant and treatment provider. Out-Patient Participate actively and meaningfully in group therapy a minimum of once per week and in individual therapy twice per month or as deemed necessary by provider.

31 Phase 4: Self-sufficiency Objectives Practice coping skills necessary and demonstrate ability to incorporate them into daily living. Length of Phase Minimum of three (3) months or longer, in collaboration with treatment provider, if lack of functional improvement and treatment progress warrant

32 Requirements Phase 4: Self-sufficiency Follow and update treatment plan with provider. Abstain from alcohol & illicit drugs as well as unapproved over the counter medications. Attend court appearances every days. Submit to random urinalysis testing as ordered by Court (if there is not random system set up, participant must submit to testing 3 times/week- to include alcohol testing with one of alcohol tests consisting of an ETG test). Keep all scheduled appointments to the program. Attend 12-Step or other support groups in collaboration with treatment provider who assesses that this is part of the individualized treatment plan. Be actively engaged in 12-step work with a sponsor; or an equivalently effective recovery support system as agreed upon between the court, participant and treatment provider. Have continued active and meaningful involvement in an aftercare program. Participate actively and meaningfully in group and or individual therapy once per month or as deemed necessary by the treatment provider.

33 Graduation Negative drug tests for consecutive 90 days within Phase 3. Consistent attendance and demonstrating functional improvement in problems that threatened public safety or increased legal recidivism and crime, with no unexcused absences for 60 days. Must have sponsor or continue to be engaged in a meaningful support network. Employed and /or meeting educational goals unless this requirement was waived by the Court. Adherence with individualized treatment plan. Completion of any sanction imposed during Phase 3.

34 From Punishment to Lasting Change Implications for Sanctions and Incentives 1. Sanction for lack of good faith effort and adherence in treatment not for signs and symptoms of their addiction and/or mental illness. 2. Treatment provider responsible to keep court apprised of any risk to public safety, not just passive compliance with attendance and positive or negative drug screens.

35 From Punishment to Lasting Change Implications for Sanctions and Incentives 3. If client is not changing their treatment plan in positive direction client is doing time not doing treatment and change. 4. Incentives for clients can be explored/matched to what is most meaningful to them. 5. A close working relationship between client, judge, court team and treatment providers needed to actualize this approach.

37 w w w. c h a n g e 37 c o m p a n i e s. n e t

David Mee-Lee, M.D. Senior Vice President The Change Companies Carson City, NV www.changecompanies.net www.asamcriteria.org www.tipsntopics.com davidmeelee@gmail.

38 David Mee-Lee, M.D. Senior Vice President The Change Companies Carson City, NV These materials have been prepared under the auspices of the Bureau of Justice Assistance (BJA) Drug Courts Technical Assistance Project at American University, Washington, D.C. This project was supported by Grant No DC-BX-K005 awarded to American University by the Bureau of Justice Assistance. The Bureau of Justice Assistance is a component of the Office of Justice Programs, which also includes the Bureau of Justice Statistics, the National Institute of Justice, the Office of Juvenile Justice and Delinquency Prevention, and the Office for Victims of Crime. Points of view or opinions in this document are those of the authors and do not represent the official position or policies of the U.S. Department of Justice.

The New ASAM Criteria: Implications for Drug Courts

The New ASAM Criteria: Implications for Drug Courts NADCP 21 st Annual Training Conference July 29, 2015 Washington, DC David Mee-Lee, M.D. Chief Editor, The ASAM Criteria Senior Vice President The Change