Critical Treatment Issues Webinar – Session 1

Critical Treatment Issues Webinar – Session 1


CAROLINE: [INAUDIBLE] to
the first of our 12 session treatment series
interactive webinar that is being sponsored by the
Bureau of Justice Assistance Drug Court Technical Assistance
Project at American University. I want to welcome
you to the session, and thank you so much
to David Mee-Lee, who will be the presenter. This session is
going to address what to expect from state
of the art addiction treatment for criminal
justice populations in applying the
new ASAM criteria. We’ve organized the
sessions for these series in a little different from the
way we’ve done it in the past. Most of the 12 sessions
will be two segments, where we’ll have the first
segment like today spending about 45 minutes to
address the key principles and issues and 15 minutes
for questions and answers. And then a follow up session,
which will be in this case tomorrow, to address additional
questions that you may have. So we encourage you to
send in your questions through the Q&A line on the
website, as well as follow up. You will get an evaluation
form after the session and indicate any other
questions you have, and then we’ll try to
address those tomorrow. And you do need a
separate registration to register for the
session tomorrow, which was in the original
email that was sent out for this registration. If you need it, if you don’t
have it, just let us know. I just want to thank
everybody for joining. We have a great array of people. We have over 250
people participating– judges, treatment providers,
probation officers, a whole array of treatment
and court personnel. We have people from 46 states
and Alberta, Nova Scotia, and Ontario, Canada. So I wanted to thank
everyone for participating. I also wanted to mention that
our series with David Mee-Lee is going to be I think
about nine specific topics, and then interspersed with that
three additional sessions that will address applications– case
studies, clinical case studies, that illustrate the principles
that are being addressed. So in addition to
sending questions, we hope that you will
send some challenging cases in that we
can then discuss in these different segments. And if we can do that
through the quick Q&A, we will, but we wanted to
have some challenging cases that you all are
encountering that we can get the benefit of Dr.
Mee-Lee and others’ sessions. So without anything
further, I’m going to turn it over to Dr. Mee-Lee. Thank you. DAVID MEE-LEE: All right. Thank you very much. Thank you, Caroline. Just to let people
know about who I am, and I appreciate the
opportunity of doing this. I am a board certified
psychiatrist and certified by the American Board
of Addiction Medicine, so that I’ve been involved in
my career in both mental health and addiction treatment. And in the context of
this, I am the chief editor of The ASAM Criteria. So I have been with
the ASAM criteria since its beginning of
the first edition being published in 1991 and the latest
and current edition in 2013. Some of the work I do is
with the change companies. And I’m based in
Davis, California. Just to give you
the context of ASAM, which is the American Society
of Addiction Medicine– pronounced “ay-sam,”
not “ass-am”– some people think it’s
a pain in the “ass-am,” but ASAM is an organization of
about 3,000 plus physicians who are interested in helping
with addiction treatment. And as founded, as you can
see, in 1954, but now currently called the American Society
of Addiction Medicine. And for your information,
if you are not a physician, you can be an associate member. So if you are wanting to
be more involved with ASAM, there is a way, even if
you’re not a physician. I want to start off
though with just getting on the same page about what
is addiction and addiction as a brain disease. Because you hear
a lot about this, but there are implications of
thinking about it as a brain disease. And this is really– we’re going
to get too technical with you, but you’ve probably
all seen these pictures before of the brain
reward system involving the ventral tegmental area
and the nucleus accumbens and the frontal cortex. And this reward system, where
somebody takes methamphetamine, you can see the
neurotransmitter of dopamine that there’s a spike
of dopamine rush. And then it starts falling off. And the same thing
with cocaine, which is why you get a quick
high and then it falls off. We’re not going to go
too much into that. But just to remind us about
neurotransmitters and the brain reward system and addiction
as a brain disease. And this is one of
those brain scans where you can see in the healthy
brain, there’s activity, the darker red there. But when a person’s been
using cocaine in this example and depleting their dopamine
stores, you get less activity. And that affects the function
of all of the brain systems. ASAM in 2011 provided a new
definition of addiction. And there’s much more
detail than this, but “addiction is a
primary chronic disease of brain reward, motivation,
memory and related circuitry.” So again, emphasizing
the brain reward system, where using drugs activates
the dopamine system. And when you get dysfunction
in these circuits, then that’s where you see
the typical characteristics of biological and
medical problems and physical health problems,
psychological and psychiatric difficulties, social problems
like legal difficulties, money, family, relationships,
all of those social and environmental impacts. And then certainly the
spiritual manifestations of addiction, where it really
looks at people’s values and demoralization and so forth. Another aspect then
of ASAM’s definition is that people with
addiction are pathologically pursuing reward of
that reward system by using drugs or relief
from pain by using substances and other addictive behaviors. So we know in DSM-5
now, the latest edition of the Diagnostic
and Statistical Manual, the addiction
chapter is called substance-related and
addictive disorders, with the one
behavioral addiction that’s currently
recognized by the APA being gambling disorder. Although there’s
future work being done on another
addictive behavior, internet gaming disorders. So that may well come
up in the future. But the point is that addiction
is about brains, not just about behaviors. It’s certainly about behaviors. But when we think
in criminal justice, we’re focused more on behaviors
and criminal activity, legal recidivism, and
so it’s understandable that the public and
criminal justice systems are focused on
behavioral problems. But it’s important– and we’ll
talk about the implications of this– to recognize that it isn’t
just about behaviors. It’s also about
neurotransmitters and a brain disorder, which has
implications for to what degree we hold
people accountable for those behaviors. Holding them accountable for
their behavior [INAUDIBLE],, but then how do we address
that if we think they have the disease of addiction? This is the current
edition of The ASAM Criteria, 465 hardcover book. And we’ll give you some
information later on how you can learn more about that. What we’re trying to do with
The ASAM Criteria is really to move the whole treatment
field and everybody involved as important stakeholders in
people who have addiction– and that, of course,
is criminal justice, child protective services,
employers, family members, the public– helping everybody to understand
addiction treatment as really being an individualized
clinically and outcomes driven process. Where we’re moving away from
placing people into programs, especially for fixed
length of stay, which has been the tradition
often in addiction treatment, and is often the tradition
in criminal justice, where we place people
into a program for a fixed amount of time, thinking
that that will then result in a great outcome. And predominantly in many areas
still, addiction treatment is thought of by the public and
by criminal justice personnel and by even treatment providers
as somebody going off to rehab and completing a program. And The ASAM Criteria,
right from its beginning, has really taken the approach of
addiction as a chronic disease, potentially
relapsing, which needs to have a continuum of
care, and where treatment is based on an
assessment of a person’s biopsychosocial aspects,
where somebody is looking then at what are the problems and
priorities within this person in an individualized
assessment approach looking at this particular person
severity of the illness and level of function
and then matching that to the right
intensity of services. What modalities does a person
need in their treatment plan? By modalities, we’re talking
about different strategies from different
schools of thought. So cognitive
behavioral modalities, medication modalities,
individual therapy treatment, group therapy, family
treatment, DBT, MET, all of these evidence-based
practices that you hear about. What are we going to do for a
person in their treatment plan? And then what level of
service can we safely provide that level of treatment? And then to track their
outcome and progress– are they getting better? What’s their new severity of
illness and level of function? If they’re not
getting better, what do we assess as the
problem, and how do we change the treatment plan? If they are getting
better, and they’re making good progress
and a good outcome, what do we assess needs to be
done next in the treatment plan to help move them through
chronic disease management and through to recovery? So this individualized
treatment approach is what you should be
expecting to see instead of the [INAUDIBLE]
addiction treatment. And what criminal justice
and court personnel should be expecting
of people, not to plug a person into a
program, but expecting them to do
individualized treatment, based on a look at these
six assessment dimensions. And these six dimensions are
what drive The ASAM Criteria process and that define
the kinds of severities and functioning that best are
treated in what level of care. So very quickly, the first
dimension, acute intoxication and/or withdraw
potential, has to do with to what degree does
this person need withdrawal management services. And we don’t have time
now to go into it, but actually this is
an important dimension across all aspects
of health care. Because emergency
rooms should be thinking about this dimension. Surgeons should be
thinking about it. Mental health people should
be thinking about this. When we see somebody on the
street acting strangely, we should be thinking
first, could this be acute intoxication? Is this a person
who may be impaired, and that’s why they’re driving
recklessly or erratically? So actually, all people should
be trying to think about, is this contributing to
this behavior problem that we’re seeing? But in a clinical
treatment sense, dimension one is
about looking at what does this person need in terms
of withdrawal management? What does this person
need in dimension two around physical health services? So diabetes,
hypertension, asthma, HIV. What does a person
need in dimension three around mental health services? Do they have mood
swings because they have an actual co-occurring
addiction and bipolar disorder, or are they having mood
swings because they’re using uppers and downers? So dimension one, withdrawal
management services. Dimension two, physical
health services. Dimension three,
mental health services. Dimension four, motivational
enhancement services. Because we know from
stages of change work that not everybody is
ready to embrace recovery from day one. And that treatment may need
to be education, risk advice, and attracting people
into a change process. It would be wonderful if
we could mandate everybody to be perfectly
abstinent, perfectly non-psychotic, perfectly
non-anger, perfectly drug free. But the fact is that if a person
has the disease of addiction, it’s an essential
part of that illness to often have ambivalence
about whether you even have the illness
and whether you’re ready to make the
changes necessary to get a good outcome. Dimension five is looking at
relapse prevention services, although you can’t have a
relapse unless you first thought you had a
problem, wanted to stop, did stop, got into recovery,
from which you relapsed. So many of the people
that we send to treatment from the criminal
justice situation are not really even ready for
relapse prevention services from day one because
they may not even think they have a
problem of addiction to even be concerned
about relapse. Of course, they think
they have a problem. They think they have a judge
problem or a probation officer problem or a spouse problem. But they don’t think they
have an addiction problem. So in that case, we
have to work with them first on how you’re going to not
continue to use so that you get arrested again, how you’re
going to deal with continued problems of psychosis or
mood swings or depression or suicidality so that
it doesn’t blow up. So this is an
important dimension in making sure we
keep people safe, and also help them to,
once they are in recovery, prevent relapse. And then dimension six is
looking at, where do they live? Who do they live with? What are their
friends and family? What are their legal problems,
money problems, transportation, child care. So you can see that this
is a holistic assessment because it’s important
to identify these needs. Now, very quickly,
and when we’re aware of the
criminogenic factors, there is an overlap between
what we look at in terms of antisocial values. This can have implications for
dimension three, mental health issues. Can have implications
for readiness to change and attitudes about changing. Can have implications
for dimension six. Who are their friends? Who are they hanging out with? What are their cultural values? And the same with criminal
deviant peer associations. That would be
recovery environment. Substance abuse would be
involved with intoxication withdrawal and can be involved
in other dimensions as well. And then, of course, the
family relationships clearly is related to dimension six. We’re sort of seeing
the cross-walk there between
criminogenic factors and what we should
be assessing instead of the multi-dimensional
assessment. And then once we’ve
done an assessment, we have to plan treatment. And a good treatment
program is going to want to be able to deal with
motivational issues, stages of change. Are they skilled at
motivational interviewing? Are they skilled at doing
stage determined interventions? If somebody is at an
early stage of willingness to change and doesn’t
think they have a problem, how are we going to do
a different treatment plan for that
person from somebody who is absolutely sure
they have a problem and never wants this
to happen again? It involves care management,
looking at the needs in all six dimensions. It may involve medication
for dimension one, for withdrawal, or what you
often think of as detox. But in the new edition
of the criteria, we refer to
withdrawal management because we need to manage
people’s withdrawal, not just make sure they don’t
die from a withdrawal seizure. We may need medication for
their physical health problems– diabetes, asthma, hypertension. For their mental
health problems– psychotropic medication,
antidepressants, anti-psychotics,
anti-manic medication. And we may need
medication assisted treatment for relapse issues
in addiction treatment. So that again,
remembering that addiction is a brain disease, that
if we have medications that can affect those
neurotransmitters, we can do a lot to help
people with craving, with relapse prevention, to help
people with withdrawal as well. And medications then are
not an issue of philosophy. They’re an issue of treating
the bio aspects of this brain disease if necessary. Not everybody needs
medication, but if necessary to
get a good outcome, we shouldn’t be
excluding that because of some philosophical issues. Meetings– I’m talking
about self help, mutual help meetings for dimension two,
for people’s diabetes support groups, their cancer
survivor group. For dimension three, for
their Dual Recovery Anonymous, Double Trouble in Recovery. What we’re trying to do
with Emotions Anonymous, Schizophrenia Anonymous, for
their mental health issues. And then when we think about
dimensions four, five, and six, we’re trying to help a person– if we send them to AA or
NA or SMART Recovery– develop that support system
that will provide them with ready access to
people who can nurture them through recovery. And then we have to monitor all
this because severity changes in these dimensions. Not everybody walks lock step
through a change process. So that we can change
the treatment plan based on the outcome
and the progress. Then we have to
do this somewhere. So a good treatment
program is going to not have just one level of care. They’re going to have
a continuum of care. And these are the broad levels
within The ASAM Criteria. Outpatient treatment,
intensive outpatient and partial hospital, the
residential and inpatient levels, and then the most
intensive and expensive hospital type level of
care, medically-managed intensive inpatient treatment. And this is just to
emphasize, again, that if we think of addiction
as a chronic brain disease that needs a continuum
of care, that when we send somebody for treatment– and if a court is
gracious enough to give the person a chance
at treatment believing that treatment of
their addiction may in fact reach
the goals we all want of increased public safety
and decreased legal recidivism and crime– that we think this
person is performing illegal behaviors because
of an addiction illness, well then we have to give
them a chance at treatment. And to recognize that The
ASAM Criteria talks not just about one level of
care– residential– but a whole range of levels. And I’m going to very
quickly breeze through these to give you a sense about what
the levels are, because you often think of–
or the public often thinks of treatment– as
going off to rehab for 28 days or three months or six months. And they think of that as going
off to a residential program. But really, state of the
art addiction treatment is really focused on a
whole continuum of care. Early intervention, 0.5, is
for people who do not have yet the disease of addiction. So this would be somebody who
gets their first DUI, impaired driving. They may be arrested for an
adolescent minor possession, something drug related, but
not necessarily because they have the disease of addiction. They’re going to need early
intervention services, like education, risk
advice, and the hope of making sure they don’t move
into an addiction illness. For people who have
opioid use disorder, we have a whole section on
opioid treatment services, where we talk about
the importance of methadone, antagonist
medication like naltrexone, which you may know of as
injectable extended release naltrexone, the
trade name Vivitrol. And buprenorphine, which
is an agonist medication, but does the same sort of
thing as the neurotransmitters. And buprenorphine
combined with naloxone you may know as the
trade name suboxone. That’s just one
of the medications in addiction treatment. There, of course,
are medications for alcohol use disorder and for
nicotine use disorder as well. Very quickly, just to make you
aware that for detoxification, that we call now withdrawal
management in the new addition, there are five levels of
withdrawal management, from ambulatory levels
to residential levels to more medically and
nursing care levels. So that when we think about
detox or withdrawal management, which is what we want
to be naming it now, we are really talking
about a continuum of care and not just putting someone
into a hospital for three days and then discharging them,
wondering why they use again within a week. Because we haven’t actually
managed their withdrawal. We just made them– made sure they didn’t die
from a withdrawal seizure, but that’s not
managing withdrawal. That’s just making sure they
don’t die from withdrawal. In the level of care for
outpatient treatment, we have level 1, which is less
than nine hours of service a week for adults and less
than six hours of service a week for adolescents. And of course, there’s
much more detail on this in the actual
ASAM Criteria book. The level twos are 2.1,
intensive outpatient, which is nine hours or more
for adults or six hours or more for adolescents, and
2.5, partial hospital, which is 20 hours
of service a week or more for adults
and for adolescents. The residential
levels are made up of 3.1, which is clinically
managed low intensity treatment, meaning 24
hour living support where a person may not need 24 hour
treatment because they’re not in imminent danger, like in
the other level 3’s, but where you don’t want them
living back on the street. You don’t want them being with
negative influence in terms of their recovery environment,
where they may not have enough skills to
manage cravings to use, but they don’t need
24 hour treatment. So this is 24 hour
living support, which is often overlapped
with some intensity of clinical services. This is a special
level, 3.3, which has to do with people with
cognitive difficulties. Traumatic brain injury,
they may have specific needs for a slower pace of treatment
or more individualized treatment because
they can’t cognitively address all of the issues. So this is a very
specific population of residential treatment. But they’re still in
some imminent danger. That’s why they need to be in
a 24 hour treatment setting. Residential treatment,
3.5, is, again, 24 hour treatment,
meaning, by ASAM Criteria, that if you are there, you
are in some imminent danger that if you are not
in 24 hour treatment. So if you put somebody
in a residential program, and then they go to
a pass to the mall, or you give them a pass
to go home for a day, by ASAM Criteria, that would
not be residential treatment. That would be more like a
supportive living environment, perhaps 3.1, with some
intensity of clinical services. When we’re talking about
residential treatment in The ASAM Criteria,
we’re really talking about people who
have been up there, have very impulsivity around drinking and
drugging or using or hurting themselves. They may have great difficulty
in controlling impulses, and that if they’re not
in a 24 hour setting, they could be some
public danger. So this is a necessary
level, but people normally, by ASAM Criteria, wouldn’t
be there for weeks and months and even a year. That would be more some living
support plus clinical services. If they have
medical issues, they may need 24 hour nursing,
with a doctor available to see them as necessary. And if they’re very
unstable physically and mentally and
psychiatrically, they may need a
hospital level of care with 24 hour nurses and doctors
available whenever needed. So that is a very quick
overview of the levels of care. And I wouldn’t expect you
to remember all those. But I do want to
emphasize the point, that when we’re thinking about
state of the art addiction treatment by ASAM
Criteria, we’re not thinking about
one level of care for one fixed length of stay. And when we’re talking about
criminal justice populations, this is where we run
into some difficulty, because we are often used
to mandating somebody to a level of care and
a particular of stay, when really what we want
to mandate somebody to is assessment and
treatment adherence. In other words, what
level of care you go into and how long you stay
in that level of care and how you move through
the continuum of care depends on your own
individualized assessment and how you’re doing
in terms of outcome. Are you really
developing the kinds of skills that a
treatment provider can say to the core team personnel,
this person is changing, such that we believe that they
are incorporating the skills and the lasting
change process that is going to increase
public safety and decrease legal
recidivism and crime and safety for the
children and families? If a state of the art
treatment provider can’t give you the
information that is helping you to understand
that their client is actually changing, then those
are the hard questions we want to ask of
treatment providers. And in reverse,
treatment providers have to be asking the court
to please mandate assessment and treatment adherence, not
a particular level of care and a particular length of stay,
because how long this person stays in this level
of care depends on their needs
and their progress and whether they are
actually changing to reach the outcomes that we all want. Let me pause here
and see, Caroline, if there’s any
questions or things that need to be clarified before
I go on to the next section of bringing this all together. CAROLINE: No, there are
no questions so far. But please, everyone, feel
free to send your questions in, and then we can send
them to Dr. Mee-Lee. DAVID MEE-LEE: Good. And, again, if it’s
not specifically on exactly what I’ve said,
please raise any questions. My goal here is to help you
to get a sense about what good treatment
should be and how do we start opening up the
conversation between each other about that. Now, to try to
pull this together, it then starts off with,
what does the client want? And in the session
that we’re going to be doing on Monday,
March 14, we’re going to be talking about doing
treatment or doing time, moving beyond program phases
to real, lasting change. Because what we’re
really trying to do in addiction treatment
that is mandated for people who have addiction is to really
make sure they actually change. And so it starts off with,
what does the client want? Why is this important? Well, because we want to
engage them in the self change process. We want them to enter
that treatment program not because they are just doing
what somebody else wants them to do, but to help them
to identify why they chose to enter the program. Now, many of them may say, well,
I didn’t choose the program. They made me come. Well actually, they did
choose and give permission to enter the program. And they actually
do want something. Otherwise they
wouldn’t have gone. Now what they may want
is to get off probation or to complete drug court or
some other specialty court, or to get their children
back or to end up getting a job or housing or whatever. But the first step is
to engage that person around taking some
responsibility for why they chose to go into treatment. And we’ll go much
more into this when we talk about stages
of change and when we talk about doing time,
not doing treatment, not doing time. But I do want to make sure that
under dimension four, readiness to change, we’re really
trying to look at, what is that person action for? And that may not be. And for many
clients, it isn’t, be it action for
abstinence or sobriety or for wellness or for recovery. That’s all right. Instead, [INAUDIBLE]
addiction treatment, we take people where they’re
at, not where we think they should be at, and
then move from that point to attract them into recovery. The next step we have to do
then is to use The ASAM Criteria dimensions to quickly
run through and make sure that the client doesn’t
have any immediate needs, to make sure that they’re safe. So that if, for example,
somebody has just stopped using alcohol or
some other drug that’s going to send them
into severe withdrawal, even to the point of
seizures, well then we would want to
identify in dimension one, acute intoxication
withdrawal, the fact that this is somebody who has
an immediate need, that we have to make sure they actually get
into some withdrawal management level to make sure they’re safe. Or if they, on dimension
three, emotional, behavioral, cognitive conditions and
complications or suicidal, we would want to make sure
that we took care of that. So wherever a person comes
in, you may remember sometimes that people have been
jailed, and then they’ve been found hanging themselves or
some sort of suicidal behavior because they may
have been jailed when they were intoxicated. And then once they sort of
detox as it were in jail, start feeling shameful and
depressed and even suicidal, that then something bad happens. We have to assess then
these important dimensions to make sure there isn’t
some immediate need. Of course, on dimension two,
the biomedical conditions and complications, if somebody
has an acute problem with they can’t breathe– and we’ve seen criminal
justice situations where somebody died on
their way to the jail because they had an
immediate need in terms of physical health problems. So certainly in those
first three dimensions, we’re looking at imminent
risk in terms of life threatening problems. In the dimensions
four, five, and six, we’re looking at imminent
needs in terms of readiness to change. If somebody doesn’t think
they have a problem, or if somebody hasn’t got
a clue about how not to use is going to get themselves
into a dangerous situation, or if somebody is
living in an environment where they’re going to
freeze to death tonight, that would be an immediate
need in terms of dimension six, recovery environment. So again, we use those six
dimensions to run through and to look at, what
are the immediate needs? We want to make sure
that they’re safe enough. If there are immediate needs,
of course, we take care of that. If there’s not, we go back
through the six dimensions to assess what we need to know
to make sure that they first have a diagnosis. And I’m referencing the
Diagnostic and Statistical Manual of the American
Psychiatric Association here, but you could use ICD-10,
International Classification of Diseases, to first
work out, does this person have a diagnosis? So if somebody does not have
a diagnosis of a substance use disorder, but has been
arrested for driving drunk, they will need some
kind of service, but that’s where they
would, in ASAM Criteria, get an early
intervention 0.5 service. That would be like your
typical impaired driving classes for somebody who
has a first time arrest. Now, it could be that
that person who’s in that impaired driving class
actually does have a substance use disorder. So that good state of the art
impaired driving providers should also be able to identify
who does have a diagnosis. It isn’t a matter of
just complying and going through x number of
sessions of education to meet the legal mandate that
they have to have some classes. A good provider of
impaired driving service is going to want to identify
which of these people, even if it’s just a
first time arrest, actually have the
disease of addiction, for which then just having
them complete an education class does not address
the real problem, which is why you see repeat offenders– first DUI, second
DUI, third DUI– because they just went through
the hoops of compliance with some legal mandate,
but didn’t actually get an intervention in the
disease of addiction. Something that we would never
do for any other illness. If somebody came in
with an asthma attack and had trouble breathing,
we wouldn’t just stabilize that and then
send them on their way without making sure they
have some ongoing help. And if you identify somebody
with an addiction diagnosis in a mandated impaired
driving class, and then we don’t do
anything to make sure that they get help for
their disease of addiction, then guess what? They’ll be back threatening the
public safety, not to mention the problem that
[INAUDIBLE] for that person in not getting treatment for
an illness that they have and that we should recognize. So diagnosis is an important
part of the process to identify, does this person
need just education risk advice, or does this person
need addiction treatment? And so if you mandate
somebody to treatment, a good program should be
verifying the diagnosis to make sure that
this person actually needs addiction treatment. If you have somebody
who’s been arrested for a drug-related
offenses dealing drugs, and they’re not
using their inventory for their own
addiction– they’re just a business person,
an entrepreneur gone bad doing illegal things–
that person doesn’t need addiction treatment. They need a criminal
justice consequence for breaking the law. But if that same person
who is dealing drugs is also using the drugs
because of their addiction, then that’s fine. They need addiction treatment. But this is the importance
of understanding, do they have a diagnosis? And then we go through
the six dimensions to look at a multi-dimensional
severity or level of function profile, trying to
understand, what are the priorities for
this particular person? Because in the assessment,
we’re trying to look at, do they have dimension one
problems, dimension two, three, four, five, six? Which of these dimensions
are most severe? And I say level of function
here because we’re not just looking at pathology. A good state of the
art program should be looking at strengths,
skills, and resources. How are they functioning well? What, when this person
wasn’t being arrested, when this person was not
in trouble with the law, when this person was working
and had good relationships, what was going well in their life
in these six dimensions? Oh, they weren’t using
on dimension one, and that was why they
were working well. They were in dimension
six, recovery environment, living with very positive
people and had good friends. That was why they weren’t
getting into trouble. Or this is a person
who on dimension two was running marathons. And then their physical
health was really looking out for physical health. This was when they
were functioning well. So we want to look at,
when have things gone well in these six dimensions? And a good treatment
program will be looking not just at
pathology in these areas, but what are their strengths,
skills, and resources? And then the focus then is to
once we’ve looked at those six dimensions to assess what are
their treatment priorities, because within each of
those dimensions where there is a higher severity,
we want to know what specifically are we going
to work on in their treatment plan. Are we going to
work on depression? Are we going to work
on cravings to use? Are we going to work on the
fact that they don’t even think they have an addiction problem? Are we going to work on
dimension six, the fact that they have friends who all
drink and drug and who are all involved in criminal activities? Are we going to look
at, on dimension three– emotional, behavioral,
cognitive– the fact that they have bipolar
disorder or trauma? So we’ve got to identify
in each dimension where there is some severity
what the focus and target is so that we can then make
sure that the treatment provider will provide the right
services for that problem, and that they provide
the right dose and intensity of those services. Not everybody needs
the same services for depression or
for cravings to use or for difficulty with anger. Some people will need specific
services to deal with that, and not everybody needs
the same dose of that. Just as it is in dimension one,
acute intoxication withdrawal. If somebody has a
withdrawal problem that needs detoxification and
withdrawal management services, if their withdrawal
is very severe, they’re going to need a big
dose of withdrawal management services– doctors,
nurses, IVs, and all that. Or it may be that they just
need a small dose, where they could quite safely
get that as an outpatient. Because that leads
them to the next aspect of where can these
services be provided in the least intensive
and safe level of care? Now, we say least
intensive because we want to be good
stewards of resources. There’s only limited
amount of money. And we want to make
sure that we don’t put a person into a more
intensive and expensive level of care than they need. That’s wasteful of resources. And what can often happen
is that the person then is in a level that is more
intensive than they need, and they disrupt the
treatment milieu. They end up just leveling
off and being passive and just sitting there and
not really being challenged. We don’t want to put them in
a less intensive unsafe level of care than they need
because then they get sicker or they get more impulsive. We want them to be in
the right level of care. And this is what we do
across all of health care. Not everybody starts
their treatment for depression or diabetes
or bipolar disorder or schizophrenia in an
inpatient level of care. We want to start them at
whatever level of care they need and then
move them through. And as they progress
in treatment, we want to look at
what is their outcome. Are they progressing
because they’re doing well? And then what level of
care could they be in? Are they not progressing well,
and they’re just sitting there and not really changing? And what do we have to do then
to really review and go back to the process? So pulling that all together,
if somebody is not doing well, we want to go back and say,
did we miss a diagnosis? Did we miss [INAUDIBLE] trauma,
their PTSD, that’s going along with their addiction? Or do they not even have
an addiction diagnosis? And so we have them in
the wrong level of care. They should be getting
early intervention services. Or they may not be
progressing and doing well because their severity of
their dimensions has changed. Something has gotten
worse, or something we missed when we went through. So this is why these
feedback loops are here, to say let’s go back through
what’s going wrong to identify, has something changed in
one of the dimensions? Now, we’ve been working
on relapse prevention on dimension five, when
actually dimension four needed to be dealt with, because
they don’t even think they have a severe problem. And then are they not
doing well because we need to change the focus
of what we’re working on? Or we’re working on the
right focus and target, but the services
need to be tweaked? Or we have the right
services, but we don’t have the right
dose of those services? And that’s going to
impact what level of care we put a person into. So this is a dynamic
process, not where somebody comes into a program
and graduates at a certain amount of time,
as if everybody walks lock step through a change process. That’s not how change happens. That’s not how we’re going to
get the outcomes that we want in terms of increased
public safety and decreased legal recidivism and crime
and safety for children and families. It has to be an individualized,
outcomes driven, assessment-based process,
where the treatment is changing all the time. So what court personnel should
expect from treatment providers is a clear
articulation about what our assessment has found as
being an important priority to go into. And the court doesn’t
have to necessarily know every specific gory detail. You have to take into
account confidentiality. But the court should
expect to hear not just somebody is in a
program and showing up, but are they actually
changing, and are the outcomes actually moving in
a direction that we can expect them to have
better behavior in the public and to have better behavior
in terms of criminal activity. And if the treatment provider
can’t articulate what they’re working on in an
individualized treatment plan, or more importantly, if
the client can’t articulate what they’re working on–
individualized treatment plan, then something’s
gone wrong in terms of individualized treatment. If the client just says, I just
have to be in this program, then they’re just drifting
through a program. They’re not actually in a
treatment change process. And what treatment
providers can hopefully expect from court
personnel is the mandate to do a good assessment
and then to engage that client in a change process
that’s going to be sustainable. And so that’s why
it’s important not to mandate a particular
level of care and a particular length of stay,
because it depends on progress and outcome, not depending on
just doing a treatment program. All right. Let me pause there again and
see if there’s any questions. I don’t know if people are
not sure how to do that. You just type into
the Q&A area there. And we want to make sure
that we’re keeping up to date with any questions you have. CAROLINE: No, we have quite
a few questions, David. And I just want to say,
one of the common themes is that can people
get the PowerPoint? Yes, we’re going to send
the PowerPoint and the link for the archived webinar. So here’s a couple
of questions that I think are really
on point because we find this in our technical
assistance very, very frequent. First, can you
provide some examples of substantive
information evidence that treatment programs
can provide for the courts, for justice partners, to
demonstrate that a client is moving toward lasting change? DAVID MEE-LEE: Yes. So if we go back to
the six dimensions, you would want to
be able to hear from treatment providers
what is changing in each of these areas. So say, for example, they say
when Joe came in for treatment, he didn’t have any
withdrawal problems because he was incarcerated
just before he came, he was pretty
healthy physically, so we weren’t too
worried about that. We were concerned about his
emotional behavioral issues because he’s had a number
of angry outbursts, and he does have a
history of having been in a psychiatric hospital. And so we’re evaluating
this further. We haven’t seen yet any
outbursts that make us worried. But we are looking at once
he gets a little clearer, perhaps getting a
psychiatric evaluation because there’s a history of
trauma and some outbursts. In terms of readiness to
change, he’s basically here to get through drug court and
is ambivalent about whether he really has a problem,
whether he wants to change his [INAUDIBLE]. That’s why we’re working on
a motivational plan with him. And he is starting to
make some movements, saying that he may be in
fact have more of a problem than he thinks. And then in terms
of dimension five, he doesn’t really have
a clue about how he just thinks I’m going to stop, and
yet he’s said that many times and hasn’t been able to. And on dimension
six, he still has a lot of friends who we
want to work on helping him, once he sees the
importance of this, that he needs to
look at changing in terms of his friends. In other words, a
treatment provider should be able to say more
than, he’s just here attending groups, and be able to give
you a rundown of what’s working, what’s not working,
and what direction things are changing or not. CAROLINE: Thank you. And one of the things that we
find in many of our site visits is that often the
client does not have a copy of the treatment
plan, nor does the court. Is that something that’s
important for them to have, David? DAVID MEE-LEE: The
treatment plan, the person who should know
the treatment plan best, is the client. The counselor has many
clients in their caseload. It could be
understandable they might have to look at the chart. But if a person is in group,
and the counselor says, let’s go around and
each of you tell me what you want to get out of
group to advance your treatment plan, and the client looks
at you blankly and says, I just have to be here,
they’re not doing treatment. And we’ll talk some more
in later webinars on what a good treatment plan would be. But the bottom line is
that the client should know their treatment plan. This is what I’m working on. I don’t even think
I have a problem, or I think maybe
I have a problem. I’m working on gathering the
data to prove that I either don’t have a problem, or to
prove that I do have a problem. I’m ambivalent about
giving up these friends, but I can see how maybe
they get me into trouble. So I’m looking at how hard
would it be to give up friends. I’m looking at these
cravings to use. I’m still getting
cravings to use. I’m not sure what the– In other words, they should
know what they’re working on and what should be the
strategies that they’re trying to do And so
yes, the client should have a copy of their treatment
plan and know how to do it. So if a judge or
court personnel says, tell me about your
treatment plan, that would be a good
question to ask a client. If they say, well I’m
just in the program, something’s gone wrong. If you say, what are you working
on in your treatment plan, if they say something
generic, like well I’m just learning about my
disease or gaining insight, that tells you something about
the quality of the addiction treatment. If you say, tell me
about your treatment. What’s the thing that
you’re working on most now? And they say, well I’m not even
sure I have an anger problem, but I’m getting into trouble
with anger management. And in my treatment plan,
I’ve got to role play with somebody next group. And because I don’t think
I have an anger problem, I’m going to show the group how
to handle that without getting into a fist fight. Then you know you’re getting
some more specific kind of treatment. So whether the court has to have
a full copy of the treatment plan, that’s something
that can be worked out between the client and
the provider and the court as to how much detail you want. But what the court should
know is that real treatment is happening. And you can tell that
by to what degree the client and the
treatment provider can talk about the treatment
plan in an individualized way. CAROLINE: Thank you. And I know time is short,
but there’s two questions I think that are very apropos. One of them from Curtis Tindle– actually, both of from Curtis– is, it was my understanding
that the individual had to have a high level
of criminogenic score to be in a wellness court. And that does not sound like
it’s taking the participants where they are at. And I think this
kind of is a broader question about the focus
is on high risk, high need participants. Is there some indicator
that you would suggest indicates high risk, high need? Or is it taking all
these dimensions together and seeing how they’re moving
as a person progresses? DAVID MEE-LEE: Yeah. So when we talk about
high risk, high need and focusing resources into
that population for drug courts, that’s an example of trying to
be efficient with resources, and to focus resources on
the highest need people. So when we talk about
high risk, high need, we’re talking about
high risk, high need in terms of legal recidivism. So criminogenic factors,
my understanding is, has to do with high risk, high
need in terms of likelihood to re-offend. And there is some
overlap, as I pointed out. So when we’re thinking about
criminal justice and addiction treatment, it may be the ones
that we put the most intensive resources into being the
high risk, high need in terms of the risk of legal recidivism. But what I would
also say though, that if you have a
person with addiction, say you have a person in
addiction who doesn’t have all these criminogenic factors, but
has been arrested for a DUI, it would make sense to make sure
that person gets some addiction treatment– not necessarily
residential treatment– because they then recidiviate
and end up getting another DUI, as we see so often. So my argument would be,
if somebody actually has a disease of addiction
that we think results in criminal behavior
or offending, we need to give them
some sort of treatment. We may reserve our most
intensive resources for the high risk, high need
people that we can identify in terms of legal recidivism. That’s where criminogenic
factors come in. But we need the
continuum of care, I think, for anybody who
has an addiction problem who we think that causes
legal problems, if we think treatment
of that will then result in decreased legal recidivism. CAROLINE: Thank you. And one of the things
that we’re encouraging is to have multiple
tracks in drug court, so that it can be individualized
in terms of the resources that are needed. So here’s another question
from Curtis, which is related, another common question. We have a five phase
system for our program that each client
goes through, doing all the same requirements. But what I’m hearing is
that individually, a client may not need all five
phases, or may skip phases. So one client may use the entire
10 months and another six, which I’m so glad you raised
this question, because that’s something we hear all the time. Could you comment on
that, Dr. Mee-Lee? DAVID MEE-LEE: Yeah. So we’re going to go into more
detail on this in the March webinar as well, but if
you’re going to have phases, have the phases be linked
to functional improvement, not to jumping
through hoops or time. So you may want to
have phases as a way to know where is this person at. But to use those phases
so that a person can move from one phase to the
next or even skip phases if their function has
already been achieved, it’s a bit like if you’re
testing out of a course, they give you an exam first. And if you test out, that you
don’t need some of the classes, you don’t get those classes. And in a similar
way, if your phases are describing
levels of function, then it may be that somebody
comes into a situation further along than somebody else,
or somebody’s progress through those phases is not
as fast or maybe faster. So in general, phases
can be used correctly if they’re linked to function. But if they’re
linked to just time and jumping through
certain hoops of going to certain numbers of meetings
and so forth, or certain drug screens and whatnot,
then you’d have to look at whether the phases
are actually encouraging people to think of this as just
going through phases, rather than focusing on
accountable real change. So there is a way to
use phases in a way that can be individualized,
and there’s a way to use phases
that are counter to real sustainable change. And we’re going to address some
of that in the next webinar. CAROLINE: Yes, I
know that you’re going to address this
in the next session. We have one more, and then
we have other questions, but we will address these
tomorrow, as well as anything else that people submit. [? Marv ?] [? Levy ?]
asked, does Dr. Mee-Lee have any suggestions
of functional multi-dimensional assessment and/or risk
need screens that you could recommend? DAVID MEE-LEE: Well, when you
think about each of those six dimensions, there are
all sorts of instruments within those dimensions,
standardized instruments that can help you look at
readiness to change, look at craving scales, can
look at mental health stability, can look at physical
health stability. So depending– for
research studies, people get very
detailed about that. But you don’t
necessarily have to have a lot of standardized
instruments, even though they exist
for dimension one, for withdrawal severity,
and each of those dimensions have scales that you can do. But even if you
just look at that from a clinical point of view,
a good treatment provider should be able to tell
you whether things are changing in that. But they are recommended– I mean, there are
a whole variety of standardized measures for
each of those six dimensions. I wanted to point out
a couple of resources. Asamcriteria.org if you want
to know more about The ASAM Criteria, and there are
some e-training modules that you can also see at
asamcriteria.org as well, so that you can have a
chance to build knowledge on this if you wish. So we will, I hope, have more
of these questions tomorrow. Do you have a bunch still left? CAROLINE: Yes, we
have several that have been submitted that I think
we’ll take some time to answer. And I thank everybody
for sending them in, but please send more,
and we will then reconvene tomorrow for
those that you are free, and have a chance to interact
with Dr. Mee-Lee on some of these issues. I know it’s really bringing
a whole change of paradigm to many of the programs. So we really appreciate
so much, Dr. Mee-Lee, your working with us. So I think [INAUDIBLE]. DAVID MEE-LEE: Sure. And again, people have to
re-register, is that right? If they want to be tomorrow. CAROLINE: Right. Just re-register. If you have any questions,
just send an email back, and we’ll send it back to you. And then you’ll be
all set for tomorrow. Well thank you,
everyone, for taking time to participate in this session. And we look forward to
following up tomorrow. And thank you, Dr.
Mee-Lee, for your time and all your insights and your
patience in working with us. DAVID MEE-LEE: Sure. Thank you. CAROLINE: OK. Bye. DAVID MEE-LEE: Bye.

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