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
www.changecompanies.net
www.ASAMCriteria.org
www.tipsntopics.com
davidmeelee@gmail.com
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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
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Criminal Justice’s View of
Presenting Problem and Solution
3 C’s Consequences
Compliance
Control
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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
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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”
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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
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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
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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.
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Phase 2 - CHANGE
GOALS
•
•
•
•
•
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
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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.
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Phase 3 - CHALLENGE
GOALS
•
•
•
•
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 45-60 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)
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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.
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Phase 4 -SELF-SUFFICIENCY
GOALS
•
•
•
•
•
•
•
•
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 60-90 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
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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.
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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. 43-53
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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
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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
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Phase 1: Orientation
Requirements
• 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.
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Phase 1: Orientation (cont.)
Requirements
• 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.)
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Phase 1: Orientation
Residential
• 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.
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Phase 1: Orientation
Outpatient
• 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).
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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.
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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
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Phase 2: Change
Requirements
• 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.
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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).
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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.
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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.
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Phase 3: Challenge
Requirements
• 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 45- 60 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.)
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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.
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Advancement
Residential
• 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.
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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
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Phase 4: Self-sufficiency
Requirements
•
•
•
•
•
•
•
•
•
Follow and update treatment plan with provider.
Abstain from alcohol & illicit drugs as well as unapproved over the counter
medications.
Attend court appearances every 60 -90 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.
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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.
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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.
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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.
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companies.net
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.com
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. 2012-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.
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