Below is an excerpt from David Mee-Lee’s Tips and Topics newsletter from November 2014 (Volume 12, No. 8).
The emails and verbal appreciations are gratifying. This month however, one reader, Izaak Williams, went much further than simply read and digest a previous edition. In the March 2011 edition, I wrote in SKILLS about the sometimes negative, unintended consequences of “graduation” ceremonies in residential treatment.
Izaak researched the topic and wrote his version in a peer reviewed paper entitled “Drug Treatment Graduation Ceremonies: It’s Time to Put This Long-Cherished Tradition to Rest” He even received permission to allow you free access to the whole paper at this link:
So I asked Izaak Williams to summarize his paper for the November edition. Here is how he did that (with some minor edits from me.)
Are Graduation Ceremonies a Therapeutic Celebration or Hollowed Concept? You Be the Judge
- Where did substance use treatment graduation ceremonies originate?
The history of this tradition finds its roots in “early 19th century treatment institutions. It was the practice in the Keeley Leagues (KL) – (for example, the patient-led recovery mutual aid fellowship within the Keeley Institutes) for the person leaving treatment to recount their experience, receive the best wishes and guidance of other KL patients before KL members walked the departing patient to the train station in Dwight, Illinois. The function of this ritual was to reaffirm commitment to sobriety, cement the bonds of fellowship, and form a bridge between the institutional group and the Keeley League meetings in one’s own home” (Personal Correspondence, W. White, November 6, 2014).
- What’s wrong with using the term graduation or commencement?
Just about any dictionary definition of “graduation” or “commencement” spells out the notion of “wholeness” that refers to completion of everything needed or required. When we talk about graduation in the education system the discussion shifts to prerequisites and credits towards a degree program—requirements that are clearly articulated.
For example, asking a high school or college student if he or she will graduate would invite the student to talk about how many credits they’ve completed or what classes they plan to take in the near future in order to graduate or commence. Moreover, while the meaning of commencement in the dictionary may refer to “a beginning”, this very same definition is often qualified with cross-reference to graduation. In other words, to start anew or “begin” one must first completely finish (high school or college degree program).
With this in mind, how does one commence or graduate from a substance use disorder?
Why might it not be such a Good Idea to Graduate Treatment Participants?
Here are Izaak’s thoughts on how graduations appear to affect participants:
- There can be an overblown sense of confidence about their prospects of not returning to use. This reinforces a willpower stance toward addiction. It seems to foster a particular relationship with their drug of necessity which directly contributes to continued drug use or relapse.
- For some clients who tend to reward or celebrate with drug use, a festive celebration with entertainment value may trigger a drug craving in order to enhance the fun.
- It may foster the false belief that “cure” has occurred and that treatment support or ongoing mutual aid is no longer needed or will ever be required.
- Treatment participants may be working on repairs or making amends while relationally cutoff from loved ones. If loved ones are not invited or refuse to participate in graduation, this can provoke client distress, anxiety, and other not-so-good feelings and negative emotions.
- Returning to treatment after graduating would seem to provoke a sense of stigma in light of embarrassment and disappointment of having to face treatment staff and possibly other peer clients who celebrated with them.
- What is the future for graduation ceremonies?
There are many ongoing changes in drug treatment industry standards in light of the Affordable Care Act (ACA) and Mental Health Parity and Addictions Equity Act (MHPAEA)(2008). In the future, the existence of graduation ceremonies will hinge on the availability of empirical evidence to support it as a therapeutic practice. This is because traditional stand-alone addiction treatment programs which perpetuate this tradition mostly aim at targeting drug use on the basis of stabilization. This is an acute care model; it’s not sophisticated enough to be effective for chronic disease management. One emerging model of care is the patient-centered “medical home” or “Patient-Centered Primary Care Home Program” (PCPCHP) (see: http://www.oregon.gov/oha/pcpch/Pages/index.aspx for patient-centered primary care programs). In short order, here are but a few of the key standout words characterizing this model: comprehensive, integrated, coordinated, continuous, patient and family centered, collaboration.
As treatment industry standards encourage collaborative plans of intervention that are holistic and promote wellness, the future of both acute care model and graduation ceremony is bleak. This is because both appear antithetical to the new standards of care conforming to the medical model of drug addiction promoted by ACA and MHPAEA.
- Is there another way of thinking about Graduation Ceremonies?
- One suggestion is that the word “graduation” and its substitute or euphemism-“commencement”— be avoided in program speak. This would then permit the notion of continuum of care transition to creep into thought rather than
“end of treatment”, “completion”, or “graduation.”
- Perhaps the proverbial graduation ceremony performed in a grand ballroom could be scaled down to a more individualized patient-centered setting-an intimate meeting- between the treatment team, client, family members, sponsor, and friends willing to offer ongoing support. This forum would provide a structured opportunity to talk safely and formulate support roles. Add to this: the possibility of clarifying misconceptions about addiction dynamics and facilitating ongoing treatment recovery processes.
- As David Mee-Lee suggests, this could be called the Reflection, Celebration, and Anticipation (RCA) (see http://www.tipsntopics.com/2011/03/march-2011-tips-topics) stage. At its very essence, what this entails is establishing a road map to help patients and his/her support system see where they are now and where they are headed in treatment recovery. This might be called a ”life in recovery transition day” centered on the sharing of a solid, longitudinal, community-based Continuing Care Recovery Plan (CCRP) in supporting further stages of recovery.
In closing, Izaak indicated that Thomas McGovern, editor of the Journal of Alcoholism Treatment Quarterly invites comments in response to the article entitled “Drug Treatment Graduation Ceremonies: It’s Time to Put This Long-Cherished Tradition to Rest” (Vol. 32 issue 4). “We welcome critique and criticism to stimulate further dialogue, compel critical thinking, and encourage empirical scrutiny of substance use disorder treatment graduation ceremonies.”
Izaak L. Williams, Hawaii State Certified Substance Abuse Counselor (CSAC), was selected in the 2014 cohort of emerging leaders by the Center for Substance Abuse Treatment’s (CSAT’s) Behavioral Health Leadership Development Program. He can be reached at: email@example.com
Williams, Isaak L (2014): “Drug Treatment Graduation Ceremonies: It’s Time to Put This Long-Cherished Tradition to Rest” Alcoholism Treatment Quarterly Volume 32, Issue 4, pages 445-457
Published online: 06 Oct 2014 http://www.tandfonline.com/doi/full/10.1080/07347324.2014.952995