Saturday, July 09, 2022

Training The Staff - Opioids Part Two

Update: Fresh example from today of people rejecting drug solutions. Third-to-last paragraph.

Three Shall Be The Number! 

When I worked on a neuropsychiatric behavioral unit, we would often have a behavior plan for the patient to discourage some behaviors and encourage others. The Behavior Plans were much beloved by some of the staff who felt that many misbehaviors needed to be taken in line, even with an air of punishment, rather than just waiting around for new medications to work or testing results to come back. The behavioral psychologist would chuckle that "three shall be the number" of behaviors we were targeting to change. We would have to discuss as a team what was key, usually assault or explosive threats or urinating inappropriately.  And then that would be it, for now. It got too confusing to try and include too many targeted behaviors. Long experience had taught him that keeping the focus on three behaviors was the ticket.  Once those were addressed, we could move on to other behaviors if necessary. This forced the staff to consider what is really important.

The system would fall apart quickly at first, unless it was with staff who had implemented many before. A patient might earn the right to go out on an unsupervised privilege for 30 minutes by following the program. But somehow it would not happen, because he would get in trouble for something else and the privilege be cancelled. When we discussed this, some irate worker from an off-shift would say "I just can't see letting Jeremy out on privileges right after he has called the nurse vile names." But vile names weren't on the list of three.  If we want to include it, we would have to take something else off.

Because the Behavior Plan was not so much designed to change the patient's behavior as the staff's behavior. One had to be careful where this was said, but it was true.  It was the staff which could not focus on what was important, and they needed to develop the discipline of sticking to the program. The patient would start getting it right as soon as we did. 

We would send the patient home after patiently reducing the target behaviors over six weeks and the pattern would repeat. A month later the community team would complain the behavior program "wasn't working."  We would have them in for a discussion and return of the patient, and it would gradually come out that they were no longer using the real behavior program, if indeed they had ever done so.  They had reverted to what they had been doing before, festooned with pieces of our plan. We would keep them talking long enough, and someone would eventually spill the real thinking. "We don't want Sam to stop hitting women because he's getting tokens, we want him to do it because he understands it's wrong!" This would be a developmentally disabled client they were talking about. You can make the necessary leap that the reasoning is equally bad when talking about drug addicts or schizophrenics. What is the behavior you want to change?  

The best reply was when the psychiatrist pulled out his wallet and took out some bills. "I work for these little green paper tokens every day.  So do you."

****

Something similar comes up in the treatment of sex offenders. Those acts really activate even professionals who are supposed to be dispassionate.  Behind closed doors I have heard nurses advocate for castration, or for the patient not to get the medical care or prefered diet or rights of communication and visitation that are required by law, because it just infuriates them to see such people enjoying themselves or being happy. They want them to have at least some suffering so that they'll KNOW. 

Or going in the other direction, because for some reason these are individuals that people just want to either punish or rescue, will be staff making impassioned pleas that the goal for Jimmy should be rehabilitation, that he learn not to even want to do these bad things anymore.  Learn empathy or something. Have lots of therapy.

But even offenders who have lost the use of their genitals somehow (don't ask) can still molest and traumatise victims. And rehabilitation is tough to measure - and we can get fooled by guys who are working 168 hours a week at fooling us while we are only working 40 to not be fooled. When we focus on rehabilitation, without noticing we start to think about giving them more freedom eventually.

No. The number one priority is the safety of the public.  If we could send them to islands forever, it wouldn't matter if they enjoyed it, if we sent them good scotch and lots of porn.  Not really, from a public health perspective. From a philosophy of valuing the individual we might want them to be improved, even redeemed, and that might even be "more important" in some cosmic sense. But if he's convicted and you are turning him over to me as a consequence, it's not really my job to weigh whether the salvation of one soul is worth the molestation of five hundred children.  My first job is to keep the public safe.  Not to punish or rescue the offender, because when those creep in, public safety goes to hell.  It just does. What is the real result you want? Learn to swallow the other stuff.

*****

I think of this whenever drug addiction interventions are discussed. What are the changes we want to see? Fewer overdoses? Less drug use in general? Do you mean smaller dosing or fewer people? A reduction in young people picking up the habit? Fewer people making money in the industry - legal or illegal? Perhaps what we want is there to be less crime, especially theft and intimidation, around the addiction. It is not merely an intellectual exercise to make our interventions more efficient - though it might do that. We find our focus on the few things that are key in order to reveal our mission creep. 

Because mission creep very often involves bad motives, of wanting to punish or rescue people.  So that they'll KNOW how much they have hurt others, and know how much we disapprove. Or that they will change inside in some hard-to-define way. When drug legislation is brought up, comment sections explode with mission creep, usually in the direction of punishment or rescue, though a half-dozen other things like cost or precedent can come in. We should punish the drug companies that make money on this. Why should this be my problem at all? It's their life. No, we don't want to give addicts needles (or a place to shoot up or methadone) because that will just encourage them.  If you subsidise something you get more of it, right?  You guys are just stupid.   

Update: Gateway Pundit, which has become a ridiculous site, is upset about harm reduction methods. Biden is handing out crack pipes across from a NYC preschool filled with 3-4 year old children. Presumably not Joe himself, and the children aren't walking to school from six blocks away unsupervised.

The principle of not rewarding bad behavior is a good one, because it has some effect and is philosophically appealing as well.  But it carries two huge blind spots. First, you might want to reward a bad behavior when the alternative is a terrible (even deadly) behavior, as here. Secondly, the more important part of the reward-punishment system is not punishing good behavior. Somehow we are willing to punish people making a poor attempt, just so our name isn't associated, our hands aren't dirtied by rewarding - one could say "helping" just as easily - problem behaviors. When you look at how you have actually learned trial-and-error, reward-and-punishment lesson, in your life or in the raising of your children, you will likely find that rewarding partial compliance, or at least not punishing it, has been what worked with you and your children.

I was a purist who didn't like the Harm Reduction methods at first.  They proved themselves to me with their successes in front of my eyes.


4 comments:

  1. As to the video clip, one of the oddities of Britain is that it is bracketed by policing bureaucratic regimes. After the hand grenade blows up, the switch to a set of policemen who start running towards the explosions. But Rome ruled in Britain before the Fall, and we have very bureaucratic records from that period still extant. The movie -- which I hate, because it effectively disarmed Arthurian myth for a generation or more -- rightly shows that Arthurian heroism is impossible in the face of such institutions.

    Yet as Chesterton said, such things pass. He was on their side, but even he noted the oddity: after centuries of records and bookkeeping, suddenly all the writing is of men with swords fighting giants, dragons wrestling under deep wells, forests moving to war.

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  2. The number one priority is the safety of the public.

    This could also be said of incarceration as well, I think.

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  3. Great post. I don't know the rest of the behavioral and mental health world like you. But, sounds like exact parallels.

    When it comes to drug use I think a lot comes down to subconscious moral categories that we create but don't often interrogate.

    If you believe that drugs are inherently "evil" (like prohibitionists believed about alcohol) and that the body is a "holy temple" then drug use falls into the category of a "taboo" behavior. It profanes the holy. Taboos are unique in that the consequences of the action are irrelevant. And, if the community doesn't punish the person, the divine will punish everyone. So, if you get in the way of associated harm from the action, you stand in the way of the will of the divine.

    The primary moral alternative that is offered is from a utilitarian/consequentialist perspective. Lets decrease harm and increase happiness/pleasure. From a public health perspective, those moral categories make sense. But, it also seems like most people intuit that that framework is also lacking. Do we really want to live in Huxley's Brave New World? Do we want to be left on the island of the Lotus Eaters?

    The category that I think helps to make sense of it all is Aristotelian virtue ethic theory. This is a bit oversimplified but for Aristotle character comes in three parts: what you desire, how you desire it, and the practical knowledge to achieve the good.

    Typically, I think drug use is categorized as bad people who want bad things and do so in a bad way. But, in my experience, people use drugs to try and achieve certain kinds of goods: better physical or mental health, community with others, experiences of transcendence, alleviation of pain, relieving stress, and a sense of love and connection. The problem is not that drugs don't achieve these things at all but that they are very good at temporarily achieving these ends (or something very like them).

    In this way, I think most problematic drug use and addiction can be understood as an issue of practical knowledge.

    Instead of heroin use being taboo, it is like climbing Mount Everest. The desire to climb the mountain isn't bad but there are so many ways it can go wrong I'd never recommend anyone do it and would be supportive of lots of restrictions on who can even try. But, at the end of the day, if you are going to make that choice I'd hope you are as safe as possible.

    And, this establishes limited access for those who do have sufficient practical knowledge. Fentanyl is the ideal opioid for childbirth and is great for surgery because it is fast-acting, fades quickly and is incredibly powerful. Those benefits in the hands of an anesthesiologist are the dangers for those using illicit fentanyl.

    But, we also get language from virtue ethics for talking about folks who have already made that choice at some point to use and now have a substance use disorder. (I get into this in ch 15 on "Choice" in Addiction Nation.) Aquinas wrote about how once a person eats food that makes them sick, it is no longer in their power to not eat the food. So, focusing on the initial act isn't particularly helpful. It is now about learning new ways to achieve those goods. And, he acknowledges that once a person has learned a specific set of habits to try and achieve certain goods, the process of learning new ways is very long.

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  4. This is why I like AVI's observation's here so much. Focusing on a few small areas at a time may actually help people build related kinds of habits that can help in other areas as well.

    One of my favorite moments from volunteering at syringe exchange programs was asking people if they had reversed an overdose since the last time they came. Most people had. I always stop for a moment, look the person in the eye and say, "Thats fantastic. So good to hear you saved someone's life. I bet that person is grateful you are such a good friend."

    Virtue ethics help us understand why a standard economic model doesn't explain the success of syringe exchanges. Most things that we "subsidize" we also incentive and get more of. But, I think harm reduction "works" in part because it allows people to form new sorts of habits and see the positive results. Their wounds clear up, they see their friends live instead of die... And, if the day comes when they want to seek additional treatment, they also have formed the requisite relationships in order to achieve their next step of healing.

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