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."

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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.

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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.