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Should treatment centers consider retiring the graduation ceremony?

January 2, 2015
by Gary A. Enos, Editor
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As the addiction field's perspective on treatment shifts away from episodic care and becomes more about ongoing recovery management, does this make the traditional “graduation ceremony” for patients an outdated concept?

Izaak L. Williams, an addiction counselor who has worked in multiple programs in Hawaii, sees several downsides to a practice that field historians say dates to the earliest mutual aid fellowships. In an Alcoholism Treatment Quarterly article published online in October, Williams argued that graduation ceremonies convey to patients that they are leaving treatment with all the tools they need to maintain lifelong recovery—a message that could set the patient on the road to problems later.

“What happens, then, when a client relapses shortly after graduating?” Williams wrote. He added that “graduation can engender an overblown sense of self-esteem and confidence, which tends to constitute a psychological setup for relapse.”

Addiction Professional recently interviewed Williams and The Change Companies' David Mee-Lee, MD, architect of the ASAM Criteria who frequently addresses field professionals on patient-centered care approaches, about the role and impact of the graduation ceremony. Williams says little formal research has examined this tradition's actual effect on patients. Mee-Lee believes program executives should at least think harder about whether the graduation ceremony fits a chronic disease model that is moving the field from program-based to patient-based care.

“A graduation places an emphasis on your completing treatment,” says Mee-Lee. “In a chronic disease model, you're doing a piece of work in one level of care.”

Implications of language

Williams and Mee-Lee both point out that they do not want to underemphasize the achievement of success in a residential or outpatient program. But even the language often used to describe services carries risky implications, Mee-Lee says. When professionals talk of “primary treatment,” for instance, consumers hear that as being the “real” treatment, with any other support received at a different stage seen as secondary, he says.

And when so much attention is placed on “graduating” from “primary treatment,” what might happen psychologically to the patient who experiences a slip or setback just days later? As Mee-Lee describes the possible mindset of the patient, “One week ago everyone was rah-rahing. Now, one week later, what am I?”

Readers' view

Addiction Professional asked members of the Addiction Professionals group on LinkedIn about whether they included graduation ceremonies as a major part of their treatment program. Here are some of the responses, which reflected a variety of views:

  • “At our agency we do not hold graduation services because it implies the treatment has ended and thus the journey to recovery has ended. While we recognize the fact they have made significant progress to improve their lives, we stress more work needs to be done.”

  • “Instead of graduating from a lifelong process we celebrate our success in achieving a new lifestyle!”

  • “Graduations are an important part of our agency's work. We want to celebrate our participant's completion in our programs. We do not view completion of a program as a cure but as another building block being put in place in the new foundation the individual is creating for him or herself.”

  • “We have another name for the event marking the end of a client's treatment stay: “goodbyes.” It is important to give departing clients some closure and acknowledge those staff members and peers that have made an impact.”

  • “'Graduation' does sound like 'completion,' but we all know that successful discharge from a residential program represents an accomplishment, and I like the idea of 'adios' and closure. We do offer a certificate and a coin as well as the opportunity for others to provide commentary and the departing client to acknowledge those who supported (or challenged) the journey.”

Alternative suggestion

Williams wrote in the journal article, “I argue that a graduation certificate has no value other than as verification of being exposed to treatment.” He added, “The number of clients who return to treatment after 'completing' or 'graduating' tells a somber story about addiction treatment that graduation ceremonies fail to capture.”

He suggests in the article that the field's traditional graduations be reformatted as a “life in recovery transition day,” with a focus on the sharing and pursuit of a long-term recovery plan.

Mee-Lee suggests that if a facility wants to conduct a ceremony, it could be branded as a moment for reflection about the past, celebration of the present, and anticipation for the future, emphasizing what is and will continue to be a lifelong journey.

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Comments

Facebook Fan Court Nichols has this to say: "I think they are important! I remember when I actually graduated I felt accomplished! And for many addicts it was the first thing we ever completed" Do you agree? Do you have a better name for the ceremony?

I worked in several rehabs and in a few of them, we used to call them a Leaving Ceremony. Ongoing mutual aid involvement and other support was emphasised. They were powerful and emotional experiences for all concerned, especially counsellors.

I can see both sides, but I think the message at "graduation" or completion of treatment needs to be clearly stated: "you are not done!" A graduation marks the transition from one point to another - We make it very clear that the hard part is just beginning when a client leaves our facility.

Izaak, congratulations on another publication.

It seems to me that perspective is the guiding force for each of our conceptualizations about what treatment is about in a person's life and whether or not treatment graduations support treatment adherence from an public health outcome perspective. Williams and Mee-Lee are correct; from the perspective of outcome measures and the temporariness of treatment adherence, graduation needs to be clearly understood, qualified, or not used at all. Since our society’s construction of SUD and recovery defined (SAMHSA) in terms much closer to prosocial engagement within our society, graduation feels like qualifying for recovery in some sense. Recovery as folk-religion should contain no graduation.

I work on the criminal justice side of treatment delivering. Actually, an in-facility residential treatment, euphemistically labeled "Level 3". I de-emphasis the graduation experience because CJ clients usually conceptualize the experience as acquiring their ticket out of prison. I have lobbied against big ceremonies on graduation day. CJ male patients usually suffer from a grandiose self-appraisal, according to the literature coming from U of Cincinnati CJ programs and Dr. Samenow’s work on criminal personalities. Within Hawaii’s criminal justice community addiction is treated as a feature of an antisocial personality disorder and not as an Axis 1 SUD disorder. Evidence is required before treatment interventions can be used. CBT has won the day, so far.

Another argument in support of treatment graduations is the right of passage from treating an acute episode of an illness to long term recovery, mentioned above. This is a time honored perspective and does not fit with the changing nature of behavioral health and addiction profession ideology. Ideology among addiction professionals is still suffering a hang over from 12 step “treatment” and everyone can benefit from a “good step-one”, an argument I don’t pursue with my staff or patients.

It is refreshing to see the professional field studying epistemology. For too long the majority has viewed graduation as a commencement ceremony that leads from discovery to recovery. I have evaluated a program that requires a fee to graduate.

Each staff and patient will take away something different with or without a graduation; an in the eye of the beholder thing. I am with Williams and Mee-Lee about rethinking our core understanding of recovery, treatment, completion ceremonies and many other areas that have become part of a tradition. A tradition formed without foundational literature, empirical studies, or even a cursory reading of the texts concerning behavior change, a learned and intentional practice of new behaviors. Our society is moving in the direction of SUD as a public health issue within the behavioral health paradigm and conceptualizations. It is a good time to reevaluate.

Thanks, Gary, for the article and a chance for people to rethink what we do. If anyone wants to read more about Izaak's article and where I suggest another possible name - an "RCA" ceremony, you can see the November 2014 edition of Tips and Topics at http://www.tipsntopics.com/2014/11/ or go to www.changecompanies.net, click on Blogs and then Tips and Topics and go to the Archives for the November 2014 edition. Just a suggestion for an alternate name - "RCA": Reflection, Celebration and Anticipation.