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becomes more about ongoing recovery management, does this make the traditional “graduation ceremony” for patients an outdated concept?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?”
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.”
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.