Journal of Substance Abuse Treatment 55 (2015) 45–51

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Journal of Substance Abuse Treatment

Mobile Phones in Residential Treatment: Implications for Practice Scott Collier, MSW, Ph.D. a,⁎, Mardell Gavriel, Psy.D. b,1 a b

HealthRIGHT 360, 1735 Mission St, Suite 2050, San Francisco, CA 94103, USA Healthright 360, 1735 Mission St., San Francisco, CA 94103, USA

a r t i c l e

i n f o

Article history: Received 10 October 2014 Received in revised form 17 February 2015 Accepted 22 February 2015 Keywords: Mobile phones Cell phones Residential treatment SUD Substance use disorder

a b s t r a c t A nonprofit primary care, substance abuse and mental health treatment provider that operates nine separate residential treatment facilities in both northern and southern California began allowing clients to keep their mobile phones while in treatment. From the advent of mobile phone technology and its widespread adoption through early 2013, the organization prohibited clients from having phones while in treatment. Calls to and from clients needed to be made and received at the house phone. After years of enforcing the policy with diminished success as phones became cheaper, smaller, and more prevalent, agency leadership decided to experiment with allowing the clients to keep their phones while in treatment. Elopement data as they relate to the policy are examined along with data from staff interviews about its implementation and impact. Results show that elopements resulting from being caught with a mobile phone were eliminated and some clients were able to be returned to treatment using the devices. All seven (100%) of the interviewees were supportive of the new policy and thought it should be continued. The impact of the policy on clinical disruptions, lost/stolen property liability, and confidentiality issues are discussed. © 2015 Elsevier Inc. All rights reserved.

1. Introduction The widespread adoption of mobile phone technology has changed how people communicate. Mobile phone technology has also had implications for the treatment of health conditions and is playing a role in emerging treatment techniques for various different conditions, including substance use disorder treatment, by providing tracking, education and support (Boyer et al., 2012; Gustafson et al., 2014; Hazelden mobile applications for the iPhone, iPad, and iPod touch, 2014; Marsch, Carroll, & Kiluk, 2014). Residential substance abuse treatment programs have also been impacted. As more and more clients began bringing mobile phones into treatment, the reaction of many facilities was to prohibit them because of the fear that they would negatively impact or disrupt treatment. For example, clients might use their mobile phone during groups or as a tool to obtain drugs. The current research examined the results of a change in policy regarding the prohibition of mobile phones for residential treatment clients at a large provider in California. 2. Background Most residential substance abuse programs either restrict or prohibit client use of mobile phones while in treatment. A brief look at the Web pages for residential treatment providers will give an idea of the various policies. Many programs restrict the times of day that clients can receive calls at a centralized telephone shared by multiple residents. Some go as far as restricting who can call on the shared lines and when in the course ⁎ Corresponding author. Tel.: +1 415 912 6759. 1

Tel.: +1 415 967 7042.

http://dx.doi.org/10.1016/j.jsat.2015.02.004 0740-5472/© 2015 Elsevier Inc. All rights reserved.

of treatment they can receive those calls. Most do not allow clients to bring mobile devices at all and restrict Internet and email access as well. The same is true for publicly funded residential programs. One Website even proclaimed that “Cell phones serve no positive value in the treatment environment” (Recovery Connection, 2014). A niche market has developed for “executive recovery” programs for clients who need to continue to run a business while in recovery. One such program advertises on their Website that they are “mobile and laptop friendly” and that they have an “inclusive mobile phone and laptop policy.” A closer look at the policy shows that the facility and the clients together “determine the appropriate time frame for these privileges” (Frequently Asked Questions About Hotel California by The Sea's Program, 2013). There are several valid reasons for these restrictions. Mobile phones may distract clients from participation in treatment. They also hold contact information for friends and family and, in the case of those with a substance abuse disorder, contact information for people who may provide the very substances the client is trying to avoid. Programs believe that building a sober social network may be easier without ready access to friends and other contacts from a time when the individual was actively abusing substances. In addition to disruptions in treatment, mobile phones have the potential to disrupt the “residential” portion of residential treatment. Clients usually share rooms and mobile phones can be a source of frustration if a client is talking loudly when his/her roommate prefers a quiet environment. Additionally, mobile phones are often expensive and can become a source of conflict, as can any other valuable personal property. One of the more prominent concerns is client confidentiality and HIPAA. Most phones have video and photographic capabilities, so the

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threat of a violation of confidentiality is real. Prohibitions on the use of mobile phones seem like a good way to ameliorate all the problems described above. However, these policies are generally ineffective, require extensive monitoring to enforce, and result in clients losing the ability to effectively integrate technology in their treatment as numerous substance abuse interventions that require mobile phones are beginning to emerge (Boyer et al., 2012; Marsch et al., 2014). Hazelden has a series of applications for different mobile device operating systems (Hazelden mobile applications for the iPhone, iPad, and iPod touch, 2014) and a recent randomized clinical trial of a postresidential treatment recovery support application suggests that former residential clients who used the technology for support experienced significantly fewer “risky drinking days” than the control group (Gustafson et al., 2014). Clients may also feel that relinquishing their mobile phone results in an unacceptable level of restrictiveness and negative impact on daily life such that they decide to defer treatment. Inability to contact family and other members of the individual's sober social network is another potential barrier to treatment. When clients are caught with an illicit phone while in residential treatment, they will often decide to abandon treatment, rather than relinquish the phone or accept any consequence for the infraction. 3. New mobile phone policy Agency leadership decided that the negative outcomes associated with the prohibition policy and the difficulty of enforcing the policy outweighed the benefits of banning mobile phones while in residential treatment. A decision was made to terminate the policy and replace it with one that allows mobile phones. The first part of the revamped policy was designed to eliminate departures wherein the primary cause was the possession of an illicit mobile phone. Because the agency collects narrative descriptions of each premature departure, there are data to suggest that getting caught with a mobile phone may result in the client abandoning treatment. These data are described in detail below. Completely removing the restriction on mobile phones was expected to eliminate all cases of clients leaving prematurely because they were caught with a phone while in treatment. Although there are no quantitative data to support the notion, the agency's intake director reports that, “There have definitely been instances of clients refusing treatment because of having to turn [the phone] in.” Therefore, the elimination of the restriction was also expected to prevent clients from deferring or refusing treatment due to giving up what may be their primary interface with modern society. In addition to the prevention of unnecessary premature departures and the elimination of one of the justifications for deferring or declining treatment altogether, clinical leadership also believed that the devices held the potential to successfully return clients to treatment after a premature departure. Simply giving the staff a mechanism to contact the client to ask them to return to treatment may reverse an impulsive decision or a lapse in judgment. Because a large proportion of the residential clients are homeless (N80%) they often do not have phone numbers on file with the agency. Nevertheless, homeless individuals adopt mobile technology at fairly high rates (Humphry, 2014). Because mobile phones were not allowed at all in the facility, when clients eloped the result was that no attempt to re-engage the client was made because there was no land-line phone number for the client and the facility was not privy to the mobile number. Even in situations where there is a home or land-line phone number available, the likelihood of getting the client on the line after a premature departure from treatment is low. Before the change in policy, clients with mobile phones hid them and certainly did not share their mobile phone number with staff. Because the new policy mandated that clients share their number with the agency for the specific purpose of follow-up after a premature departure, those with mobile phones

receive a call from staff encouraging them to come back to treatment and letting them know that they are still welcome at the agency. The potential to re-engage clients after a premature departure was a key factor in the decision to allow mobile phones. As stated in the new policy, when elopement occurs, the staff attempt to call the client to let him/her know that they are still welcome to return to treatment. Staff members were trained on how to leave an appropriate message letting the client know that she/he was welcome to return to treatment. If the client responded within 24 hours, then she/he would be welcomed back to treatment without a discharge. The client would still be expected to accept clinically appropriate consequences for the departure and any substance use that may have occurred during program elopement. Because of the interest in tracking incidents wherein the phone was used as a tool to return the client to treatment, staff were asked to complete another narrative form (Premature Departure Retraction Form) to describe these incidents, in addition to the narrative form completed upon premature departure. This process was implemented 6 months after the initial policy change. 3.1. Implementing the new policy Agency leadership attempted to predict challenges prior to implementation in an effort to structure a written policy that would minimize drawbacks. Predicted challenges included enabling clients to make or receive “drug drops”, confidentiality issues, group disruptions, roommate issues, and personal property liability. An early draft of the policy allowed no “smart phones”, primarily because of their financial cost and the potential for loss, but also because of the Internet and photographic features. This became another barrier as most phones started to have Internet capabilities and most all have the ability to capture and store photos. It also precluded using clinically relevant mobile phone applications to aid in recovery. The restriction was quickly scuttled and the decision was made to allow clients to have any type of mobile phone while they were in residential treatment. The agency's current mobile phone policy uses general language to describe respectful use of mobile phones and allows individual program directors to modify rules regarding quiet areas, in-room use, and dictate other aspects of respectful use. The text of the current policy is as follows: Mobile phones are permitted in our facilities, but you must share the phone number with your Care Coordinator. Your Care Coordinator must document any mobile phone brought into the facility. Mobile phones should be used respectfully and kept on silent during groups and classes. Each facility has its own specific phone use policy. Please see your Care Coordinator for details. Additionally, each client who wishes to retain his/her phone while in residential treatment must sign a mobile phone contract that outlines the appropriate uses of the device and consequences for infractions. The current study addresses three issues. The first is the impact of allowing clients to keep mobile phones while in residential treatment. The second issue is how staff experience the change in policy and their impressions of the positives and negatives of allowing phones while in treatment. The third is whether the new policy facilitates client re-engagement because staff have a mechanism to contact clients after premature departure. 4. Methods Because the organization has collected elopement data for years, there are extensive archival data to establish a baseline of the impact of mobile phone restrictions on client retention. Elopements at any of the agency's residential treatment houses are documented with a written narrative of the departure completed by staff. These data were examined for any mention of a mobile phone in the narrative wherein the phone policy was directly related to the departure. In total, 613

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premature departure forms from prior to the implementation of the new policy were examined. These narratives covered elopements during the time period between November 1, 2010 and October 31, 2012. The new policy was implemented November 1, 2012. In one program, the funder imposed a mandatory suspension of the new mobile phone policy. This was utilized as an opportunity to examine the impact of the policy before it was in place, during the relaxed policy, and after the policy was temporarily suspended. After the new mobile phone policy was implemented, the agency continued to collect and monitor narrative data on elopement from treatment. Researchers examined 473 post-policy implementation premature departure forms to determine if a mobile phone or related policy may have played a role in the discharge. Data collected before and after the policy implementation, including data from the facility where the policy was halted, are discussed below. Narrative descriptions of situations where an individual returns to treatment after a premature departure were also collected. These data were examined to determine the impact of the policy allowing the staff to contact the client after a premature departure in an effort to re-engage the client. After the new mobile phone policy had been in place for a year, interviews were conducted with seven staff members including clinical and operational leadership as well as house managers in the residential treatment program. All of the narratives were read by the same two researchers who coded the transcripts in an effort to extract salient themes. The seven respondents have differing levels responsibility for the development, implementation, and management of the new policy and include 2 vice presidents, 2 managing directors, 2 program directors, and 1 clinical manager. The 2 vice presidents hold responsibility for all 9 of the agency's residential facilities and the remaining interviewees represent 5 different residential treatment facilities. The respondents included 2 males and 5 females. Five of the 7 respondents are certified AOD (alcohol and other drug) counselors, one holds a MSW and one is a licensed clinical psychologist. They had between 8 and 18 years of experience with the agency (mean = 13 years; median = 15 years). All seven (100%) of the interviewees were supportive of the new policy and thought it should be continued. Their reasons for supporting the policy change were different, but all concluded that the change was beneficial to both the client and the program. Interview participants were asked to detail both positive and negative changes that resulted from the policy. In addition, any challenges to implementing the policy were solicited. Several themes emerged from the staff interviews and are discussed below. 5. Results 5.1. Elopement related to mobile devices Researchers reviewed 613 archived elopement forms. Thirteen of them (2.17%) specifically cited mobile phones as a contributing factor in the departure. This often took the form of a client being found to possess a mobile phone and choosing to abandon residential treatment rather than accept any consequences for the contraband. A selection of the narratives describing these departures is presented in Table 1. As expected, review of elopement forms post implementation of the new mobile phone policy cited zero instances of mobile phones as a contributing factor towards elopement. Following the temporary closure of one of the agency's residential facilities by the funder, the policy allowing clients to keep their mobile devices while in treatment was suspended at that facility. During the period of time in which mobile technology was banned, the facility experienced an increase in elopements related to the possession of a mobile device. Graph 1 below illustrates the trend of mobile device related elopements over time at that facility. Elopements specifically related to the possession of a mobile device were not happening every day, but rather, once every 8 to 12 weeks. There were zero instances of this type of elopement during the period

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Table 1 Examples of elopements related to mobile phones. Date of departure

Narrative

12/2/2011

Client was using a cell phone on the back porch by the laundry area. The client is already on contract for previous infractions and behavior issues. The client has been told that any further rule violations could be referred back to parole. Client chose to walk out of treatment. Client was seen with a cell phone outside the facility. Client admitted to having cell phone; however she did not want to turn it in to staff. Client decided to abandon treatment. Client was observed by staff texting on a cell phone inside the facility. Client was addressed about his behavior. Client gave staff the cell phone for storage. Client left the office. Later, client returned to the office and asked for his phone, then, he left the treatment program. Client was caught with a cell phone; client did not want to accept her sanctions. Client was closed to counsel and decided to abandoned treatment.

5/7/2012

6/1/2012

6/23/12

that the devices were allowed and none during the nine weeks the facility was closed. Within 30 days of re-opening the facility with a mobile device ban in place, there was an instance of elopement tied to possession of a phone and two more within 4 months.

5.2. Elopement retractions There were 473 documented elopements reviewed after the permissive phone policy was implemented. Twenty-six of those (5.5%) were “retracted” because the client returned within 24 hours. Of those 26 returnees to treatment, 8 (30.8%) were believed by staff to be because of the phone call placed to the client. Table 2 below shows examples of narrative descriptions from elopement retraction forms.

5.3. Completion rates before and after policy change Relapse data are not available, but completion rates for clients in the participating residential treatment programs were examined both before and after the policy was changed. Completion rates regularly fluctuate between 30 and 40% for the agency's residential treatment programs. During the 4 months prior to the policy change, the completion rate for residential clients was 32.5%. The first 4 months after the policy was changed saw a completion rate of 31%. During the next 4 months, the completion rate raised to 37.36%. These fluctuations all fall within the normal range for these facilities, suggesting little or no impact of the mobile phone policy on completion rates.

5.4. Incident reports and confidentiality complaints before and after policy change Any time a client reports loss of confidentiality, an incident report is completed. There were no incident reports alleging loss of confidentiality due to clients possessing mobile phones in the year prior to the new policy or in the year after the policy was implemented. During the same time period, there was one incident involving a student intern violating client confidentiality with social media. Another incident occurred where a client took a picture of a staff member who asked to have the photo deleted. The client refused because the policy did not specifically say it was against the rules to photograph a staff member. The staff response was to temporarily take away the phone. The client was frustrated and indicated that she used the phone to maintain contact with her children. The restriction was then lifted for a half hour each evening so the client could contact her family. She soon acquiesced and willingly deleted the photo in question.

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Facility Closed

Facility re-opened October, 2013 with mobile phones once again prohibited

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Before mobile devices were allowed in residential

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Graph 1. Phone related elopement before, during, and after new phone policy: 5.1.12 to 5.1.14.

5.5. Thefts/property issues

5.6. Clinical disruptions

Property issues have always been a concern in the residential facilities. The most common type of mobile phone related property issue is a client complaining that they turned a mobile device into staff and that the device was missing upon discharge. Client to client property issues are generally resolved at the facility level. The topic of phone theft or destruction was addressed in the interviews with staff. Specifically, the interviewees were asked “Have you become aware of any property disputes related to mobile phones?” One respondent indicated that property issues primarily occurred when the agency would take possession of the mobile phone for the clients.

Prior to implementing the new policy, one of the major concerns was that allowing the devices would result in major clinical disruptions. Administrators thought that it might be too burdensome on staff to constantly have to deal with mobile phones throughout the facility. Two interview respondents directly addressed this question.

That is when cell phones, real or not, were coming up missing and/or lost and/or stolen. The final policy used the phone as a clinical tool, one to contact them or them us—BUT they signed a waiver that we were not responsible for any lost, stolen, or misplaced cell phones. All of a sudden, very rarely have we had any reported missing or stolen. [Interview 1] A program director at one of the other agency residential programs gave input on the property liability issues by stating, [Property issues arise] perhaps once or twice a year. For example, one participant threw her roommate's phone across the room and cracked the screen. Given the number of participants and phones we have in the house, this is a rare occurrence. [Interview 2]

[The need to intervene when someone is using a mobile phone in the facility] happens all the time, but no more than other problems. Just like we have to remind them to speak softly when in the house, we have to remind them how to appropriately use their phones. People generally try to be respectful because they don't want to lose the privilege. [Interview 3] Another interviewee described the impact of the policy as follows: We have guidelines on where and when phones can be used. Clients do not want to lose their cell phone privileges and are very receptive to verbal pull-ups. If someone loses all their privileges, say due to a relapse, then they turn their cell phone in and can have it when they complete clinical sanctions. Phone calls then are through a house phone. All in all it has saved a lot of conflict and staff can address clinical issues related to individual needs and assessments instead of being cell phone police. [Interview 1]

Another respondent echoed those sentiments by stating, Participants value their phones and are thus fairly conscious of the guidelines. In contrast, when they were banned we were confiscating them daily, and often multiple phones from a single participant in a span of weeks or less. [Interview 2] Table 2 Phone related elopement retractions. Date of retraction

Narrative

5/25/2013

Client left the program on Friday. On Saturday morning, CR left him a voice message that he could return to the program. He called the facility at approximately 10:30 pm and arrived back a few hours later. I spoke with client yesterday on 5-28-13, and he told me that he would return to the program within an hour. It took him a few hours to return but he did return and is willing to give the program another try. Client went on an outside appointment to the doctor and never called or returned. Staff was able to contact client on her cell phone and client stated that she was in the hospital but would be returning to the program. On 5/31/13 at approximately 5:15 pm client returned to the facility however had no discharge paperwork from the hospital.

5/29/2013

5/30/2013

Interview participants were specifically asked to address property issues and clinical disruptions, but eight other themes were also identified through the interview and coding process. Each of these themes is described below. 5.6.1. Theme 1: futility of banning and policing the devices One respondent reported that, with limited staff, it is impossible to enforce mobile phone bans in residential treatment: These individuals are very resourceful and have honed the ability to get their needs met in very difficult circumstances. If they want a phone, they will get one. If Charles Manson can get a phone into his cell at Corcoran [State Prison], then we cannot stop clients from

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having a phone while in treatment. Treatment programs feel like taking away the phone is taking away the problem. This is not realistic. [Interview 2]

that led to harassing behaviors. The agency's clinical leadership weighed-in on this topic and tied the incident back to using the device as a clinical tool, saying:

Another respondent echoed that sentiment by saying that, “things are just above board now. The only reason it was a problem was because we made it a problem. It's one less thing we have to police.” [Interview 4]

I am aware of an incident of stalking. The client's phone was taken, not so much in a punitive way, but to help the client gain control over those behaviors. We identified the need to have a clinical intervention beyond taking the phone. The approach was not just to remove the phone but to help the client accept the situation and move forward. [Interview 6]

5.6.2. Theme 2: ability to contact the client for case management During residential treatment, clients are trying secure housing and employment, access healthcare and rebuild family and support networks. One of the house directors pointed out the benefit of mobile phone technology in aiding clients in securing these important connections during his interview when asked for his overall impression of the policy change. It's been great. I wish we had done it a long time ago. It is another tool we have to reach them (clients). If a client goes out on an appointment and the psychiatrist calls and says, “I can get him in right away”, then I can just call the client rather than pretend they don't have a phone or trying to get a message to the client wherever they are. [Interview 4] Another interviewee stated, “It's a good thing for the most part. We're able to contact them and they can keep in touch with their families.” He continued: If they are going to an appointment, then they can maintain contact. That way, if they are late they can call and let someone know. If a client relapses while they are out of the facility, then they will sometimes call and see if everything is okay. Another positive is that they can call and receive calls related to job searching on their own. If an AOR [Parole] comes to the facility to check on a client and she/he is out, then the AOR can call the client and check-in. [Interview 1]

5.6.3. Theme 3: clinical teaching tool/aids in deeper clinical response One repeated theme was seizing the opportunity to utilize the device as a tool for teaching skills. This theme re-appeared in several of the staff interviews. One interviewee commented, We tell them the rules when they come in. We're teaching them to use it productively. If they violate, then there are consequences. They may have to check their phone in and out if they can't use it responsibly. Those caught in the middle of the night may lose their phone until morning. There might be a writing assignment to go along with losing it temporarily. It's a learning tool. [Interview 4] Another interviewee shared, There will be many times each day when staff will have to remind clients about the appropriate use of phones. Reminding them to use their phones at the right times, in the right places and in the right ways is an ongoing task, but one that will benefit them as they take those skills and expectations further into their recovery. [Interview 6] By allowing the phones while in treatment, it forces a deeper clinical response. An interviewee illustrates this theme with an example from the residence. A male client began texting and emailing a former client who had moved out of the area. She made it clear that she was not interested in the relationship any longer and that he should quit contacting her. The immediate response of staff was to take the client's phone in an effort to get the unwanted contact to stop. When the phone was taken, the client began using the postal service to send unwanted letters to the woman. Even if it had been possible to prevent the client from ever using a phone, the harassment would have continued. The deeper response was to help the client accept and process the end of the relationship and learn the skills necessary to control the impulses

5.6.4. Theme 4: empowers clients One interview participant noted that people who are entering residential treatment are, “…already giving up a lot and anything we can do to give them some control can be really empowering.” She continued, It may allow a Child Protective Services involved parent to be more predictable in his/her relationship with the child. The parent can fulfill a promise to call without waiting for others to be done with the phone or waiting for his/her caseload group's night to use the phone. [Interview 2] The agency's vice president of programs further supported the notion that the policy empowers the clients to manage their own lives and lowers the level of anxiety many of them face. It cuts premature departures because people can talk to their families. It reduces anxiety if they can reach people in their family or those they care about. For example, if someone's mother is sick or their partner has a baby or something, they can call and check on them. It's a cell phone world now. [Interview 5] These statements illustrate the futility of trying to manage every relationship in a client's life versus giving the client the tools to manage the relationship(s) themselves. 5.6.5. Theme 5: creating an artificial environment is not helpful Clients will need to utilize mobile technology if they are to be successful outside of treatment, so it is not beneficial to simply remove the device because it is a distraction to group treatment. The solution is to have a deeper clinical response as described above and make it applicable to the real world. The agency's clinical leadership staff echoed that sentiment in an interview: One of the goals of treatment is for them to learn to be responsible to themselves and other people again in everyday life. If you make an artificial condition—they don't have to deal with it because it isn't there anymore—then they are not learning any skill about how to deal with it or to use it in everyday life. We would be creating such an artificial environment and when they leave, the skills are not generalizable because now they have to deal with the technology. If we ban phones, then the minute they leave and get their phone back, if their first impulse is to call their dealer, then we haven't done a very good job. [Interview 6]

5.6.6. Theme 6: treatment re-engagement The new policy did not just allow mobile phones during residential treatment, but rather, required that the client agree that the agency could contact them in the event of an elopement in an effort to return the client to treatment. One staff commented, “If a client doesn't return from a pass, then we can contact them and let them know everything is okay, even if they have lapsed, and that they should return to the facility as soon as possible” [interview 7]. This further supports the data gathered on the treatment re-engagement forms (see Table 2).

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5.6.7. Theme 7: improved phone access A common challenge in the residential milieu is client access to the telephone. Allowing mobile phones has reduced interpersonal conflict and un-necessary administrative work to manage access to the single land-line phone. Prior to the change, each caseload had one night a week that they could have access to the land-line phone. There were long lines and arguments over how long people were on the phone. If a client missed the once-a-week opportunity to use the phone, they had to either wait until the next week or they had to get special permission for a call during the day in the staff office. [Interview 3]

5.6.8. Theme 8: change brings challenges Problems do arise when mobile phones are commonplace in a large shared house. Before the policy change, these problems were already occurring because phones were already prevalent. Clients who were previously unlikely to complain about mobile phone related issues may be more likely to report it now because phones are no longer contraband and reporting an issue will not lead to someone being asked to leave the program. Confiscating a phone is one thing that can be done in response to challenging behaviors, but staff report that it is not very effective. A client can get a new phone quickly and will not report the new one to staff. That removes any chance of using the phone as a clinical or teaching tool. Another potential challenge to the use of mobile phone s in residential treatment is the possibility that a family member could call the client and say something to the effect of, “We need you here.” That may cause the client to leave treatment to go help his or her family. Clients can also use their phones to make or receive drug drops. Interviewees noted that these were issues before the change in the mobile phone policy and are simply facilitated by the accepted presence of mobile phones. In the past, these issues would present themselves with the use of the land line. There is no evidence that drug activity has increased or decreased since the adoption of the policy, nor any evidence that more clients are leaving treatment to be with loved ones. Lastly, interviewees noted that mobile phones sometimes disrupt groups, while noting that the same thing happens in staff meetings or trainings. There are also occasional roommate issues centered on phone usage. As discussed previously, these are treated as clinical opportunities. According to one residential director, “We capitalize on negative and positive things to help teach people.” [Interview 7] 6. Discussion Data from staff interviews show strong support for continuing the policy allowing mobile phones in residential treatment. There are also some quantitative data supporting the continuation of the policy. Reduced elopements, increased ability for successful case management, empowering clients, and decreasing the artificial environment thereby allowing for enhanced clinical intervention are all successes of the change in policy regarding mobile devices in residential treatment. The agency has also learned several lessons since initiating the change in policy. For programs considering a similar change in policy, it is important to have written guidelines. The agency in this study requires each residential client who wishes to have a mobile phone while in treatment to sign a contract specifically for the phone that outlines appropriate use. The conversation around confidentiality is constantly ongoing with clients. They receive the message that what is said during groups stays in the group and that all interactions throughout the facility should be treated as confidential. This sensitivity to confidentiality is extended to the phones. This is an area where a facility cannot afford to be lenient or loosely enforce a policy. The incident wherein a client photographed a staff member illustrates the importance of having a comprehensive written policy and also of

flexibility in response to issues that arise. She may have elected to leave treatment if she were denied the ability to contact her family. Staff were able to prevent that outcome while teaching about the appropriate and inappropriate uses of the technology. They were also able to get the photo deleted without escalating the situation. Had the written policy been clearer, it is likely that relieving the client of her phone would not have been necessary.

6.1. Implications for practice The agency is working to find ways to utilize mobile phone technology in treatment programs by implementing mobile recovery applications in treatment. There is much more to do to explore ways of advancing recovery beyond the obvious of people being able to stay in touch with a pro social network. Mobile phones can be a tool for addiction, and organizations can do more to have clients understand how they have used their cell phones to advance their addiction in the past. At the same time, the goal is to increase their commitment to using that tool in a different way which would be in the service of recovery. For instance, one idea is to help clients “burn bridges”, a technique that comes from an adaptation of Dialectical Behavior Therapy by having them delete contacts they used to buy or use drugs (if they are willing). Beyond that, the goal becomes teaching clients to use the technology to get support if they are feeling vulnerable to relapse. The phone could become a tool for reminding people that they can ask for help, reminding them about relapse prevention principals, reminding them to avoid neighborhoods of use, and raise their awareness of certain emotional states that could cause vulnerability. The agency's Vice President of Clinical Services summed up the implications by stating, I do think the policy should be extended to our partner programs. I think we learned the lesson and I think the notion that we can block people from doing something is flawed. There is a balancing point to be made. For instance, in the old days of the agency, we used to not let people contact their families early on in treatment because we thought so many of them come from using families that it would undermine their recovery. That created a sort of blind spot in the agency around utilizing the family for support. I think the cell phone could be similar in that we're recognizing that a global policy to ban it is not a very good policy, but instead we need to be more selective and refined in how we look at it. [Interview 6] If having a permissive mobile phone is problematic for some clients and they give the treatment provider the ability to create their structure to help, then taking away the phone may make sense for a period of time. However, it is problematic to assume the entire population requires the same level of structure. It makes the job more difficult because treatment requires, rather than a global policy, thought about how the technology can be utilized in the service of each individual. It is assumed that individuals in residential treatment, even if somewhat ambivalent, have some commitment to it. If a client uses their cell phone to obtain drugs, the richer conversation is about the ambivalence of what the person wants to do in the moment and how to work with them to resolve that becomes the clinical task rather than simply responding with a rule.

6.2. Limitations There are several limitations to the current study. These include the lack of qualitative data from clients that detail the policy from their perspective. There are no quantitative data regarding relapse rates to more fully examine the policy's impact on substance use. Group disruptions and other incidents related to mobile phones are not documented unless they are part of a premature departure narrative or rise to the level that prompts the completion of an incident report.

S. Collier, M. Gavriel / Journal of Substance Abuse Treatment 55 (2015) 45–51

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