Measuring Legacy Dosage for Patients with Co-Occurring Disorders: The Ten-C Expectation Findings

Legacy Intervention (LI) in the form of storytelling has been found to be a helpful therapeutic approach for its effect in increasing self-awareness when life stories can be positively retold. Sharing positivity from a past-to-future perspective where the client is the center of change is the legacy creation principle [1]. The legacy building process can generate an interventional effect that serves as a common feature in the search for meaning in life from the past for future references similar to reminiscence therapy [2,3]. LI also allows for an individual’s experience to impact the lives of others, particularly in ten group therapy sessions that use an empowerment approach to help them find meaning in life [1]. The legacy meaning is translated into lessons learned and emotional burdens overcome for future generations who may be predisposed to addictive behaviors and mental illnesses.

Purpose and significance

This study connects the legacy definition generated from a previous study with a focus on LI implementation [1]. A unique aspect of this current study is to use legacy practice to address issues faced by those suffering from co-occurring disorders through measuring its measureable impact on improving mental health. Many patients do not recognize the worth of the successful coping experiences they have lived through. Through a personal legacy journey, they can analyze past coping strategies against adversities. With clinical guidance, they define their legacy to link to previous efforts to overcome the disorder as a recallable experience. By studying those wishing to leave the world with a positive legacy, results can be used to also plan services for their surviving families.

Legacy defined step-by-step

In the first step during this LI journey, patients focus on the bright side of their lives by transferring past information as a present lesson. Tales with happy endings are not required, but each patient recites memories with a sharing attitude and positive motivation. In a study about motivation, Dupont et al. [4], found that an intervention mapping strategy helped 31 cannabis users found positivity in their lives that motivated them to make changes after a four-session intervention. Their major accomplishment is a positive lesson for their future and next generations. A second step involves expressions of treatment expectations [5]. When legacy is related to one’s cultural connection, tangible memories are re-experienced by an individual or a group of people. In a study reported by Savishinsky [3], patients were encouraged to compare common concerns, discuss the lessons learned from a personal account and make a concrete creation based on a new perspective to answer the question, “Did my life really matter?”. This question guided the design of an empowerment LI project without any stigma attached.       

This article reports the third step of the LI definition process from a LI group of 37 patients with co-occurring disorders of similar nature. This step was an outcome stage where the legacy was used as a concrete means to communicate the symbolic meaning of life. Hunter’s framework [6], was used to stress the confidentiality value and mutual support with a focus on strengths, not weaknesses. The LI treatment aimed to affirm that patients must redefine past experiences from a positive lens. Through the legacy creation and a self-narrative process, each patient created a project without a verbal presentation until feeling comfortable about it. They achieved an attentive participation in the learning-by-sharing activity after being encouraged to choose their presentation method and contents.

Legacy dosage illustrated by a composite case

To illustrate how to measure legacy dosage, a case vignette was composed with the LI materials collected from 37 Partial Hospital Program (PHP) patients with similar co-occurring diagnoses. After the first two steps of LI preparation, these patients entered the third step focusing on their presentation as an educational journey. Using one patient as the main character representing all 37 of them, this composite case highlighted the function of legacy definitions. Based on the fact that all patients in this PHP were men, this educational case started with a fictitious name “Samuel”:

Samuel is a 55-year-old widowed African American man. He reports at intake that he has been using drugs and alcohol daily to self-medicate the depression he feels since his wife died 10 years ago due to an unexpected physical illness. He states he does “not have anything to live for.” His grown children are raising their own children and do not tolerate his drug use habit. They have not been in contact with Samuel as a way to avoid contact between him and their children due to his addiction and mental health symptoms. Samuel states that he is tired of living. While attending a partial hospital program, Samuel attends a Ten-session LI. At baseline, a question is asked, “How do you define your legacy?” He states “I guess my legacy will be what people say about me when I am dead. I don’t know what I have that is worth mentioning at my funeral. I have lost it all.” In the LI sessions, Samuel explores his life review topics: proudest moments, unfinished business, lessons learned, and termination while creating a tangible project on legacy that can carry on to the next generation. He chooses to write his journal each week reflective of topics discussed in treatment. In processing with other group members, Samuel begins to uncover his legacy through sharing his stories and experiences.    

In the LI process, Samuel shares four major experiences, each facilitated to be ending with a positive note: the birth of each of his three children and the feelings associated with “being part of a miracle,” seeking forgiveness for “taking my wife away from me,” lessons learned about “self-medicating the feelings associated with grief and his expectations related to “something to share with my children and grandchildren”. He begins to speak openly in sessions about his wife’s death, but gets angry when he catches himself sharing too much that is negative about himself. Samuel does not attend the final session when termination is discussed with an expectation that he would have to present his legacy project to the others. It is rumored among his peers that he has relapsed with drug use due to the upcoming anniversary of his wife’s death. When he returns two weeks later, he confirms the truth in the rumor. He states he is interested in completing the project so “I will have something to show for my life to my children and grandchildren.

The legacy journey 

With the composite materials from these 37 patients, the social worker who facilitated this LI intervention briefly described the legacy journey by gathering thoughts from the patients while they created legacy projects and completed their reflections in writing. With Samuel's reflections as an example:

I’m an alcoholic. My wife died ten years ago and some days I feel like wanting to die too. I have lost relationships with my children due to my addiction and I would love to repair them someday. I have learned in treatment that addiction is an illness. I know that I don’t have control over my addictive use and I should work on it so that I won’t lose the only control I have for myself. I can talk to friends and the social workers here who help me make better decisions about how to handle my depression and anxiety. I realize now that my legacy is all the stuff I have been through and where I am today, Some days I receive more help while other days I must work hard to find help to get out of the blues. I want to meet up with my children again. I am beginning to forgive myself for the things that happened to me. I must find myself.

Client-defined legacy dosage 

Before the start of the LI, each of these 37 male patients marked a pretest score on an Individualized Self-anchored Scale (ISS) to measure the helpfulness of his own legacy guiding toward successful treatment. This ISS measure aims to connect the individual sense of legacy with client-focused anchored terms and self-assessment with a score from 0 to 10 about the helpfulness of past personal experiences, where 0 = nothing was positive, to 10 = extremely positive (on a continuum of 11 points with the patient’s own indicators and anchored with one or more specific examples) for defining each point assigned. Table 1 showed four legacy steps: learning, recognizing, sharing and valuing (Table 1).

Table 1: Individualized Self-Anchored Scale (ISS).
Note: *The definitions of legacy dosage were based on each patient’s own definition associated with the self-anchored score reported at the end of each session.

Patients were asked to select topics of interest: Anger management, coping skills, chemical dependency, stress management, medication management, life skills, relationship building, communications, mental illness, hygiene and self-care. Theywere given time to process these topics with a focus on how their surroundings had helped them. In each session, they focused on their individual legacy dosage as connected to a concrete list of their past coping strategies and successes. This list matched with the types of legacy related to physical traits, genetics, values and talents that were related to their expectations of treatment.

During the LI process, the patients created and continuously built their legacy project with the components defined in the first session for subsequent sessions. After each session, they expressed which and how expectations were accomplished. They then provided a score on the ISS again to show the extent their legacy building further helped them manage life stressors in a positive fashion. No comparisons were made between or among patients unless the patients initiated them to highlight variations of successes. With their own storytelling input, they considered their legacy dosage as appropriate when it could reach the client’s own defined goal. This goal was composed into ten action-oriented expectations. 

Legacy dosage within the ten-C expectations

Patient expectations were described as achievements through measuring their mental clarity and physical cleanliness-two main goals for most patients with co-occurring disorders in this cohort. When the patients could identify which expectations had been accomplished, they added points from 0.1 to 1.0 per accomplishment to their legacy dosage chart at the end of a session. Due to the uniqueness of dosage definitions, patients could provide examples to further clarify their sense of legacy.

The ten-C expectations

These ten-C expectations were connected to the definition of legacy and personal examples from these patients, as represented by Samuel:

1. Connection: Legacy is being remembered by the ever-changing stories of lives (e.g., proudest moments, forgiveness of certain behaviors, lessons learned from past experiences and stories shared by others).
2. Continuity: Legacy is identified consistently and continuously with more life experiences to be added (e.g., success stories with children being present).
3. Creativity: Legacy is presented with creativity (e.g., writing, journal entries and poetry).
4. Concreteness: Legacy is measured beyond words that can be described (e.g., a drawing mailed to a friend to represent the legacy created in the session).
5. Congruence: Legacy represents the proudest moment congruent with the self-defined goal of recovery (e.g., raising children or grandchildren, using triggers, signs and symptoms to stop substance use).
6. Compassion: Legacy is a means toward forgiveness of self and others (e.g., sexual abuse, domestic violence, substance use).
7. Capitals: Legacy is the ability to identify human/social capitals and other resources to stay sober and mentally healthy (e.g., educating their loved ones to remove hard feelings; presenting how and with whom to pass the learned lesson to others during and after treatment).
8. Contributions: Legacy contributes to those who follow (e.g., sharing how to balance struggle and triumph with peers and family).
9. Common sense: Legacy is a self-identity to promote a better understanding of current needs (e.g., its appropriateness for healing).
10. Cognizance: Legacy is an awareness of one’s accomplishment with a future-focused meaning (e.g., affirmed the usefulness of their stories for substance use prevention).

In practice after talking about their experiences, patients can define their legacy dosage based on the positive expectations of how they cope or respond to a crisis. Their legacy dosage is clarified further with expectations and examples. Since this measure can be perceived differently among culturally and ethnically diverse patients, each patient may receive a chart marked with the scores to show a visualized trend of “Personal Sense of Legacy” (Figure 1). Its purpose is to create a sense of ownership along with the trend of legacy dosage at each session after the patient has built a part of the personal legacy.

Figure 1: Visualization of legacy dosage: A composite case example.

This study offers several strengths for exploring a diverse group of patients who shared similar co-occurring disorders in relation to their legacy creation and development. LI is a short-term, cost-effective and easily administered intervention. It provides a unique opportunity for creating a voice for patients who have lived with chemical dependency and mental health diagnoses but have not had an opportunity to share their learned lessons. The benefits of studying this population can be connected to the personal and intergenerational learning for individuals, their families and peers, as well as for professionals who work with them. 

However, due to the vulnerability of the population with multiple losses and the complexities in co-occurring disorders, it is not easy to reach a sample large enough to test the validity of the dosage definition and the individualized measure. Individualized charts are not reported to protect confidentiality of each patient. With the use of a composite case, the ten-C expectation list is a beginning effort to check how the recording of dosage increases could encourage patients to continue treatment. The planned contents in these ten therapeutic sessions have added legacy dosage because of the immediate effect of treatment on patient’s positive perception toward themselves. Short-term benefits included engagement in a purpose to focus on completion of a project. Future studies must address long-term effects after controlling for external factors (i.e., multiple drug use, number of hospitalizations and the absence of post-treatment motivation to continue treatment). The exploratory nature and group format might present threats to external validity and generalizability of their dosage definitions.

Implications for clinical practice

Legacy embraces the idea that reality is socially constructed and therefore could be changed for future learning and growth. Taking past experiences and choosing different social reactions in the future creates change in behavior. Patients share personal definitions of legacy and then recite life stories revealing influential social constructions. According to White [7], individuals construct the meaning of life in interpretive stories, which are then treated as truth. While the use of language in stories creates meanings and formulates cultural backgrounds, each story is true for the person telling it, just like in the composite case used in this article. Akard et al. [8], reports in a bereavement study that legacy making is action-oriented and created with a sense of reality and memory. When measuring the legacy dosage, thus, social workers must focus on the clients’ own experiences so that resistance to share discourse could be positively responded to with encouragement. Corey [9], names this legacy making process double listening, for understanding individual issues and helping clients construct desired changes. LI may support patients in taking control of their treatment and utilizing personal perspectives to move toward positive outcomes. Patients can use their own thoughts, feelings and experiences to define legacy and the dosage of its positive effect as measured by a sense of helpfulness. Patients are offered an opportunity to discover the separation of self and others. When patients have the opportunity to discover how their worldview has been influenced by others, they can make changes to reflect how they feel about themselves along with a positive lesson learned from the past. In individual therapy, clients can create a legacy project to give meaning to life satisfaction and self-efficacy as tested to be two of the many important outcomes [1]. The social workers in this PHP begin to incorporate legacy creation and definition into individualized treatment plans. 

In this study, legacy dosage is measured with the ever-changing stories of patients’ lives with elements related to pride, forgiveness, lessons learned from overcoming addiction and mental illness, etc. that can be presented in a tangible creative project. Further investigation is needed to target the effect of legacy creation on the external environment when there is a strong legacy dosage already linked to their internal system such as family and children [10]. Specifically, such effort can identify triggers for addictive behaviors and mental health symptoms (i.e., depression, codependence), how to seek help through treatment programs and how to maintain recovery [11,12]. The most important lesson learned is about prevention. When measuring legacy dosage, two patients explicitly stated their wish to spare children from experiencing addiction and mental illness by educating them on how to “not fall for the addiction game” and to know that being a child of an addict “makes them more susceptible to both”.

Determining how to measure legacy dosage is needed to support its use in work with patients with co-occurring disorders for physical and mental health benefits. Hunter [6] and Allen et al. [10], suggest the use of legacy creation in empowering patients to make treatment decisions, pay attention to life-threatening issues, reduce emotional symptoms and identify barriers to improve interpersonal relationships. Additional research on how the ten-C expectations illustrated by the patients in this study can be further tested to find support of the legacy retold. The individualized legacy dosage measured with client’s own expectations can inform practice in working with diverse populations in health and mental health settings. For the use of a tangible project with an emphasis of “I created it all by myself,” the ten-C expectations may serve as a reference to measure how the 11-point individualized scale can be presented at the beginning to establish a baseline and after the legacy project to measure treatment outcomes. Through this dosage measure, patients in treatment can concretely witness a positive impact of their legacy creation process on their mental health improvement.