Vol. #21, No. 11 – February 2024

Welcome to the February edition of Tips and Topics and to Black History Month.

In SAVVY, STUMP THE SHRINK and SKILLS, I respond to a question about Alcohol Moderation and its implications for how to work with people not yet ready to embrace abstinence and recovery.

In SOUL, it has been five years since losing my wife suddenly. Embracing retirement has opened up opportunities to travel and with companions to make that fun. One special companion has raised my awareness about African Americans and their ancestors....a fitting connection in Black History Month.

David Mee-Lee, M.D.
DML Training and Consulting

SAVVY, STUMP THE SHRINK and SKILLS

Earlier this month, I got this message from a Drug and Alcohol Therapist:

Have you heard of Alcohol Moderation as a Harm Reduction method of treatment for those with mild to moderate Alcohol Use Disorder (AUD)? I keep getting a lot of negative feedback from 12-Step based treatment programs and the 12-Step members that make up the majority of the staff in these facilities - even medical directors. It's concerning to me. 

I would love to hear your thoughts.

My response:

Hi:

Back in the day, there was Moderation Management and this sounds similar, though I haven’t heard any presentations on “Alcohol Moderation” itself.  

Consider someone who has severe AUD but is at Precontemplation or Contemplation stage of change in terms of readiness to consider abstinence, sobriety or recovery. “Alcohol Moderation” can be a useful motivational enhancement strategy: Develop a treatment plan that I would call a Discovery, Dropout Prevention plan that has the client collaborate on if and how they could moderate their use: “I’ll cut back, but I don’t need to totally stop. I can stop anytime”.

So then you experiment with the client to do as Alcoholics Anonymous says, “attraction, not promotion”.  Work on attracting the person into recovery as s/he discovers that they may not be able to successfully cut back or stay abstinent for a trial period of time.  This raises consciousness to their “loss of control”.

If you go to my newsletter Tips and Topics and in the Search on the right hand side put in Harm Reduction, you can read what I’ve written in previous editions; and also if you put in Discovery, Dropout Prevention and Treatment planning, you should come up with other ideas I have written about.

David

Tip 1

SMART Recovery has a useful, succinct summary of Abstinence vs Moderation.

The SMART Recovery article starts nicely with: “This word “abstinence” can be an intimidating word to many, especially those in the early stages of recovery.”

Take a look at the full article, but here are a few highlights in their words:

• Why abstinence?.... the simplest, easiest, safest and surest way to keep from repeating past behaviors is total abstinence. This is not to say one may not go thorough a period of “day at a time,” or “week at a time,” or even try a “harm reduction” approach. Still, if you want the easiest way to minimize the problems in your life, go for abstinence eventually.

• Is abstinence the only way?... Studies have shown that in some cultures there are a small percentage of people who can return to moderate drinking....Attempts at moderation may not be worth the effort or the risk when considering the consequences....What has the empirical evidence in your own life been? Have you tried to moderate and not been successful? Then that’s your answer.

• What if I lapse or relapse?... Learn from it and don’t beat yourself up...Your commitment isn’t broken and you can renew your resolve. If you do slip...it can be a powerful learning experience. It does not mean that you will repeat this behavior in the future. Forgive yourself, learn from it and remember that a commitment applies to what we plan for the future.

Tip 2

If a person is not convinced they need to be abstinent, what does a Discovery, Dropout Prevention Treatment Plan look like?

Years ago, I remember hearing couples therapist, David Treadway, Ph.D. say something to the effect: “The trick is not to have the light bulb go off in your head. It is the have it go off in their head”. You may be absolutely right that this person with severe addiction needs to be abstinent. But if they don’t see it, we have to work with them until the light bulb goes off in their head.

I’ll cut back, but I don’t need to totally stop. I can stop anytime”.

Therapist (T): OK, so how much are you willing to cut back? Or since you can stop anytime, how would you feel about doing a diagnostic trial of abstinence for a few weeks just to prove you don’t even have an addiction problem?

Well, yes I’m not an addict. I can stop whenever I want. So OK, I’ll stop for a few weeks just to show you I’m not out of control.”

T: OK, if you are a social drug user, it should be no problem to go 3 or 4 weeks without using. We’ll do random drug testing to document being drug-free; and check in with your family weekly to see what they notice about how you are doing.

Wait...drug testing and checking with my family?! Don’t you believe me?

T: I believe you, but I don’t know about believing addiction. So this is just a lab test to track if your plan is working. We do the same with diabetes to test blood sugar; psychotropic medication blood levels to get the right dose of medications etc. We also check in with families to see if the diabetes or Bipolar Disorder is stable or not.

How does this sound for your Treatment Plan?

  • Priority Statement“I am not an addict and can stop using for 3-4 weeks.”
  • GoalTo demonstrate and document being drug-free in a diagnostic trial of abstinence.
  • Methods and Plan(a) No drug use for 3-4 weeks. (b) Random drug testing three times per week. (c) Weekly check-in with family to monitor the effects of abstinence.

OK, that sounds alright and won’t be a problem because you’ll see that I can stop anytime. I’m not an addict and don’t need treatment.”

With a Discovery, Dropout Prevention plan, we want to keep the client engaged in treatment to discover any out of control substance use and “have the light bulb go off in their head.” It is most simple to start with a diagnostic trial of abstinence. But if the client insists on a “cutting back” Discovery plan, then start there. This will require more family or significant other check-ins to get feedback on whether s/he appears to be actually cutting back on substance use.

SOUL

Every February, I have acknowledged and remembered the loss of my wife of 46 years and the mother of our three children. If you want to track my grief process you can go to Tips & Topics and look at the February edition of every year in the Archives starting with the February 2019 edition when I announced her sudden passing.

Now five years later, how am I and our children doing? While we of course still miss her and think of her often, we are all thriving....carrying on the legacy of her vitality and zest for life; her love of learning and exploring different models of communication, health, fashion and music. While I value my alone time and don’t plan to marry again, I am not a depressed, withdrawn, grieving widower.

Quite the opposite, I have been mostly retired, which has opened up lots of fun international travel time. I traveled alone in over 25 years of full-time training and consulting.  Now I want companionship while exploring the world.

Happily, I have developed some meaningful and multidimensional relationships with a network of wonderful women....one in particular happens to be African American. With this being Black History Month, I am acknowledging and appreciating her raising my awareness of a whole variety of stereotypes and biases that have seeped into my thoughts and beliefs by cultural osmosis. It has been quite an educational and illuminating process that is only just beginning. (Of course it hasn’t all been in-person school. There’s been lots of fun companionship and travel too.)

In particular we recently traveled to Ghana and the Cape Coast where it was sobering to stand in the very dimly lit and poorly ventilated dungeons where thousands of African men and women were imprisoned.

Cape Coast Castle is one of about forty "slave castles", or large commercial forts, built on the Gold Coast of West Africa (now Ghana) by European traders.... It was later used in the Atlantic slave trade....They were used to hold enslaved Africans before they were loaded onto ships and sold in the Americas...This "gate of no return" was the last stop before crossing the Atlantic Ocean.”

As I stood at the Door of No Return (see the plaque at the top of the door photo), I could only faintly imagine how those ancestors of Black America must have felt. I lost my wife. They lost their families, homeland, and freedom enduring unimaginable inhumane treatment that robbed them of their dignity, culture and for many, their lives.

Until Next Time

Thank-you for joining us this month. See you in late March.

David

January 2024- Vol. #21, No. 10

Welcome to the new year and the January edition of Tips and Topics.

In SAVVY, guest writer, Kristin Dempsey explains Harm Reduction and her just released book The Harm Reduction Workbook for Addiction.

In SKILLS, Kristin includes some of her favorite exercises that can be used to explore one’s relationship to substances or processes. The exercises are based on the spirit and skills of motivational interviewing.

In SOUL, I experienced what it is like to show up to an island village in Ghana unannounced and unexpected only to be treated like a welcome guest. Even with menu ingredients in hand, can you imagine these “guests” (intruders) expecting you to cook and serve them a meal?

David Mee-Lee, M.D.
DML Training and Consulting

SAVVY

Kristin L. Dempsey, EdD, LMFT, LPCC, is a psychotherapist, counselor educator, and trainer. New Harbinger, NH asked Kristin to write a book on motivational interviewing. After some discussion, they settled on her writing The Harm Reduction Workbook for Addiction. It is a guide to explore one’s relationship to substances or processes via a number of exercises based on the spirit and skills of motivational interviewing. The book was just released this month.

Earlier in the year, Kristin had asked me if I would be willing to check out a PDF galley version of the book and write an endorsement blurb. I was so focused on fun traveling and non-work, that I told Kristin I was staying away from as many projects as possible.

I said however that if she agreed, I would have her guest write for Tips and Topics (TnT) and briefly summarize the main points of the book as a way to get the word out. So here is Kristin Dempsey’s content just edited to fit TnT format.

Tip 1

Harm reduction strategies are not the opposite of abstinence. Harm Reduction strategies include abstinence.

  • According to the Harm Reduction Coalition, “Harm Reduction is a set of practical strategies and ideas aimed at reducing the negative consequences of drug use.” It is also a social justice movement “built on a belief in, and respect for, the rights of people who use drugs” (National Harm Reduction Coalition, 2023).
  • Harm reduction strategies are not the opposite of abstinence. Increasingly, wellness and recovery are viewed as not a binary of harm reduction vs. abstinence. Harm reduction can be thought of as a collection of strategies that includes abstinence among many other strategies that reduce the potential harms associated with substance use or process behaviors (e.g. gambling, sex, shopping…) For instance, cutting back on drinking can be harm reduction, as is using test strips to check drugs for dangerous additives, such as fentanyl, as is stopping substance use entirely.

Tip 2

Harm reduction (HR) aims to engage and support people who use substances. Motivational Interviewing is “how” you do HR.

If harm reduction is the “what” and “why” of a philosophy aimed to engage and support people who use substances, then motivational interviewing can be seen as the “how”. Motivational Interviewing (MI) is a conversational approach based on practitioner humility and curiosity. MI providers come to meetings without an agenda, but rather an openness regarding what the help seeker needs to explore and build their own recovery.

  • Given the way MI enables a provider to collaboratively and non-judgmentally explore a person’s reasons for change, I joined a community of MI providers inspired to create a resource for individuals to explore their substance use using MI principles as part of the exploration process.
  • The great joy and challenge of this book was determining how to create exercises that allow the workbook readers to explore how they can step into the MI “spirit” and show themselves self-compassion and acceptance while noticing their strengths and who they can connect with for support. They also practice building their own reflections on their life and ask themselves evocative questions while exploring their values and identifying change talk. If it serves them, they can build their own specific plans for next steps.

SKILLS

In my new book, The Harm Reduction Workbook for Addiction, I have included exercises that can be used to explore one’s relationship to substances or processes via a number of exercises based on the spirit and skills of motivational interviewing. I have included here some of my favorite exercises:

Tip 1

Self Compassion.

Self-compassion is being able to tap into compassion – the desire and ability to help reduce the suffering of others. It is an important component of exploring change. A compassionate stance helps us overcome competing interests and judgments and instead compels us to ask, “what is the next best thing that can be done for the person in front of me right now.” In terms of the workbook, the compassion is directed toward the reader, so one of the first exercises is to explore one’s own self judgments and consider how reframing as learning instead of failure can be useful.

Exercise for self-compassion:

  • Describe a situation that you experienced as difficult that you did not handle as well as you might have liked.
  • Reflecting back on the situation, how did it make you feel? What did you think about yourself?
  • Spend a moment and think about how this situation might have been a step First Attempt in Learning (F.A.I.L.) instead of a failure. That is, what did you learn from this situation that you can now use.
  • How does looking at this situation as a F.A.I.L. feel different to you?
  • How will you use this information that you learned from your F.A.I.L.?

Here is an example of how this exercise might look: Joe’s FAIL situation was driving a few times when he knew he was over the legal driving limit. Looking back on the situation, he feels really stupid and angry with himself for putting himself, his license, and others at risk. When asked to think of it as a F.A.I.L., he immediately connects to feeling grateful that he did not get into an accident as the result of his drinking. He feels more relief and less shame when he thinks about being grateful that he is thinking about it now; and can maybe avoid any other drinking and driving incidents. He states he wants to make sure he prepares a designated driver if he is going to go out in the future.

Tip 2

Moving from Judging to Noticing.

Moving from Judging to Noticing

  • Part of the challenge of exploring one’s own substance use is getting caught up in shame regarding past regrets and behaviors. Shame is often activated by how we think about ourselves; specifically, we often experience more shame when we judge our behaviors. In order to get some space between judging that can activate shame, which can paralyze movement toward recovery, this exercise allows us to practice noticing instead of judging.
  • Start with noticing an automatic negative thought you have about an event related to your substance use.
  • How does this judgment make you feel about yourself? What additional automatic thoughts spring from this judgment?
  • Now shift from judging the thought to describing it without using any judgmental terms. Perhaps you start with the phrase, “I notice that…” or “I see that…”.
  • Now spend a moment noticing how describing vs. judging has you thinking about your self? What is the cost of holding onto your judgment? What is the benefit of describing your situation instead of judging it?

Here is another example of how this exercise might work. Cassie finds herself thinking “I should stop smoking so much weed. I am a loser”. She notices that the judgmental thought has her thinking, why should I try? This is hopeless. When asked to describe or notice the situation leading to her experiencing this self-judgment, she stated, “I notice that when I smoke throughout the day, I do not complete all the chores I was hoping to finish.” She further noticed that holding onto the judgmental thought made her feel annoyed with herself and less confident that she could quit. When she thinks about the description, she focuses less on her problematic behavior and more on the goal she wants to achieve completing the chores. Cassie reports such a shift in perspective helps her focus on what she needs to do instead of what she is not doing.

Tip 3

Explore the Continuum between “I quit” and “I don’t quit” a substance.

(a) Imagine that you are on a continuum with quitting a substance and not quitting a substance being on either end of that continuum:

I quit!________________________________________________________I don’t quit!

  • Look at the line and just notice all the space in the middle between “I quit” and “I don’t quit”.
  • Imagine for a moment, what kind of other behaviors might be between the two statements. Write down as many as you like here. You do not need to be committed to any of these behaviors right now:

Examples:

  • I can cut down one drink a day
  • I can have one cigarette before 8 AM instead of three cigarettes before 8 AM.

Write your answers here:

(b) Look at your list, you might notice, that you can write down a vast number of options between the two ends. You might even what to step away and return to this list tomorrow and write some more.

When you feel as if you have a listed all the most meaningful options between these two behaviors, circle 1 to 3 options that you might consider as a starting point in your own journey of exploration. You are not committing to anything at this time, you are just thinking about what might be possible for you.

List your options her

1.

2.

3.

As you look at your options, choose one option. Consider for a moment, what might it take for you to be more open or willing to consider exploring this behavior. Write your answer here:

How to Buy the Book:

Where to purchase The Harm Reduction Workbook for Addiction, released on January 2, 2024:

Kristin’s bio:

Kristin L. Dempsey, EdD, LMFT, LPCC, is a psychotherapist, counselor educator, and trainer. For thirty years, she has supported individuals with exploring their own relationships to substances. She is a member of the Motivational Interviewing Network of Trainers (MINT) and has been privileged to provide motivational interviewing (MI) training to thousands of people in behavioral health, primary care, public health, school, corrections, and human services organizations.

Kristin sees clients in her psychotherapy offices in San Francisco and Burlingame, California, and she teaches counseling psychology as core faculty at the Wright Institute’s Counseling Psychology Program and as Lecturing Faculty in the San Francisco State University’s Counseling Program. Kristin is currently serving as board president of the California Association of Licensed Professional Clinical Counselors.

SOUL

I was just in Ghana for two weeks soaking up as much of the culture as one can in a brief time. (I also was soaking up the sweat of hot and humid weather).

One day, we took a canoe ride on the Amudado Mother River in the Volta region of Ghana en route to an island village. As it happened, there was some trouble in the outboard engine so we diverted to a closer island and disembarked. Unannounced and unexpected, we walked into the village on Gabikpo Island.

The Queen Mother of the village greeted us as if this was a well planned tour. We had brought fish, tomatoes, peppers, onions and akple (like corn meal) that was to be cooked on the original destination island. Without missing a beat, the Queen Mother started preparing the meal.

How would your particular culture or subculture handle having complete strangers showing up at your door unannounced and unexpected? Even with menu ingredients in hand, can you imagine these “guests” (intruders) expecting you to cook and serve them a meal?

This is how what happened was explained to me:

  • In Ghana, traveling guests are always welcomed, even before a family member would be.
  • This is because it is believed that God can try you by taking on the form of a traveler. One never knows who they might be entertaining. Therefore a traveler is treated with the utmost respect and welcoming spirit.

I recognized some cross-cultural religious similarities of beliefs:

  • In the Christian tradition – “I was hungry, and you gave me something to eat. I was thirsty, and you gave me something to drink. I was a stranger, and you welcomed me…..The king will answer them, ‘I tell all of you with certainty, since you did it for one of the least important of these brothers of mine, you did it for me.’ (Matthew 25:35, 40 International Standard Version)
  • “Don’t forget to show hospitality to strangers, for in doing so, some have entertained angels without knowing it.” (Hebrews 13:2 World English Bible)
  • “Prophet Muhammad reminded us of the high status of one who treats his guest well when he said, “…Let the believer in God and the Day of Judgment honor his guest….In Islam, the hospitality relationship is triangular; it consists of host, guest, and God. Hospitality is a right rather than a gift, and the duty to supply it is a duty to God.” (“Treating Guests the Islamic Way“)

You might dismiss these cultural stories as quaint and irrelevant to the real world of the USA and other Western countries. At the start of this contentious Election year, it will be easy to see anyone who votes for the other side as unwelcome strangers. But in this context, I wouldn’t mind challenging my thinking to see:

  • Travelers at my door as guests.
  • Strangers as possible angels, or sons and daughters of God.

Until Next Time

Thanks for joining us this month. See you in late February.

David

December 2023 – Vol. #21, No. 9

Welcome to the December edition of Tips and Topics and happy holidays to all.

In SAVVY, “Parochial empathy” helps understand why we are so polarized. It is not a lack of empathy for others, but can be extreme empathy and care for those in our own community.

In SKILLS, for there to be a solution to conflict and polarization, there has to be empathy for the other side. But how to do that? Start not with facts and judgements, but rather share our stories and narratives.

In SOUL, Keith Magee paid his Uber driver for an extra hour so he could park and explain why he was a fervent Donald Trump supporter. Magee came away with a better understanding of the fears and hopes that motivated his driver, and a strong sense of human connection despite the gulf between them.

David Mee-Lee, M.D.
DML Training and Consulting

SAVVY

I have never heard of the term or concept of “parochial empathy”. So when I listened to a November 22, 2023 segment of Here & Now Anytime, it helped me answer the questions: “Why are we so polarized in so many arenas and have we lost empathy altogether?”. More importantly, it gave me hope on what to do about it.

Stanford University, Jamil Zaki, a psychologist who's devoted his career to studying empathy, gave some SAVVY and SKILLS tips about “parochial empathy”. The content is all from Here & Now Anytime. I have merely formatted it in Tips & Topics style.

Tip 1

Conflict and polarization is not a lack of empathy for others. It is more complex.

A couple of definitions to ponder:

  • “Psychic numbing” is when the number of victims rise in a tragedy or conflict, our ability to empathize drops.
  • “Empathy” is our ability to care about, understand and share the experiences of other people.

Bad actors in politics, business, or any agency of power are interested in stamping out our empathy for others. In conflicted and polarized communities, it was thought to arise from a lack of empathy for outsiders.

But it is more complex than that because It’s not that people don’t have empathy, they may be very empathetic.

  • Political conflict arises from people who have extreme care and empathy for people in their own community.
  • “Parochial empathy” means that we hear very well the pain and turmoil of people in our own community.
  • That intense caring and empathy though can use up our empathy on those inside our community leaving little empathy for those outside our community.

Tip 2

Parochial empathy arises when you feel you and your family is at existential threat.

Parochial empathy arises because of the existential threat to that community.

  • Parochial empathy is our default and that increases in existential threat situations like the current Middle East conflict (for both Israelis and Palestinians).
  • When you feel you and your family is at existential threat, it is natural to circle the wagons and pour all your energy into those in your circle.
  • This results in dehumanizing those that are a threat and schadenfreude (delight in another person's misfortune and pain).
  • When you see someone who is a threat to you, it relaxes you to see that threat in pain.

Tip 3

How would you feel if something bad happened to someone on the other side of your community? 

Such a question is confronting and forces you to stop and think, especially when you consider yourself to be a compassionate person.

  • We want to be moral people who care and feel for humanity.
  • Yet when we feel we are in a zero sum setting where the other side and we are locked in a struggle, it can feel like it is emotionally unaffordable to care for the other side.
  • In times of conflict, we want a black and white story where we feel we are on the right side of history.
  • We want to believe that anyone who we are against is just as wrong as we feel we are right.

But when we see and contemplate such suffering of clearly innocent people, it challenges that ability.

  • It can even feel that empathizing with the other side is a betrayal of our own community.
  • Extreme voices on either side, can actually treat us that way. That if we even stop and express sympathy for a victim on the other side, that somehow we are abandoning our own side and are traitors.
  • Leaders and propagandists can weaponize parochial empathy. Look at the admittedly horror and victims on our side and the only thing that can be done is to have overwhelming revenge on the other side.

SKILLS

With that understanding of parochial empathy, what are some solutions and skills to address polarized conflicts?

Tip 1

Empathy beyond Parochial Empathy is not weakness or betrayal of those on our side.

For there to be a solution, there has to be empathy for the other side. But how does that happen?:

  • We don’t owe empathy to others under whom we are in direct threat.
  • But there is power when we try to extend empathy beyond parochial empathy.
  • Empathy for outsiders does not have to be a weakness or betrayal of those on our side.

Tip 2

Empathy for those on the other side is a strength and opens up curiosity about those not in our community.

Solutions:

  • In Dr. Zaki’s lab, when they teach Democrats an Rebublicans that empathy with outsiders (for the other side) is a strength, they become more curious about outsiders and want to learn about the other side. They communicate with outsiders in a more open-minded way.
  • If you want someone to listen to you, one of the best things you can do is listen to them first.

Tip 3

Engage in conversations where it is important to not start with facts and judgements, but start with our stories. 

We imagine the average outsider to be much more aggressive and violent than they really are.

  • When we have the space, safety and bravery to engage in conversations, it is important to not start with facts and judgements, but start with our stories.
  • When people share narratives with each other, that opens the door for a shocking amount of common ground.
  • “Self compassion” – suffering tends to be a wall. When it turns into parochial empathy, it separates us from people. 
  • But it can also be a bridge when we share loss and allow ourselves to listen to the pain of others on the other side. It is something really deep and tragic that so many of us have in common.

SOUL

Keith Magee is senior fellow and visiting professor in cultural justice at University College London Institute for Innovation and Public Purpose. He is the author of “Prophetic Justice: Essays and Reflections on Race, Religion and Politics.” Earlier this month, he wrote an opinion piece about meeting someone with radically different views and how he learned an important lesson.

Here is the beginning of his piece:

It was a car ride that changed my life.

I took an Uber in Cleveland, Ohio, years ago focused only on getting to my destination, and found myself quite by chance being driven by a man whose politics were radically opposed to my own. I might have been tempted to sit in silence or to climb out of the car, but I did something else instead: I canceled my plans and paid him for an extra hour so he could park and explain to me why he was a fervent Donald Trump supporter.

I came away with a better understanding of the fears and hopes that motivated my driver, and a strong sense of human connection despite the gulf between us. For his part, he was moved that an “opponent” cared enough to listen to him. It was a moment that crystallized for me the profound power of empathy.

You can, if you want, read his full essay and the rest of the story. I was impressed with Magee’s willingness to not only cancel his plans but to also pay money to listen to the “other side”. It got me thinking:

  • Do I ever take the time to actually listen and empathize with those who have radically different views; or do I stick with my own bubble of news and views?
  • How often have I found joy in someone else’s misfortune or even pain (schadenfreude) like when a person from the opposite political spectrum gets caught for doing the very thing they have railed against in the past?
  • When have I self righteously condemned the other side from a position of parochial empathy and dehumanized others in the process?

In this season of peace on earth and good will to all people......not pretty reflections.

Until Next Time

Thanks for joining us this month. See you in late January. Happy New Year!.

David

November 2023 – Vol. #21, No. 8

Welcome to the November edition of Tips and Topics and a happy Thanksgiving to all in the USA.

In SAVVY, when clients present with mental health problems and are also using alcohol and other drugs, there could be three diagnostic possibilities. When mental health clinicians are not savvy about addiction and vice versa, misdiagnosis is easy to do.

In SKILLS, assessment guidelines on timelines and drug-free periods can help tease apart what is going on in the relationship between substance use and mental health signs and symptoms.

In SOUL, I invite you to ponder what you might say at the Thanksgiving dinner table when someone says: “Let’s share what you are grateful for this year.” Try out Marshall Rosenberg’s modified 3-step process.

David Mee-Lee, M.D.
DML Training and Consulting

SAVVY

Recently a friend introduced me to his 36 year old daughter who had just started seeing a therapist for anxiety. I talked briefly with the young woman who knew I am a psychiatrist and she was surprisingly quite open saying, unsolicited, that she was a “functional alcoholic”.  She has quite a demanding job with much responsibility and is doing well in her work.  But she went on to tell me that she often opens a bottle of wine at night and ends up drinking the whole bottle. She felt a good connection with her therapist who is doing cognitive behavioral therapy (CBT) with her.

It wasn’t my place to do a clinical evaluation, but her drinking raised a red flag for me and got me wondering:

  • Did her therapist do a substance use history?
  • Are they even knowledgeable about addiction and have the skills to explore addiction?
  • If they do discover her drinking, will they know how to engage her into a change plan for risky drinking; or will they explain away the drinking as a symptom of anxiety disorder?

Unfortunately too many mental health trained clinicians are not savvy about addiction, believing that substance use is just a self-medication coping skill for unresolved mental health issues.     

 

Tip 1

Risky substance use can be a self-medication coping mechanism. But it can be an indicator of a co-occurring substance use disorder that needs evaluation.

When clients present with mental health problems and are also using alcohol and other drugs, there could be three (not mutually exclusive) diagnostic possibilities:

  • The person may be attempting to self-medicate a psychiatric disorder with substance use.
  • The mental health problems may be signs and symptoms of the addiction illness e.g., depression because of the crash after a cocaine binge or mood swings because they are getting high on uppers and downers.
  • The person may indeed have both a co-occurring mental and substance use disorder.

 

Tip 2

It is easy to label people with mental health signs and symptoms as having a mental disorder and prescribe medication. It is better to medicate diagnoses not signs and symptoms.

  • When mental health clinicians are not savvy and skilled in addiction diagnosis and treatment, the tendency is to fall back on what you know; and not know what you don’t know. A client presents with anxiety and gets an Anxiety Disorder diagnosis and prescription. Similarly with a presentation of depression (Major Depression) or mood swings (Bipolar Disorder).
  • On the other hand, it is also easy for addiction counselors, not savvy and skilled in mental health, to see all substance use as a Substance Use Disorder needing addiction treatment. 

This is why all behavioral health professionals need to be savvy and skilled in co-occurring disorders.  Using assessment guidelines can help prevent:

  • Misdiagnosing everyone who uses substances and has mental health problems a co-occurring disordered client.
  • Misdiagnosing a mental disorder for people with mental health signs and symptoms who are actually suffering from a Substance Use Disorder with mental health manifestations of addiction; or a Substance Induced Disorder.
  • Misdiagnosing a substance use disorder for people using substances who are actually self medicating a Mental Disorder.

SKILLS

Of the three diagnostic possibilities in SAVVY Tip 1 above, it is not always clear which applies to any one client. Here are some assessment guidelines to help make a hypothesis on what might be going on:

Tip 1

Examine timelines to see if addiction problems preceded mental health problems.

  • Did the client first start experiencing mental health issues before problems with substances?
  • If the mental health problems appeared first and the client started using substances to cope, begin working on the mental health problem rather than sending the client to addiction treatment. Notice what happens to the substance use. The client could be self-medicating a mental disorder.
  • If the addiction illness came first, you might begin with a focus on the addiction; then observe what happens to the mental health problems.
  • If mental health signs and symptoms persist with effective addiction treatment and/or if substance use problems persist with good mental health treatment, this may indicate co-occurring addiction and mental disorders.

 

Tip 2

Review the time relationship between substance use and mental health signs and symptoms.

  • If the client was using substances at the time of, or not long before, the acute mental health presentation, you could be looking at a possible Substance-Induced Mental Disorder directly related to the pharmacological effects of the substances being used at the time e.g., a methamphetamine-induced depression, or an alcohol-induced anxiety disorder.
  • Check for any drug-free periods in the person’s life. Ask what happened to the mental health signs and symptoms during those drug-free times. Did mental health problems still persist strongly even though the person was abstinent? Perhaps this indicates a Mental Disorder rather than a Substance-Induced Disorder.
  • If the psychiatric problems dissipated after drug-free periods of weeks to months, then it could be that the mental health problems were substance-induced.
  • If a person could stay abstinent for a period of weeks to months and mental health signs and symptoms dissipated, but substance use flared back up, this could indicate a Substance Use Disorder and inability to stay abstinent.
  • If mental health problems persist and substance use flares back up, this may be a person suffering from co-occurring disorders.

In your clinical decision making, these guidelines are prompts to use. This is not a computer algorithm that spits out the diagnostic answer without using your clinical judgment.

SOUL

Over thirteen years ago, I wrote in the March 2010 SKILLS about how to make expressions of appreciation powerful. 

As I write this during Thanksgiving week in the USA, I invite you to ponder what you might say at the Thanksgiving dinner table when someone asks: “Let’s share what you are grateful for this year.”

There’s nothing wrong with:

“It’s been a tough year, but I’m glad you are here with me.”

“I’m grateful for all my friends”

“I love my job.”

But if you want to get in touch with what you really are grateful for and why, think first about your feelings and needs that were met. And then share your more in-depth expression of gratitude.

Here is Nonviolent Communications Marshall Rosenberg’s four step process that I first wrote about in February 2007 modified for expressions of gratitude:

Step 1.  Observing means to state what you are seeing, hearing, experiencing for which you are grateful.

Examples:

(a) “This year I’ve had work, relationship and health disappointments.....”

(b) “When I think about all my friends......”

(c) “I love my job…….”

Step 2.  Feeling means to state how you feel succinctly about that observation.

Examples:

(a) “This year I’ve had work, relationship and health disappointments and feel glad.....”

(b) “When I think about all my friends I feel tearful......”

(c) “I love my job and feel excited…….”

Step 3. Needing means to then state what human need(s) was fulfilled by the situation.

Examples:

(a) “This year I’ve had work, relationship and health disappointments and feel glad because you have been with me met my need for nurturance and support.”

(b) “When I think about all my friends I feel tearful and touched because they have all met my need for honesty and consistency.”

(c) “I love my job and feel excited because I need the autonomy and creativity this job allows.”

This may all sound a bit stilted and formulaic. I’m not suggesting that every expression of gratitude has to be a rigid 3-step process.  But if you really want to understand the fullness of your gratitude, tuning into your feelings and needs will deepen your gratitude.

Have a great Thanksgiving dinner......and gratitude sharing.

Until Next Time

Thanks for joining us this month. See you in late December.

David

October 2023 – Vol. #21, No.7

Welcome to the October edition.

In SAVVY, STUMP THE SHRINK and SKILLS, a reader asks about people who have been in prison and how to evaluate addiction Full or Partial Remission when in a controlled environment. A new Fourth Edition of The ASAM Criteria is now out. I reprise a past question about assessing people in controlled environments using both the terminology of the 3rd and new 4th Editions of the Criteria.

In SOUL, I am excited to share a new podcast. As the proud father of three smart and emotionally intelligent kids, I hope you’ll enjoy The Chosen Blood Podcast - Three Siblings Watch Home Vids & Reflect. I think the Pod is entertaining, engaging and informative, but then again I am biased.

David Mee-Lee, M.D.
DML Training and Consulting

SAVVY, STUMP THE SHRINK and SKILLS

I get questions from time to time about how to diagnose and assess clients who are or have been in jail or prison. Earlier this month Ted Izydor contacted me. Ted worked for Train for Change a few years back and was doing ASAM Criteria training for them. He also trains on Motivational Interviewing and supervises newbie clinicians. In that context this question emerged about how to diagnose addiction clients in partial or sustained remission with the prison population when they are released.

Hi David,

I was hoping to get your opinion on a clinical diagnostic question for a client who had a Stimulant Use Disorder - Severe and then went to prison for 10 years and did not use stimulants. They would have the diagnosis of Stimulant Use Disorder - Severe (in full sustained remission) - in a Controlled Environment.

Here is the question:

If they get out of prison and remain “clean” from stimulants for 6 months, is the diagnosis still in Sustained Full Remission - therefore not having an active diagnosis? Or do we put it in Partial Remission post-controlled environment? I think it stays in full sustained remission, but wanted some more experts to weigh in on how to label it as the Diagnostic and Statistical Manual, DSM-5-TR (Text Revision) is not clear.

I also think of the scenario of someone in prison for 2 years who is abstinent from let’s say opioids, but is then released and before they are released they go on Medication Assisted Treatment, MAT for a previous opioid use disorder. What would that be labeled per DSM-5-TR?

Let me know what you think when you have a chance.

Best regards,

Ted Izydor, LPC, CSAC, ICS, MBA
Motivational Interviewing Trainer
tedizydor.com
fullpotentialnow.org

My Response:

Tip 1

Just because a person is in a “controlled” environment doesn’t mean they don’t have access to susbtances. It takes motivation and skill to stay abstinent.

As regards to your first scenario, I agree with Sustained Remission because 10 years abstinence even in a controlled environment and 6 months outside of that is a lot of drug-free time. As you know, prisons are not so “controlled” - drugs do get in and are used. So for someone to have enough motivation and skills to stay abstinent means that they have had to deal with cravings to use; stay away from drug using inmates; choose not to use even though it is available albeit at a higher price than the outside world. So these are skills that warrant Sustained Remission.

Note that DSM-5-TR just refers to Sustained Remission, not “Full” Sustained Remission (no symptoms of Substance Use Disorder, SUD except for craving) for 12 months or more; and Partial Remission is for no symptoms for 3 months but less than 12 months.

By the way, I put “clean” in quotes and encourage everyone to avoid saying “clean”. Use “abstinent” or “drug-free” as “clean” is stigmatizing terminology. “Clean” connotes that if you are using substances you are “dirty”....not the most engaging term and only worsens feelings of shame or guilt.

Tip 2

When a person is prescribed addiction medication and stays abstinent from all other non-prescribed and addictive substances, then they should be considered abstinent and in Partial or Sustained Remission.

In the second scenario, if the person has been 2 years abstinent and no symptoms of SUD except for cravings, then I would still say Sustained Remission even if on MAT. If while on MAT, s/he starts using cocaine or some other drug, then s/he would cease to be in Sustained Remission. If they don't use any other non-prescribed substance while on MAT, then I believe it would still be Sustained Remission because of the 2 years achieved; and taking MAT is a medication, not a flare up of addiction. I am not a DSM expert, but this is how I would think it through.

On an added note, I encourage you to start using “addiction medication” rather than “MAT” just like we say pain medication, diabetes medication, sleep medication etc.

Tip 3

How to apply ASAM Criteria multidimensional assessment for people who are incarcerated in a controlled environment.

First of all a new 4th Edition of The ASAM Criteria has just been released and you can see all about it on the American Society of Addiction Medicine (ASAM) website.

This was a STUMP THE SHRINK question from May 2008 and I will indicate the new 4th Edition Dimension terminology as those have changed slightly.

Question: Can you provide some direction about level of care determination for persons who have be incarcerated (or otherwise in a controlled environment) for an extended period of time

My Response:

1. If a person is just starting their prison sentence:

Assess, for example, Dimension 6, Recovery Environment (The ASAM Criteria 3rd edition); Dimension 5: Recovery environment interactions (4th edition)

  • Explore what your client’s life and environment was like just prior to incarceration. For example:
  • Were friends using substances addictively?
  • Did s/he work only as a drug dealer?
  • Did they live with their partners in crime; or were they unhoused living on the street? If so, their environment would not have been supportive to recovery.
  • These will be the issues (relationships, living situation, vocational, skill-sets) that they will need to work on in treatment.

2. If a person is still incarcerated and not moving towards release any time soon:

You do the assessment in the present tense, as you are trying to assess what the person needs for treatment while incarcerated. Even though a person is in prison, they can still obtain drugs. So the assessment questions include for example in Dimension 5, Relapse, Continued Use, Continued Problem Potential (The ASAM Criteria 3rd edition); Dimension 4: Substance use-related risks (4th edition):

  • How easy or hard is it to refuse drugs even while incarcerated?
  • How do they handle cravings to use even though access to drugs may not be quite as easy as when on the outside?
  • What are their attitudes towards AA/NA and relapse prevention strategies?

Similarly for Dimension 6, Recovery Environment The ASAM Criteria 3rd edition); Dimension 5: Recovery environment interactions (4th edition)

  • Unhelpful, unsupportive people exist in prison - just like friends and influences on the outside. How are they dealing with those unsupportive people in prison?
  • Are they able to stay away from negative influences?

3. If a person is preparing for release and re-integration into the community:

You assess the ASAM Criteria dimensions with regards to the person’s level of stability and function you anticipate they would have in the community upon their release. Assess for example, Dimension 6, Recovery Environment (The ASAM Criteria 3rd edition); Dimension 5: Recovery environment interactions (4th edition).

Gauge what it will be like out there upon release from a controlled environment, not what it is like now in the prison. The community care plan must address action steps around the immediate living situation, friends, work, finances etc. outside of the support of the controlled environment.

For example:

  • Are the client’s friends to whom they will be returning still using substances?
  • Does the participant have a job ready in the community?
  • Or is the only job s/he has upon release involve illegal activities?
  • If they plan to live with fellow offenders, then that environment would not support recovery.

Similarly for Dimension 5, Relapse, Continued Use, Continued Problem Potential (The ASAM Criteria 3rd edition); Dimension 4: Substance use-related risks (4th edition):

  • Was a person able to stay abstinent while in the structure of jail or prison, but now can’t explain or demonstrate any coping mechanisms or skills to deal with cravings once they hit the street?
  • With lack of abstinence skills and no established relationship with mutual help recovery groups, the risk of a flare-up would be high severity, even though they were abstinent in the structure and confines of the controlled environment.

SOUL

Responsive Image

Warning: Proud father announcement below!

My three children, Miya, Taylor and Mackenzie just released the second podcast episode of their The Chosen Blood Pod where three siblings dig through years and years of Home Video to explore and discover what's changed and what hasn't changed over that time.

They have been pondering doing a podcast for some time and rather than think and plan incessantly before “jumping onto the court”, they decided to just “Do it!” and adjust as they go. So if you look at this second episode you will see improvements already from Episode 1.

The way it works is that the rotating host chooses a clip from years of home videos and starts the session showing that surprise clip. The topic arises from that video segment for a free flowing, unrehearsed, spontaneous sibling interaction.

Big surprise: I think it is fabulous and hope you think so too. I know their mother would be beaming with pride were she still here in the physical. Take a look.

UNTIL NEXT TIME

Thank-you for joining us this month. See you in late November.

David

September 2023 – Vol. #21, No.6

Welcome to the September edition of Tips and Topics and National Recovery Month.

In SAVVYa guest writer shares her recovery journey and the role of processing trauma in moving into true joy.

In SKILLS, Leah highlights tools and treatment models that are working for her as she explores practices for dealing with intense emotions in healthier ways.

In SOUL, recovery is a process, not an event. In fact, it is a relationship process – a relationship with yourself and others. Leah shares some heartfelt insights she has discovered over the past year.

David Mee-Lee, M.D.
DML Training and Consulting

SAVVY

September is National Recovery Month “to promote and support new evidence-based treatment and recovery practices, the nation’s strong and proud recovery community, and the dedication of service providers and communities who make recovery in all its forms possible.”

In SOUL two years ago, Katie shared her heartfelt recovery story.

This month, Leah has agreed to share her wisdom garnered not just from her lived experience, but from her passion for training, speaking, writing, and researching at the nexus of trauma, behavior change, and the legal system. She comes from a professional background in education and the courts. Leah is a Statewide Treatment Court Coordinator who focuses on coordinating training and education for over seven hundred multi-disciplinary professionals.

The behavioral health and justice services fields are increasingly savvy about the role complex trauma, event trauma, interpersonal trauma, intergenerational trauma, Adverse Childhood Experiences, brain injuries, and systemic oppression play in the development of and recovery from addiction, mental health challenges and involvement in the justice system. Over the past year, Leah and I have collaborated on exploring questions like these:

• What is the balance between digging deep into past trauma and continuing counterproductive coping adaptations and focusing on living joyously and optimistically in the present?

• If trauma (in the broadest sense) is baked in on a cellular level affecting people’s fight or flight triggering responses, what is the mix of psychotherapy, body work and corrective experiences needed to allow a person to live unshackled from the past?

• How can a person with a history of trauma cultivate peace when there are physical, emotional, social and spiritual challenges swamping them?

Leah recently summarized some of her conclusions to such questions. The content in SAVVY and SKILLS is Leah’s. I have edited and formatted it in collaboration with her to fit Tips & Topics. Leah also shares from her heart in SOUL.

If you would like to contact Leah, this is her e-mail: leahelsbernd@gmail.com 

Tip 1

To achieve joy and serenity in the Here & Now, there is no getting there without processing the trauma.

The most important thing I've learned in the last year regarding the role of processing trauma in moving into true joy is that there is no escape hatch, no magic switch, no bypass. The only way out is through.

Once I emerged from decades of absolute denial, I still continued to try literally every single strategy available to me short of hard drugs, cutting, bulimia, and suicide to avoid dealing with my actual emotions, including rigid hardcore positive focus.

Ultimately, I learned that when trauma is baked in on a cellular level affecting a person’s fight or flight triggering responses, those most deeply suppressed and painful emotions have to be processed compassionately by the self, ideally in the company of a skilled therapist. This allows reintegration of disowned and exiled parts of oneself and a shift into authentic peace and joy to occur naturally.

When we try to convince ourself that I am or should be feeling joy and peace when you really don't feel that, this is brainwashing ourselves. It can become just another mechanism to bypass having to process these painful emotions, which are the true drivers of compulsive avoidance behaviors.

Tip 2

Awareness of one’s knee-jerk reactions to triggers is a first step in processing trauma.

A sense of self-trust and internal safety may take a long time to develop, as one becomes aware of their knee-jerk reactions in response to triggers. Early on in their recovery processes people often don’t realize that they even have choice in how they respond to their triggers; or that they’re even having a trauma-response.

As this awareness grows:

  • Self-shaming atrophies, and skills for diffusion, redirection, and naming those triggers develop. 
  • Only then can someone begin to truly connect with others in relationships.
  • Only in developing safe relationships to oneself and others can real healing start to happen.

Tip 3

For helping professionals to effectively facilitate their clients move towards joy, an important responsibility is to do their own internal work.

  • They can model self-compassion and self-emotional and experiential validation to clients who are struggling.
  • They can feel and show their clients genuine care, compassion, and unconditional acceptance.
  • They can meet their clients where they are with their support, resources and services.
  • I believe the most important responsibility helping professionals have in helping clients move towards joy is to first learn self-compassion and to validate one's own experiences and emotions. When helpers do their own internal work:

SKILLS

Leah goes on to offer some SKILLS Tips to process trauma.

Tip 1 

Use a variety of tools and treatment models to address the biopsychosocial impacts of trauma.

Meditation, Journaling, Internal Family Systems, Somatic Processing, acupuncture and Eye movement desensitization and reprocessing (EMDR), have all been powerful tools in my personal healing journey.

Without being prescriptive, meditation in any form (sitting silently, guided, moving) helps one feel their greater connection to everything in existence. It helps you witness your mind as it goes about its important daily work of trying to keep you safe and alive, helping to dispel the myth that “I am my mind.”

Journaling or reflective writing is a powerful tool for many people who can best organize and make sense of their observations of their own mind and their experiences by cataloging and synthesizing them on paper. However it is accomplished, self-reflection without judgement is the key beneficial factor.

Internal Family Systems, Somatic Processing, and EMDR are all more in depth treatment modalities that I encourage you to explore more deeply. They are supported to aid in the healing of trauma by extensive research, but each warrant a more in-depth discovery process than can be undertaken here, should the interest arise in you.

Tip 2

Healthier practices for dealing with intense emotions may build slowly at first, but the momentum does eventually lead to an exponential progress curve over time.

Along the way, while attending to this deep work, there is an absolutely critical need for:

  • Practicing positive psychology.*
  • Developing awareness of your triggers.
  • Directing one's focus deliberately towards what you want in life.
  • Moving steadily towards a healthier lifestyle.

But it's also critically important that these practices:

  • Do not themselves become mechanisms for bypassing painful suppressed emotions.
  • Do not help the person continue to stay in their fantasy rescue thinking, which is a habitual/residual protective adaptation that was developed in response to feeling completely powerless at the time(s) they experienced trauma as a child.

Momentum in learning to utilize healthier practices for dealing with intense emotions may start to build excruciatingly slowly. But it's been my experience that the momentum does begin to compound eventually, leading to an exponential progress curve over time.

* Positive psychology is a scientific approach to studying human thoughts, feelings, and behavior, with a focus on strengths instead of weaknesses, building the good in life instead of repairing the bad, and taking the lives of average people up to “great” instead of focusing solely on moving those who are struggling up to “normal” (Peterson, 2008).

SOUL

I am not recovering from a mental or addictive disease. But as the joke goes, I am a recovering psychiatrist in long term recovery from the stereotypical medication-prescribing MDeity. In fact, I have been accused of being a social worker not a psychiatrist.

Social Workers are taught to be more person-centered and to understand people in the context of social, economic and cultural institutions and interactions. Psychiatrists are only just beginning to pay more attention to social drivers and determinants of health.

A lot of what I learnt about Recovery came from on-the-job training with addiction counselors in long-term recovery when I was assigned to an inpatient addiction treatment team. I was assigned to that team not because of my exquisite knowledge about addiction, but because they couldn’t get anyone else to work on that team.

Recovery is a process, not an event. As Katie wrote in her recovery story, her path into and through recovery involved relationship with others and with herself. So Recovery is a relationship process.

Leah shares some heartfelt insights she has discovered over the past year. They could help you and/or those you serve.

“Only in developing safe relationships to oneself and others can real healing start to happen. Finally, as this happens, and the internal compass is gradually reoriented to it being safe to feel good in oneself, in relationships, and in the world generally, true vibrational shifts begin to occur, and thereby changes in one's frequencies of attraction begin to occur.”

What I hear Leah saying as I ponder the hours of collaboration we have had on the recovery process is this:

  • Recovery is a personal and an interpersonal healing process.
  • This takes honest, sometimes tumultuous exploration of trauma to know that you are safe in just being your authentic self and in relationships and the world.
  • As that personal and interpersonal safety grows in recovery, you experience real shifts in outlook and attract more and more joy, peace and optimism.

Leah goes on:

“As a result of my personal journey, I believe there is only one faith needed for inner peace; the faith that you will not abandon yourself emotionally ever again, no matter what emotions you feel; that ALL parts of you are acceptable and that your WHOLE self is inherently worthy of unconditional love. This radical self-acceptance blooms over time into emotional self-efficacy and authentic present-moment experiencing of good feeling emotions without fear of "the other shoe" dropping all the time. I believe that this deep inner peace is foundational to being able to experience true and lasting joy.”

Couldn’t have said it better myself.

Until Next Time

Thanks for joining us this month. See you in late September.

David

August 2023 – Vol. #21, No.5

Welcome to the August edition of Tips and Topics and to all the new subscribers.

In SAVVYI recommend you watch William Miller highlight the What and Why of some of the new changes in Motivational Interviewing (MI). I highlight how MI helps you be a more effective agent in helping people change and grow.

In SKILLS, listen to Scott Miller on Mike McGee’s podcast talk about how to use feedback to identify where you might need a coach rather than an overall supervisor. The coach is expert in a particular skill that feedback measurement has identified you as falling short.

In SOUL, Dr. James O. Prochaska, a pioneer in the field of psychology who revolutionized the science of behavior change died on July 9, 2023, at the age of 80. How do you say good-bye to such an icon?

David Mee-Lee, M.D.
DML Training and Consulting

SAVVY

Motivational Interviewing (MI) has had a huge impact not just initially on the addiction treatment field but increasingly on general healthcare and even in fields beyond healthcare. The first edition was published in 1991 and the 4th edition, “Motivational Interviewing - Helping People Change and Grow” is just out now this month. Who better to give an overview of the major changes in this new edition than William Miller, Ph.D., co-author with Stephen Rollnick.

You can watch (I highly recommend it) that free webinar if you go to The Change Companies website, click on Webinars and you will see the MI webinar and also one on the upcoming new 4th edition of The ASAM Criteria. (An interesting bit of trivia is the the first edition of The ASAM Criteria was published also in 1991 and both MI and The ASAM Criteria’s 4th editions are out this year too).

You can also go directly to the MI webinar

Dr. Miller started with the What and the Why of changes in the 4th edition. But I was especially interested in his information on what the research says about what it takes to be an effective therapist. Then he showed how MI overlaps with those characteristics and supports the development of those skills.

Tip 1

The therapist’s skills affects the outcomes of treatment far more significantly that what therapy model you believe in and practice

At minute 18:44 of the webinar, Dr. Miller summarized research on outcomes and comparisons between different schools of therapy. He said:

  • It is now well documented that when "different" bona fide therapies are compared with each other, there is usually no clinically meaningful difference in client outcomes.
  • Whereas therapists' outcomes do vary significantly.
  • Therapist factors account for far more variance in outcome than do treatment methods.

In other words, you may think your favorite model of therapy is far superior to someone else’s model of care. But actually there’s not a lot of difference. The real difference depends on what the therapist is good at, not what model they are using.

Reference: Wampold, B. E., & Imel, Z. E. (2015). “The great psychotherapy debate: The evidence for what makes psychotherapy work” (2nd ed.). Routledge.

Tip 2

These therapist factors and skills determine who does better in treatment.

At minute 19:44, Dr. Miller reviewed the therapist factors that are responsible for who does better in treatment. Here are the clinical skills that the research says really matter:

  1. Accurate Empathy
  2. Positive Regard
  3. Genuineness/Congruence
  4. Acceptance
  5. Focus
  6. Hope
  7. Evocation
  8. Offering Information and Advice

Reference: William R. Miller & Theresa B. Moyers (2021). “Effective Psychotherapists – Clinical Skills That Improve Client Outcomes” Routledge.

Tip 3

Motivational Interviewing overlaps and supports the therapist factors that make for more effective ouctomes in helping people change and grow.`

At minute 20:36, Dr. Miller explains what key elements and foundational concepts of MI overlap with the essential therapist factors effective in helping people change.

  1. Accurate Empathy - Foundational in MI
  2. Positive Regard - Affirmation
  3. Genuineness - Not emphasized before 4th ed.
  4. Acceptance - Key element of MI spirit in MI
  5. Focus - Focusing is a key process
  6. Hope - Evoke hope, support self-efficacy
  7. Evocation - Evoking is a key process in MI
  8. Information/ Advice - Included in MI

Tip 4

Motivational Interviewing helps you do better in whatever treatments and models of change you are using, both inside and outside of healthcare.

At minute 23:14 Dr. Miller explains that MI is not meant to be done instead of other treatments. It cuts across all kinds of treatments and helping models. In fact, while it started in the addiction treatment field, it is now commonly combined with other treatments as a way of doing whever else you do.

At minute 25:17, Dr. Miller reviewed all the ways MI is a way of doing:

  • Cognitive behavior therapy
  • Health care
  • Diabetes and nutrition education
  • Preventive dentistry
  • Social work
  • Case management
  • Probation supervision
  • Sports coaching
  • Education
  • Leadership

SKILLS

Last month I reviewed several issues to do with Feedback Informed Treatment (FIT). As it happened, my friend and colleague Michael McGee, M.D. also focused on FIT in his July 29, 2023 podcast with Scott Miller (no relation of William Miller, but one of a handful of mentors who have taught me so much).

So in addition to the William Miller webinar, I highly recommend listening to Dr. McGee’s interview with Scott Miller, Ph.D. There’s even a transcript of the interview so you can read and listen and not miss a thing. Mike McGee summarizes below some of what he discussed with Scott Miller, but better to hear it from “the horse’s mouth” on the podcast. (I have re-formatted what Dr. McGee wrote and put it in Tips & Topics format.)

FIT began about 30 years ago, like Motivational Interviewing. Most clinicians actually decline in efficacy over the years. More education doesn’t help. What helps to improve outcomes is getting feedback. But not just getting feedback, but actually doing something with the results. Discussing the results with clients.

Tip 1 

To improve your clinical skills, get a coach who can help you with repeated deficits in your practice that you may be blind to.

There is a psychological tendency towards complacency when we reach a certain level of proficiency, a tendency to “let it be.” To becomes clinical masters, we need to counter that tendency. By intentionally getting feedback, we can identify non-random errors in our practice that we may be blind to.

What deliberate practice requires is not supervision, which has not been shown to improve outcomes, but a coach; someone with skills that can help you address identified deficits. The way to find a coach is to be proactive and reach out and ask experts who you feel might be able to coach you.

Tip 2

You don’t need an overall supervisor. You need a coach who is expert in a particular skill that feedback measurement has identified you as falling short.

There is the need for deliberate practice, which can be difficult. This requires dedicated time. Therapy time is not necessarily practice time, it is a performance. Deliberate practice might be working with a coach to practice a particular skill, such as empathy, trying it in a practice session with your coach, and getting feedback on your work from your coach, and then trying it again. It is intentional, focused work to hone specific clinical skills that are identified from client feedback.

Here’s what Scott Miller says:

What deliberate practice requires is a coach. A good model for this is to look to Olympic athletes because most of these elite athletes don't have one overall coach and they don’t pick them from a pool of potential coaches. Instead, championship figure skaters have an equipment coach, a dance coach, a choreography coach, an upper body strength, a lower body strength coach. They have people who specialize in areas that may be in need of improvement. And therapists also need that.

We don't need an overall supervisor. You don't need the best supervisor. You need someone who is an expert in the area in which you evince shortcomings. And that means measurement.”

SOUL

About 7 years ago, I was at a conference where a trainer was talking about Motivational Interviewing and the Transtheoretical Model of Change. We were instructed to do a “real-play”, not a role-play, with an attendee seat mate.....“real-play” as it needed to be a subject that was real for us in our lives. I happened to be sitting near Jim Prochaska so we were it. I did a real-play with “Dr. James O. Prochaska, a pioneer in the field of psychology who revolutionized the science of behavior change and who died on July 9, 2023, at the age of 80.”

That was one of the last times I saw him up close and personal. I don’t think he would mind my telling you that he was at Action Stage of Change for eating more vegetables and staying healthy so he could be with his grandchildren for as long as possible.

How do you say good-bye to an icon whose work transformed the way I and thousands of other people approach addiction treatment, smoking cessation, weight management, and many other areas of behavior change? I say you say good-bye by:

  •  Embodying in our own lives the compassion, respect, humility and leadership that Jim Prochaska represented.
  • Carrying on the spirit and specifics of the Stages of Change Model that he and Carlo DiClemente championed.
  • Striving to attract more people into behavior change not by coercion, disempowering and demanding compliance but by meeting people where they are at in their various stages of change.

Jim Prochaska, Bill Miller and Scott Miller are mentors and leaders who revolutionized my knowledge and skills for the better. Two of them I can still say “thank-you” to their face. One of them, I wished I had.

Until Next Time

Thanks for joining us this month. See you in late September.

David

July 2023 – Vol. #21, No. 4

Welcome to the July edition.

In SAVVY, STUMP THE SHRINK and SKILLS, a reader asks about my thoughts on Feedback Informed Treatment (FIT). It reminded me of how far behind we still are from the rest of healthcare’s Measurement-based Care practices. Check out Jim Walt’s entertaining and informative keynote presentation about golf and what it has to do with Feedback-Informed Treatment (FIT).

In SOUL, I share another joke-with-a-message from Funsteria about cutting off the end of the ham before baking it. How often do you do something because that’s the way it’s always been done?

David Mee-Lee, M.D.
DML Training and Consulting

SAVVY, STUMP THE SHRINK and SKILLS

Earlier this month, Delilah, a student at the Hazelden Betty Ford Graduate School of Addiction Studies, asked me my thoughts on several issues to do with Feedback Informed Treatment (FIT). Her questions have broader implications for the area of Measurement-based care of which FIT is a premier example and method. Here are her questions:

In the Hazelden class we are taking now, we are discussing Feedback Informed Treatment (FIT) surveys. Do you have anything you have written, or have an opinion on Session Rating Scale (SRS) and Outcome Rating Scale (ORS) surveys.

I think surveys are impersonal and generally can be ineffective.

When it comes to counseling and a good therapeutic alliance, isn't asking for feedback by the counselor of the client, better done when the timing is right and in person?

In a person centered approach, wouldn't asking for feedback on how the alliance is going be a natural thing to discuss and get live feedback?

A lot about the surveys seem like a mediocre way to collect feedback, from what is a very personal, often sensitive relationship.

I just wanted to check and see what you thought.

Thank you in advance.

Delilah

Delilah Mahl
Graduate School Student
Hazelden Betty Ford Graduate School of Addiction Studies
Email: DMahl@hazeldenbettyford.edu

Tip 1

Hear Scott Miller, Ph.D. briefly explain FIT and the FIT Alliance Stool. His work has for years changed my whole understanding of measurement and outcomes-driven care.

Go to scottdmiller.com, scroll down to Scott’s most informative FIT TIP 4 minute video. He introduces FIT, ORS and SRS and the FIT Alliance Stool - Improving Outcomes for “at risk” Clients: The FIT “Alliance Stool” April 11, 2023

The FIT Alliance Stool highlights:

The “What?” – Goals, Meaning or Purpose
The “How?” – Means or Methods
By “Whom?” – Client view of the bond and role of the helper
With “Whom?” – Client preferences, values, identity, culture/worldview

Tip 2

Focus on Treatment Outcomes Measured in Real-Time to Guide Treatment.

Delilah said: “When it comes to counseling and a good therapeutic alliance, isn't asking for feedback by the counselor of the client, better done when the timing is right and in person?  In a person centered approach, wouldn't asking for feedback on how the alliance is going be a natural thing to discuss and get live feedback?”

You would think asking for feedback would be a natural thing to discuss; and yes, getting live feedback is the way to do it. The ORS and SRS are indeed done “live” but the timing is at every session in outpatient therapy and every week perhaps in residential settings.

If you provide counseling or therapy, how often has this happened to you?

  • You thought you had a good session with a client, pointing out insightful self-defeating patterns with therapeutic brilliance, only to have them miss the next session or even drop out of treatment?
  • The client sits passively in sessions and you feel like you are doing all the work to get them to talk.
  • The client wants to see you, but they don’t seem to be making much progress or change in their life. You wonder if you have just created a dependent relationship where you are a paid friend?

Whatever real-time feedback mechanisms you use, the goal of such measurement-based care is to guide treatment in the here and now and hopefully avoid these common clinical dilemmas.

So getting live feedback is not left to when the timing is right, but rather a deliberate and routine process at every session. When you accumulate trend data on how the client is doing and the quality of the therapeutic alliance, you can be proactive about what to change in treatment to minimize dropout, increase engagement and improve outcomes.

With treatment of chronic illnesses, changes to the treatment plan are based on treatment outcomes and tracked by real-time measurement at every visit (e.g., blood pressure or blood sugar levels are monitored to determine the success of the current treatment regimen).

It should be no different with behavioral health treatment. How do you know if the client is engaged in a good therapeutic alliance and improving if you don’t actually measure and track the alliance and outcomes?

Tip 3

Practice without real-time feedback is like hitting golf balls and not tracking where they land.`

Ten years ago, in the August 2013  edition, I wrote about this TIP and the importance of real-time feedback to know if what you are doing with clients is effective or not. At the 2013 Annual Conference of the California Association of Marriage and Family Therapists (CAMFT), Jim Walt, a licensed Marriage and Family Therapist, gave a keynote presentation about golf and what it has to do with Feedback-Informed Treatment (FIT).

It is worth watching his entertaining and informative 15 minute presentation.

A few of his points:

  • If your clinical practice is not focused with purpose, you may feel like you are doing good work, but without feedback, you don't really know if you are being effective.
  • When you drive the golf ball, you need immediate feedback on how close you came to the 3 feet circle of the hole; or how far away you were from the 145 yard mark.
  • Based on that real-time feedback, you can know whether you have to apply more force, a better angle or adjust your grip on the golf club to hit your mark.
  • Hitting golf balls with no feedback is meaningless practice if the goal is to be effective and purposeful.
  • Jim Walt talks about how we should relish getting feedback from the client on whether the session we just had hit the mark or not.
  • Even better, candid feedback on how the session was not helpful provides the information the therapist needs to know how to adjust things for the next session.

Tip 4

Questionnaires and client surveys after the fact of treatment are inadequate to measure outcomes and effectiveness of your services.

Delilah said: “I think surveys are impersonal and generally can be ineffective. A lot about the surveys seem like a mediocre way to collect feedback, from what is a very personal, often sensitive relationship.”

I agree. I don’t know if treatment and service providers are still sending out surveys after a person “completes” treatment, asking them a variety of questions about the facilities, staff, food, programming and treatment experience.

If you really want to know how your services are experienced by your clients, the only effective way to have actionable data is real-time feedback and measurement-based care. Based on the immediate feedback – good, bad or indifferent – you now have a chance to collaborate on real-time changes to the treatment and service plan and enhance the therapeutic alliance and results.

SOUL

I have written before about my daily ritual to see what joke Funsteria has come up with to make me laugh. In March 2023, I shared a joke about the bear, wolf, fox and rabbit. If you missed it, take a look because it has a great lesson for your clients.

This month, I have another joke-with-a-message from Funsteria.

A young woman was preparing a ham dinner. After she cut off the end of the ham, she placed it in a pan for baking. Her friend asked her, “Why did you cut off the end of the ham”? And she replied ,”I really don’t know but my mother always did, so I thought you were supposed to.”

Later when talking to her mother she asked her why she cut off the end of the ham before baking it, and her mother replied,”I really don’t know, but that’s the way my mom always did it.”

A few weeks later while visiting her grandmother, the young woman asked, “Grandma, why is it that you cut off the end of a ham before you bake it?”

Her grandmother replied ,”Well dear, otherwise it would never fit into my baking pan.”

How often do you do something because that’s the way it’s always been done? When it comes to being more effective in our work with clients, it’s time to do something different.  Actually ask clients, in real-time, at every session if what we are doing with them is a good fit for them; and if it is working for what they want?

If you don’t ask, you are likely doing the same thing because that’s the way it’s always been done.

Until Next Time

Thank-you for joining us this month. See you in late August.

David

June 2023 – Vol. #21, No. 3

Welcome to the June edition.

In SAVVY, STUMP THE SHRINK and SKILLSa reader asks about my thoughts on what stage of change people are who go into treatment. He somewhat disagrees with what he heard at a training: “Rarely will you see a person come into treatment in the Preparation or Action stage of change”. 

In SOULat least one reader didn’t ‘get’ the message I was sending last month when I shared Tucker Carlson’s text messages. I believe the wisdom I highlighted is so important, that I’m giving it one more try to explicitly spell out what to do about the polarization in the USA.

David Mee-Lee, M.D.
DML Training and Consulting

SAVVY, STUMP THE SHRINK and SKILLS

Fred Mills asked a question last month that prompts several learning points. He draws on the Stages of Change in the Transtheoretical Model of Change (Prochaska and DiClementefrom Precontemplation (not interested in changing); Contemplation (ambivalent about changing); Preparation (getting ready to change within the next month); to Action (taking active steps to change).

Hi, Dr. Mee-Lee. I was in a training today and the trainer said, “Rarely will you see a person come into treatment in the Preparation or Action stage of change”. I tend to disagree. I know many people who come into treatment are still in Precontemplation or Contemplation stage but I think the majority of people who go through with entering treatment would be at Preparation or Action. Can you offer some thoughts to help me understand?

C. Fred Mills, LCADC, LPCC

Targeted Assessment Specialist

Opioid Use Disorders Project (TAP OUD)

UK Targeted Assessment Program

Prestonsburg, KY 41653

fred.mills@ky.gov

Tip 1

People who go to the trouble of getting into treatment are at Preparation or Action. But they may not be at Action for what we think they should be.

Hi Fred, my experience is that just because people go through the effort of coming to treatment, that doesn’t mean they are at Preparation or Action for Recovery. They may be at Action for getting their kids back; getting off probation; staying out of jail; keeping a job or relationship, but at Precontemplation or Contemplation for stopping drinking or drugging. They will say things like “I have to be here to get my kids back” or “I can stop anytime” or “I don’t think it’s a problem but my boss has it in for me”.

Tip 2

To assess if a client is at the stage of Preparation or Action and for what, listen to what they are actually saying about what they want.

If they really are at Preparation or Action for recovery, then they would say things like “I have a severe problem with alcohol or drugs and I want to stop and I’ll do whatever it takes.” If they really are at that stage, they may not need much formal treatment unless they need immediate withdrawal management or have co-occurring physical and/or mental disorders.

They could start with Alcoholics Anonymous or Narcotics Anonymous or SMART Recovery and some outpatient education about addiction and recovery. 

Tip 3

To engage a person in a self-change process, start with what they are at Preparation or Action for, not what we think they should be at Action for.

In treatment we always welcome a person who comes, but we start with what they really want, what they are at Preparation or Action for, not what we want for them, what we are at Action for. In other words the assessment and treatment plan would focus on what they want (getting the children back) and how we can help then get their children back?

You will no doubt get to the concerns you may have about their drinking or drugging; or the partner they have at home.  As you assess with the client what concerns Child Protection Services has about reunifying with their children, their drinking, drugging or companions will inevitably come up in the assessment conversation.

 Tip 4

The collaborative treatment plan should focus on what the client is at Action for to help them get what they want.

If the client wants their children back, the treatment plan would focus on all the obstacles to reuniting with their children and what the client is willing to do or not do.

  • If the client is at Action for reunification but at Contemplation (ambivalent) about stopping drinking, the “discovery” treatment plan would focus on how to prove there is not a drinking problem rather than just getting the client to comply with abstinence.
  • If the client is at Precontemplation about separating from an abusive partner, the “discovery” treatment plan would focus on how to demonstrate that children would be safe in a home with such a partner living there. 
  • If the client is at Action for recovery, then treatment is easy. Just help them change friends, deal with urges to use, stay away from dangerous places, go to meetings etc. Such a client will happily adhere and work hard. If you get pushback, then they are not at Action for recovery.

SOUL

I don’t like all the polarization in our country....political, cultural, racial, religious and on and on. Being Asian, albeit born and raised an Australian Chinese person, I probably don’t like conflict anyway. It is only going to get worse as the election season heats up for the next year and a half.

So I will address this polarization only one more time for a while and give my message of SOUL last month one more try. The content of what I was trying to say about Tucker Carlson’s January 7, 2021 texts is so important that I am going to spell it out more clearly. This was prompted by a reader’s candid message to me as follows:

To quote a person (Tucker Carlson) who has done so much harm in spreading lies to his listeners is very disconcerting. There are so many professionals that are more knowledgeable about addiction issues that are well respected and trusted than this individual. It makes me start to question your judgment. Please remove me from your list of subscribers. (I didn’t hear back about permission to acknowledge her name, but she is a Licensed Clinical Social Worker. I am also not sure if she even read what I wrote as I wasn’t referencing his addiction knowledge. Maybe she only had time to read the email Subject Headline “Wisdom from Tucker Carlson”)

Here’s the message I was trying to send last month because for at least one reader, ‘Message Sent was not the Message Received’.

If you identify with Republicans and love Tucker Carlson:

To what degree do you agree with the insights on which Tucker reflects in his texts?

  • “.....this isn't good for me. I'm becoming something I don't want to be.”  - Is there hate, violence, a lack of compassion and empathy that is taking us over to become something we don’t want to be?
  • Much as I despise what he says and does, much as I'm sure I'd hate him personally if I knew him, I shouldn't gloat over his suffering.” – Have we become so divorced from our humanity that we can gloat over the suffering of someone with whom we disagree?
  • I should be bothered by it. I should remember that somewhere somebody probably loves this kid, and would be crushed if he was killed.”  - To what extent have we so dehumanized those we disagree with that we wish them dead?
  • “If I don't care about those things, if I reduce people to their politics, how am I better than he is?" – Have we so demonized the opposition that we have lost sight of our own humanity and compassion for others?

If you identify with Democrats and do not love Tucker Carlson:

Can you open your heart to see the wisdom that arises from a fellow human being whose words you usually despise?

  • Can we find common ground and areas of agreement to bridge the polarization between the right and the left of the political divide?
  • Can you embrace the self-reflection to take stock of whether hate, violence and lack of compassion and empathy are taking us over?
  • Even the people we think the worst of for what they say and do, can be part of healing. Can we see that they too have a human heart that has the capacity for empathy and caring about those with whom they disagree?
  • Who will reach out first to break down the dehumanizing and demonizing of others that pushes us all further apart?

Years ago, I heard a couples therapist give this great advice: The person who should reach out first to bridge the divide is the one who believes they are the most correct with God, Source, the Universe on their side.

Until Next Time

Thank-you for joining us this month. See you in late July.

David

May 2023 – Vol. #21, No. 2

Welcome to the May edition of Tips and Topics and to all the new subscribers.

In SAVVY, there is preoccupation with medication as the main and most effective treatment in physical and mental health and addiction. But there are a variety of non-medication lifestyle interventions that can be as effective as medication, if not even better.

In SKILLS, engage with clients to embrace an exercise mindset, use the power of placebo to build hope, and work with families to improve relationship time.

In SOUL, Tucker Carlson, previously a ratings star for Fox News, sent a text message to a producer on January 7, 2021 when he was watching a video of people fighting on the street in Washington. In this age of polarization and demonizing those with whom we disagree, Carlson shares some surprisingly good and insightful advice.

David Mee-Lee, M.D.
DML Training and Consulting

SAVVY

Society, psychiatry and addiction medicine are, in my opinion, too focused on medications as the answer to any ailment. Watch any TV show and you will likely see at least one advertisement for a prescription or over-the-counter medication. Rarely do you see anything promoting lifestyle change.

While scientific advancements in neurobiology, brain function and neurotransmitters have given rise to effective pharmacotherapies, they have also seduced too many into seeing medications as the most important intervention in mental health and addiction.

To balance the scale of therapeutic interventions, this month’s edition highlights some recent findings on lifestyle interventions that can be supportive of what medications do and in some cases, are superior to medication.

Tip 1

Exercise and physical activity can improve anxiety, depression, addiction recovery, and other health outcomes. For depression, exercise may be more effective than counseling and leading medications.

Here are the Headlines:

    • The Addition Of Simple Exercises To Treatment May Improve Recovery From Substance-Use Disorders, Study Indicates

The Washington Post (4/26/23, Reynolds) reports a study “found that incorporating simple workouts such as jogging or weight training into treatment improved the likelihood of recovery from a variety of substance-use disorders, including to cocaine, opioids, cannabis and alcohol.” The study was published online April 26, 2023 in PLOS One. The study’s findings “build on other research, some with animals, showing that exercise changes our brains and thinking in ways that can reduce drug cravings and relapse and might even stave off addictions in the first place.”

    • Exercise For Treating Depression As Effective As Standard Drugs, Psychotherapy, Review Suggests

The Washington Post (3/15/23, Reynolds) reports, “Exercise as a treatment for severe depression is at least as effective as standard drugs or psychotherapy and by some measures better, according to the largest study to date of exercise as ‘medicine’ for depression.” The new research “pooled data from 41 studies involving 2,265 people with depression and showed that almost any type of exercise substantially reduces depression symptoms, although some forms of exercise seemed more beneficial than others.” The review findings were published online February 16 in the British Journal of Sports Medicine.

Researchers are calling for exercise to be a mainstay approach for managing depression as a new study shows that physical activity is 1.5 times more effective than counseling or the leading medications.

    • Exercise Appears To Significantly Decrease Suicide Attempts, Systematic Review Suggests

Healio (4/3/23, Bascom) reports, “Exercise significantly decreased suicide attempts,” investigators concluded in the findings of a 17-study, 1,021-participant systematic review and meta-analysis published online ahead of print in the June issue of the Journal of Affective Disorders.

    • Supervised Exercise Programs May Be Tied To Significant Reductions In Symptoms Of Depression Among Children And Teenagers, Systematic Review Concludes

HealthDay (1/6/23, Thompson) reported, “Supervised exercise programs are associated with significant reductions in symptoms of depression among children and teenagers,” investigators concluded in the findings of a 21-study systematic review and meta-analysis “involving more than 2,400” children. The findings were published online Jan. 3 in JAMA Pediatrics. Additionally, the systematic review “revealed a greater benefit from exercise among children who had already been diagnosed with depression or another mental illness.” Anish Dube, MD, MPH, Vice Chair of the American Psychiatric Association’s Council on Children, Adolescents, and Their Families, stated that “‘in a sense, physical activity itself is similar to an intervention that we would call behavioral activation,’ in which patients engage in meaningful activities to subvert...depressive lethargy.”

Tip 2

For children and adolescents consistent and good sleep supports health, happiness and mental well-being.

    • Study Highlights Importance Of Good Sleep For Adolescents’ Mental Well-Being

MedPage Today (4/5/23, DePeau-Wilson) reports, “Sleep problems throughout the transition from childhood to early adolescence were associated with psychopathology symptoms, highlighting the importance of good sleep for adolescents’ mental well-being,” investigators concluded in a study revealing that “among over 10,000 kids, those with more severe sleep problem profiles had a higher risk of concurrent internalizing symptoms.” The findings were published online April 5 in JAMA Psychiatry.

    • Consistent sleep may be key factor in supporting children’s health, happiness

CNN (3/16/23, Holcombe) reports, “One of the keys to keeping your child happy and healthy is making sure they get enough sleep consistently,” according to a new study published in JAMA Network Open. For the research, investigators “monitored 100 children ages 8 to 12 living in New Zealand,” and “the children alternated between a week of going to bed one hour earlier and one hour later – with one week at normal time in between the two.” Investigators “covered many aspects of well-being, including an assessment of how the children felt physically, and psychologically, in their relationships with parents and peers, and how they felt about school.”

Tip 3

In anxiety, mindfulness can be better than medication and breathing exercises may even be better than mindfulness.

    • Practicing Mindfulness To Relieve Anxiety May Be Just As Effective As Escitalopram, Research Indicates

The Washington Post (1/23/23, Morris) reports, “Practicing mindfulness to relieve anxiety can be just as effective as medication,” research indicates. The findings of a 276-participant study published online Nov. 9, 2022 in JAMA Psychiatry “showed that people who received eight weeks of mindfulness-based interventions experienced a decrease in anxiety that matched those who were prescribed escitalopram.”

    • Breathing Exercises May Improve Mood, Reduce Anxiety Better Than Mindfulness Meditation, Study Says

The Washington Post (3/16/23, Sima) reports, “A study in Cell Reports Medicine showed that just five minutes of breathwork each day for about a month could improve mood and reduce anxiety – and these benefits may be larger than from mindfulness meditation for the same amount of time.”

SKILLS

Tip 1 

Engage clients in embracing an exercise mindset to improve physical, emotional and social health.

    • Exercise mindset, perception can have impact on health outcomes

The Washington Post (3/22/23, Reynolds) reports that a “new study of mindsets and exercise...shows that learning how much we actually move by tracking our steps could help us start thinking of ourselves as active people, which can pay health dividends, even if we don’t start exercising more.” The research suggests that people who “had been given inflated steps responded almost identically to those receiving accurate counts.” Investigators “suspect this signifies that many of us see little subjective difference between 7,000 and 9,000-ish steps, but plenty of difference between 7,000 and 4,000.” The findings were published in the Journal of Medical Internet Research.

Tip 2

Use the power of placebo to retain patients in treatment and improve their sleep.

    • Use Of Open-Label Placebo Alongside Methadone For OUD Tied To Greater 90-Day Retention Rates, Better Sleep Quality Compared With Use Of Methadone Alone, Small Study Indicates

Harvard Medical School’s News & Research explained placebo medication:

“The researchers found that participants who knowingly received placebo pills in addition to standard-of-care methadone treatment were significantly more likely to remain in treatment than were participants who received methadone treatment alone. Participants who received placebo pills also reported better sleep quality.

"The clinical implications of our intervention have great potential impact, as retention in treatment is a serious challenge for the field of addiction medicine,” said Belcher. “We’ve demonstrated it’s feasible to administer a placebo in addition to standard-of-care methadone in a community-based opioid treatment setting without adding a significant burden to clinic procedures, and the low-cost, low-risk nature of this intervention could provide an appealing strategy to target early methadone treatment adherence.”

It had long been assumed that deception or concealment is necessary for placebo effects to occur — “tricking” a patient to believe an inert pill contains active medication. But, a growing body of evidence from randomized controlled trials with irritable bowel syndrome, chronic low back pain, and other conditions has demonstrated that no such deception is necessary for placebo treatment to alleviate symptoms. Additionally, conditioning study participants to placebos by having them pair the placebo with an active medication — thereby potentially associating the placebo with a relief in symptoms that may be caused by the active drug — has been shown to treat symptoms of insomnia, ADHD, post-surgical pain, and more.”

Healio (4/19/23, Rhoades) reports, “The use of open-label placebo alongside methadone for opioid use disorder” (OUD) “was associated with greater 90-day treatment retention rates and better sleep quality compared with the use of methadone alone,” researchers concluded in a 131-participant randomized clinical trial, the findings of which were published online April 12 in JAMA Network Open.

Tip 3

Provide family counseling to improve parent-child relationships and encourage longer family mealtimes.

    • Longer family mealtimes tied to healthier meals for children

MedPage Today (4/3/23, Monaco) reports, “Longer family mealtimes may be one strategy to get kids to eat healthier, according to a randomized clinical trial that found an improvement in the balance of foods eaten at the table.” Results show that “on average, longer family meals induced kids to eat 3.32 more pieces of fruits and 3.66 more pieces of vegetables than those who ate during their regular mealtime duration, the researchers explained in JAMA Network Open.”

    • Teens with closer relationships to parents have lower chance of substance abuse

HealthDay (3/23/23) reports, “Teens who report better relationships with their moms and dads are healthier both mentally and physically and less likely to abuse drugs or alcohol as young adults, according to researchers.” The study also reveals that these teens “reported lower levels of stress and depression, as well as lower use of nicotine, alcohol, cannabis and other drugs.” The findings were published in JAMA Network Open.

SOUL

I don’t watch cable news shows much at all. They usually thrive on berating anyone on the “other side”; and building viewer ratings by whipping up polarizing points of view that demonize and dehumanize people.

Tucker Carlson had a huge following on Fox News before he was let go recently. Reportedly, he “made an inflammatory, racist comment in a text message to a producer about a video that showed a group of "Trump guys" attacking "an Antifa kid," writing in the message that "it's not how white men fight," according to the New York Times.”

The message was sent on January 7, 2021, and Carlson wrote:

"A couple of weeks ago, I was watching video of people fighting on the street in Washington. A group of Trump guys surrounded an Antifa kid and started pounding the living s**t out of him. It was three against one, at least. Jumping a guy like that is dishonorable obviously. It's not how white men fight. Yet suddenly I found myself rooting for the mob against the man, hoping they'd hit him harder, kill him. I really wanted them to hurt the kid. I could taste it."

He continued: "Then somewhere deep in my brain, an alarm went off: this isn't good for me. I'm becoming something I don't want to be. The Antifa creep is a human being. Much as I despise what he says and does, much as I'm sure I'd hate him personally if I knew him, I shouldn't gloat over his suffering. I should be bothered by it. I should remember that somewhere somebody probably loves this kid, and would be crushed if he was killed. If I don't care about those things, if I reduce people to their politics, how am I better than he is?"

I was impressed with the insightful wisdom that arose from Tucker’s text. Here’s what I gleaned from his text that is a good start to decreasing our country’s polarization:

    • “.....this isn't good for me. I'm becoming something I don't want to be.” - The importance of self-reflection to take stock of whether hate, violence and lack of compassion and empathy are taking us over.

    • Much as I despise what he says and does, much as I'm sure I'd hate him personally if I knew him, I shouldn't gloat over his suffering.” – Certainly we may disagree vehemently with another’s beliefs and priorities. But violence and causing pain and suffering to those with whom we disagree is never justifiable.

    • I should be bothered by it. I should remember that somewhere somebody probably loves this kid, and would be crushed if he was killed.” - Dehumanizing others is the start of a slippery slope of lack of empathy that can lead to violence and death.

    • “If I don't care about those things, if I reduce people to their politics, how am I better than he is?"Righteous indignation, demonizing others for their differing opinions pushes us apart.

Self-reflection and concern about what we are becoming; causing no harm; remembering others’ humanity; and empathy can start to bring us back together again. Who would have thought that Tucker Carlson’s texts could spark some healing.

Until Next Time

Thanks for joining us this month. See you in late June.

David

April 2023-Vol. #21, No. 1

What to do for a client with a history of addiction who is socially drinking? Twenty years of Tips and Topics. What’s next?

Welcome to the April edition, the start of year 21 for Tips and Topics.

In SAVVY, STUMP THE SHRINK and SKILLS,  two clinical vignettes about clients with a history of moderate to severe Alcohol Use Disorder and three DWIs (Driving While Intoxicated) raise assessment and engagement questions to be considered.

In SOUL, I started publishing Tips and Topics April 2003. On this 20th anniversary, I look back at what the initial goals were; whether I lived up to those; and what’s next for Tips and Topics.

Savvy, Stump the Shrink, and Skills

This April edition of Tips and Topics marks the start of my twenty-first year of writing each month about whatever is on my mind. Much of the inspiration for what goes into each edition comes from readers and subscribers of Tips and Topics….and that is no different this month. A subscriber just sent me this message:

I have two issues that I would like to know your thoughts on. 

1. I am wondering how you think a history of a moderate to severe substance use disorder (SUD) should be treated for diagnosing and treatment? For example, a client reports a history of a moderate alcohol use disorder 3 years ago but the last 12 months he reports drinking socially.

2. Secondly, what are your thoughts on a client who reports 3 driving while intoxicated (DWI) charges 2016, 2017, and the last one 2018. Then reports that during the last 12 months drinking socially? In addition, collateral information indicates concerns about his alcohol use due to the DWIs.

Thank you for your time.

Tip 1

Resist the impulse to jump to conclusions before doing a more in-depth assessment and history-taking.

In these vignettes, it is natural to conclude that if someone is “drinking socially” after a previous diagnosis of moderate or severe SUD or multiple DWIs, that they must be relapsing and heading for trouble. But here are some Assessment and Engagement Questions to consider.

Assessment Questions:

  • Have you been given a formal diagnosis of a substance use disorder or alcohol use disorder e.g., in a medical record; or has any healthcare professional said that you have addiction or are an “alcoholic”? – Just because there is a “history of a moderate to severe SUD”, it is easy to label someone as having addiction without having done a careful diagnostic criteria review. Similarly, while three DWIs would likely indicate a SUD, it is good to check that he met diagnostic criteria.
  • If you were told you have an addiction illness, who gave you that diagnosis and were they trained in addiction diagnosis and treatment? – A physician or other healthcare professional may document that the person has an SUD but may not be skilled in understanding diagnostic criteria and erroneously label someone as having a SUD when it may have actually been a severe substance-induced or substance-related event e.g., a young person who overdosed on alcohol at a party.
  • If the client indicates that he did have a diagnosis of “moderate alcohol use disorder 3 years ago”, it is worth checking on what diagnostic criteria were met back then by reviewing what alcohol related problems were showing up 3 years ago. – This serves to assess how clear the client is that he indeed had an addiction to alcohol and to check if the diagnosis was accurate; or whether it might have been a developmental phase of alcohol use as a young person; or a coping mechanism for other co-occurring issues like trauma, other mental health challenges or even physical health problems like chronic pain.
  • If it becomes clear that the client does indeed have alcohol addiction illness and recognizes that, then review what addiction treatment and/or self/mutual help the client has participated in. – He may have been diagnosed but never engaged in treatment or recovery groups; and may not be knowledgeable about addiction.
  • If the client did have formal addiction treatment, assess what worked and what didn’t work to initiate and maintain sobriety. – Did he get good education about addiction; did he attend regularly; was there continuing care and ongoing monitoring? Or was he simply “graduated” from a program with poor linkage to ongoing care?
  • Whether the client had treatment or not, how long were any periods of abstinence and how did he achieve those? – It is always good to support self-efficacy (the optimism and confidence that a person can change) by complimenting the client on whatever length of abstinence was achieved and to evoke solutions and skills that worked for whatever the period of abstinence. “You didn’t use for 6 weeks? That’s great, how did you do that – who did you hang out with, what did you do with any cravings to use, where were you staying during that time?
  • What does the client mean by “drinking socially”? Is that once a week; or beer or wine with a meal; or drinking just at times of celebrations like birthdays? Does he get drunk, blackouts or has he been told that he behaved inappropriately when drinking?
  • What other drugs besides alcohol does he use; and remember to include tobacco? How much does he gamble?– You want to assess the breadth of his addiction in substance use and other addictive behaviors.

Engagement Questions:

  • Regardless of what others have told you, do you yourself think you have alcohol addiction? If so, why and if not why not? – This indicates what stage of change the client is at and his level of interest in changing or not.
  • Is there any help you need at this point with your alcohol use? If yes, what help do you want; if not, help me understand your thinking.
  • Is social drinking something you want to continue? How will you monitor your drinking so that it doesn’t become a problem in your physical, emotional or social life? – Given his past history with alcohol, you want to engage the client in a “discovery, dropout prevention” plan to discover or not whether he indeed still has a problem with alcohol.

Tip 2

Involving family, friends and other collateral sources in the assessment and treatment of addiction is always important. 

The person suffering from addiction is often the last person to realize how out of control their addiction illness has become. The survival defense mechanism of “denial” serves to solve the cognitive dissonance a person in active addiction faces:

  • How could I be causing all these physical, emotional and social problems and doing this to myself through my substance use or addictive behaviors? It must be my partner’s fault, or my boss, or the police who are harassing me. (Minimization, projection of blame, rationalization).

This is why involving collateral sources, relatives and friends in assessment and treatment is important:

  • To get as accurate information as possible about the frequency, quantity, and effects of drinking on all significant others, including the identified client.
  • To engage and educate significant others about addiction – how it has affected their lives and how they can help or not help to promote recovery for all people affected.
  • To support and assist significant others as they live with either active addiction in their loved one; or learn how to recover with their loved one when and if addiction recovery begins – What boundaries and limits do the significant others have around their loved one’s drinking? How hopeful or discouraged are they? If recovery has begun, how is their loved one reintegrated into a family that adjusted to exclude him or her from family and parenting decisions or even from routine daily activities like family meals?

The Bottom Line:

  • Can a person with moderate or severe Alcohol Use Disorder later socially drink? – Usually once a person has crossed the line into verified addiction illness, it is not likely that a person can return to social drinking free of negative effects on physical, emotional and social functioning.
  • But before assuming that social drinking will inevitably not go well, it is important to verify that there was indeed an accurate diagnosis of a SUD. 
  • Involve significant others in the assessment and treatment of their loved one’s addiction. This is to both assure as accurate information as possible and also to guide significant others on how to help their loved one and themselves.
  • If a person does indeed have alcohol addiction but wants to try social drinking, motivational enhancement therapy and motivational interviewing is needed to engage the client with a “discovery, dropout prevention” plan. The focus is to keep the client involved in treatment and help them discover whether they can safely return to social drinking or not. You may be clear that they cannot, but our work is to have them see and experience that for themselves.

 

Soul

This edition of Tips and Topics marks the 20th anniversary of publishing what I called back then an “e-zine” – “a magazine published only in electronic form on a computer network.” As I start this 21st year, I reviewed the three original goals that launched Volume 1. No. 1 in April 2003 to see if they are still relevant in 2023.

The first reason I started Tips and Topics was that clinicians have ongoing clinical questions that need answers. I coined STUMP THE SHRINK to highlight the questions I still receive and that prompted even this very April edition. This is still a very relevant goal that underpins Tips and Topics.

The second goal, to help people apply new-found knowledge, drives the SKILLS section. It’s useful to be SAVVY about various topics, but if they can’t be implemented skillfully, the new knowledge soon fades and clinicians fall back to their familiar, and sometimes ineffective practices.

I remember speaking to my therapist soon after completing my psychiatric specialty training and starting a private practice. I was interested in getting referrals of patients wanting psychotherapy not just medication. My therapist said, just let the other psychiatrists know you want such referrals. My rookie, unconfident mentality said “But why would they refer me patients when they would want to keep them in their practice?”

My therapist said “Firstly, not everyone wants to do psychotherapy and are more interested in medication management; and secondly, just because someone has been doing psychotherapy for a long time doesn’t mean they are any good at it.” As I grew in professional confidence and also grew ‘longer in the tooth’, I observed the truth of that for some of my colleagues.

The third reason for publishing Tips and Topics was because I want to make a difference in our field. When I decided over 25 years ago to work for myself from home in full time training and consulting, it was a big risk with a family of three kids to support. In a freelance independent business, your next invitation to train or consult depends essentially on whether you are effective in making a difference in the practices and policies of your audience. There was no guaranteed direct deposit in my bank account every two weeks; no paid sick time or vacation; no health insurance benefits or retirement contributions.

I said that if I couldn’t make it, I could always get a “real” job like being a medical director for a treatment system or some other salaried position. Fortunately, by the ‘grace of God’ and the gratitude of my audiences, I never did have to take that salaried position. That tells me I succeeded in my third goal.

What’s Next?

While these three goals are still relevant and while it still is fun to pull together Tips and Topics each month, you will keep receiving it, if you wish. I don’t send this out unsolicited to random people on mailing lists – everyone in the over 7,300 people on the mailing list should have opted in. If someone else put them on the list unbeknownst to them, they can and should Unsubscribe if they want, just as anyone can do if and when Tips and Topics becomes irrelevant to you.

If you have been a subscriber over the years, you’ll know that the SOUL section is a hodge podge of whatever is on my mind that month. Some readers have told me they read the SOUL section first, not always interested in the SAVVY and SKILLS content. I suspect the SOUL section will become even more hodge podgey as I proceed more heavily into retirement mode…..there are so many interesting insights and ideas that percolate when freed from the daily grind of catching planes, Uber or Lyft, checking into hotels late at night; and all that goes with a busy training and consulting practice.

So stay tuned for some emerging thoughts on ponderings like:

  • What is the balance between digging deep into past trauma and counterproductive coping patterns versus focusing on the Here & Now of living joyously and optimistically?
  • If trauma (in the broadest sense) is baked in on a cellular level affecting people’s fight or flight triggering responses, what is the mix of psychotherapy, body work and corrective experiences needed to allow a person to live unshackled from the past?
  • Is Law of Attraction a law of the universe as fundamental and real like we accept the Law of Gravity as real and fundamental?
  • How can you be at peace when there are physical, emotional, social and spiritual challenges swamping you?

Tips on subscribing and using Tips and Topics

  • Feel free to forward Tips and Topics to whomever you wish. But if you have people you want to invite to subscribe, please have them sign up for themselves at the website where you will see at the top in red the place to “Sign Up Now!” This way they will get into the system more easily. Here’s the link to do that:

https://tipsntopics.com

  • Make sure that the email address you use is one that won’t kick Tips and Topics into Spam or Junk Mail as many work emails are programmed to do. So you may sign up, but never receive it in your InBox.
  • On the right side of the Home Page is a “Search” window in which you can search 20 years of Archives; and also click on any previous edition. Scroll down past the Google-sponsored search findings to the previous editions of Tips and Topics to hopefully see content that is relevant to your search. For example, type into Search “discovery, dropout prevention” and you’ll see all previous editions where I have written about that.

Thanks for reading Tips and Topics and for the comments you send that help me know what speaks to you or not. 

Now on with the next 20 years…..or not.

March 2023 – Vol. #20, No. 12

The bear, wolf, fox and rabbit – a joke that teaches; Feeling good – it’s your responsibility; My son, Taylor’s take on money, career, Dad and the SKILLS and SOUL that drive him.

Welcome to the March edition of Tips and Topics.

In SAVVY, the joke about the bear, wolf, fox and rabbit highlights the need to teach our clients (and ourselves) to be assertive and abandon a “victim” mentality. It’s about taking responsibility for your own happiness.

In SKILLS and SOUL, my son, Taylor writes about his take on a discussion he and I had about how his relationship to money and career and how it was impacted differently by his relationship with his mother versus me. He shares his SKILLS and what drives his SOUL.

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