Vol. 16, No. 2
In this issue:
What to Say When….; What would you say if…?
Welcome to the May edition of Tips and Topics (TNT). To the many new subscribers joining us this month, thanks for choosing to be part of the TNT community.
David Mee-Lee, M.D.
DML Training and Consulting
In the many hundreds of workshops, plenary and breakout sessions I have presented, there is one training objective I hold important: Will participants leave with something they can use in their daily work? I know I am successful in that goal most of the time. Over the years, many have told me how something they learned changed their whole perspective, practice or policy.
In particular, workshop attendees find it useful when they hear an example of how to convert a clinical principle or policy and procedure into actual words to say to a client.
So in this combined SAVVY and SKILLS section, here are some “scripts” of what to say in different situations. This is how I might say it. But you should fashion what you say in ways that make sense to you and most importantly, that make sense to your clients, patients or participants.
What to Say to Engage People in Treatment
Job No. 1 in the first minutes of meeting a client is to form an alliance with the person. You are trying to attract them into an accountable process of lasting change.
Here’s how to get started:
“Thank-you for choosing to come to treatment.”
“I didn’t choose you. They made me come.”
“What would happen if you hadn’t come today?”
“I’d do more time in prison, or won’t get off probation or I’ll lose my children, my job or a relationship.”
“Would that be OK with you if that happened?”
“Heck no, that’s why I’m here.”
“Well then thank-you for choosing to work with me so I can help you do less time, get off probation, keep your children, job or a relationship. Now lets do some assessment together to see what you are doing (or what others think you are doing) that is keeping you from getting what you want.”
Now you can do an assessment to identify with the client any attitudes, thoughts and behaviors that stand in the way of getting what they want. For example:
What are your friends like who make it easy or hard for you to stay away from crime and getting arrested again?
Does living with Vinny, the drug dealer, make it easier or harder for you to keep your children?
What do you want to do about the fact that you don’t show up to work or a family gathering because you are so hung-over and out of it?
What to Say to Orient Participants to a Drug or Treatment Court
In justice transformation, Drug and other Treatment Courts are seeing the value of treatment to reach the goals we all want – safety for the public and children and families and decreased crime and costs. Here’s one way to orient treatment court participants:
“Thank-you for choosing to enter Drug Court. The reason you have been given the opportunity to get treatment rather than be incarcerated is that you have addiction related to your charges. We believe if you receive addiction treatment and establish recovery, this will not only be good for your life, but society will benefit from increased public safety, decreased crime; and spending resources on treatment rather than incarceration, which is much more expensive. But you are accountable for doing treatment, not time; for working on changing your attitudes, thinking and behavior, not just complying with a program and graduating.”
Treatment providers’ responsibility is to keep the court informed about the participant’s level of active engagement, not just passive compliance with attendance and positive or negative drug screens; on whether the participant is actually changing in attitudes, thinking and behavior which advances public safety.
What to Say to Check on Progress
“Tell me about your treatment plan.” (Pause to see what the participant says and monitor if they are working on anything in particular to improve functioning for public safety; or whether they are just “doing time” e.g., “I just have to be here and have another three months.”)
“What you are working on to change your attitudes, thinking or behavior that has gotten you into trouble with crime, restricted your freedom and threatened public safety?”
(See if the treatment plan is only a court-order-compliance plan or if it is an assessment-based, individualized treatment plan focused on changing attitudes, thinking and behavior to improve function.)
What to Say to Track Treatment Engagement
“What would you like to do in this session or in group today to advance your treatment plan?” (Pause to see what the participant says and monitor if they are working on anything in particular to improve functioning for public safety; or whether they are just “doing time” e.g., “I just have to be here” Or “What do you want me to say?”)
What you would hope they would say is: “I don’t have an anger problem, but I am trying to get off probation so I’m going to ask someone to role play with me an angry situation. Others might get into a fist-fight but not me. I have good anger management skills and am going to demonstrate to the group how to handle that in assertive but nonviolent way. Please note that down and let my probation officer know I am doing well.”
What to Say about Positive Drug Screens
In treatment programs and treatment court programs, many still have policies and procedures mandating abstinence as a condition for treatment and expect perfection in abstinence as a condition for staying in treatment.
But how is it useful to suspend, discharge or sanction a person for a flare-up of their signs and symptoms of addiction when that is the very time they need the help to make sure their addiction doesn’t spiral out of control even further?
Here’s what to say:
“In addiction treatment, it’s not OK to use any unauthorized substance. But if this didn’t happen and everyone had perfect control over using, they wouldn’t have addiction and wouldn’t need treatment. You can learn skills and use supports to never have to use again, so it is not inevitable you will have a flare-up and use.
However if it happens to you or anyone else in treatment with you, it is your responsibility for your safety and your fellow participants to immediately address any attitudes, thinking or behavior building up to any substance use; or any actual use. Reach out to a team member, just like you would if experiencing a heart attack or feeling suicidal. They will then work with you to find out what went wrong and how to improve your treatment plan to prevent another flare-up.
If substance use happens in a residential setting, there will be a community meeting ASAP to help anyone who used with you. If you or anyone else is not interested in finding what went wrong and changing your treatment plan in a positive direction, you have the right to choose no further treatment. You can then take the legal consequences of your criminal charges.”
When treatment programs and treatment courts have zero tolerance policies, substance use, or even building up to a drink or drug (BUDD-ing), goes underground.
Participants in the program become more focused on snitching and covering up actual or potential drug use than on keeping their environment safe from drug use for their own well-being, as well as for the treatment community they are in.
Criminogenic thinking and antisocial behavior is thus encouraged.
If jails and prisons can’t keep drugs out – with all the cameras and correctional officers supervision – how can treatment programs keep a milieu safe without the help and responsibility of all participants?
Learning how to take responsibility to prevent use or catch drug use early is what treatment is all about.
Clients and participants are just as responsible as the staff to keep themselves and the program safe.
What not to say to about Drug Screens testing Positive for Substance Use
If you want participants in treatment to be honest about substance use, don’t have policies and procedures making it nearly impossible for them to be honest and still get what they want.
Here’s what not to say:
“In addiction treatment, it’s not OK to use any unauthorized substance. You are mandated to be abstinent and if you use and it is found on a drug screen, you will be sanctioned and could be set back a phase in your treatment program. If it happens more than once, you could be suspended or incarcerated for a brief period and it may even be grounds for discharge from the program.
In order to advance through the phases of the program and eventually graduate, you must demonstrate full abstinence. If you do not, there are escalating sanction and consequences, but there are also incentives for those who do stay abstinent.”
“Now be honest, did you use or not?!!”
Here’s what many clients say when backed into the corner of zero tolerance:
“No, I absolutely did not use a thing. That lab has gotten my urine mixed up three times now and anyway, it was only positive for cannabis because I had to go to the restroom where a whole lot of people were smoking weed. I must have gotten the second-hand smoke.”
What to Say in Individual, Group, or an Emergency Community Meeting when a client has used substances while in treatment
Just like a person who has Major Depression and suicidal thoughts or behaviors, you want the client to reach out for help as soon as they start thinking of acting on their impulses to use or for actual use.
Here’s what to say:
“Please reach out and get help if thinking of using or actually using so we can nip this in the bud and prevent further crises.”
If the client has a flare-up of addiction, uses substances and shows up at a group or session, first make sure they are safe and not in severe withdrawal. If the person is so intoxicated or in withdrawal and can’t function cognitively, postpone a session or group. (This is what you would do to check stability if a person with Major Depression showed up suicidal; or if a person with Bipolar Disorder showed up manic).If they are safe and not impaired after a few beers or having smoked or shot up a drug, here’s what to say:
“Now that you are here, share what happened that led up to and triggered the substance use. We want to figure out what went wrong and help you get back on track. If others used with you, please identify them so we can do the same process with them ASAP.
If you are willing to change your treatment plan and work on fixing the mistakes with commitment and effort in good faith, then treatment continues. If you are not interested in doing that, you have a right to choose no further treatment and be discharged from the program.”
Whenever there is a poor outcome in the treatment of any illness, the first step is to assess with the client what went wrong and improve the treatment plan. We would never tell a suicidal patient to go away and come back tomorrow when they are not suicidal. But providers still suspend someone who used substances to come back tomorrow when sober before coming back to treatment….or treatment providers even discharge the person.
What to Say to a Person who says they don’t want to go to Alcoholics Anonymous
There are many wonderful benefits of 12-Step recovery groups. I always want clients and participants to embrace such self/mutual help programs if they fit and work for them. But mandating people to go to meetings and getting attendance checked off doesn’t necessarily translate into active participation and change.
It is not unusual for a client to object to having to attend AA or other such groups. Here is how to address such clients:
“There are AA meetings and groups that appeal to different members in different ways. If you haven’t tried a number of different groups, it just may be you haven’t found the meeting that works for you.
Now if you are saying you just don’t want to go to AA for whatever reason, I don’t want to push that on you. Do you have another self/mutual help group that works better for you? Before you give up on AA, let’s discuss where else can you find a support group where:
1. You can have access to regular meetings every day; and even more than once a day if you really need them – and all for free?
2. You can have a coach like an AA sponsor, who is ready to have you call them at all hours of the day and week if you really need them?
3. You can be with a whole group of people and have sober fun while there are temptations and triggers all around you on New Year’s Eve, Mardi Gras, or St. Patrick’s Day?
4. You can have many friends who have been exactly where you have been with addiction; understand what you are going through from deep personal experience; and will be there for you if you reach out?
Maybe you have a group like that at your church, synagogue, community of faith, or some other group. If you receive support from that group with all the same effective features of what AA has to offer, then by all means embrace that group. This is about getting the ongoing support and guidance you need to establish and maintain recovery and well being, not pushing AA on you.”
1. Bureau of Justice Assistance (BJA) training video on The ASAM Criteria that can be viewed by selecting Adult Drug Court under Courses; then Adult Drug Court: Lessons and create an account. The system can be found at Bureau of Justice video and this video was initiated by Dennis Reilly at the Center for Court innovation.
2. Critical Treatment Issues Webinar Series, Bureau of Justice (BJA) Drug Court Technical Assistance Project at American University Feb. 10, 2016 – May 3, 2016
Critical Treatment Issues – David Mee-Lee
It is gratifying when I hear positive feedback on my training like: “We received so much from your workshop that when our team has a challenging client, we say What would Dr. Mee-Lee say in this situation?” I know then I have reached my training goal for them to learn something they can use.
But have you ever noticed that a friend may be telling you about a relationship roadblock they keep running into. As you listen, it seems clear what the issues are and what you would suggest? Yet, when you run into a similar relationship challenge with your loved one, somehow it is not clear at all what to do?
This is just the age-old phenomenon of being so close to the problem you can’t see the wood for the trees; you can’t be objective when you are too close to have a clear perspective.
I would like to take full credit for wise, perfect words when the team says “What would Dr. Mee-Lee say?” But I suspect that what is working (besides my brilliant words) is that by asking that question, it:
Helps the team obtain some objective perspective when faced with a challenging client situation.
Puts them outside the team for a moment and moves them away from being too close to see clearly what to do.
So the next time you run into a roadblock with your loved one, think what you would say to your friend who described the same situation. You might actually get a clear perspective on how to proceed around and through your roadblock.
Or you could try: “What would Dr. Mee-Lee say in this situation?”
TNT book cover
There are more scripts on what to say about treatment in Chapter 5 “Turning paperwork into peoplework” in my Tips and Topics book.
–> Get selected relevant clinical and systems tips from the years of Tips and Topics all in one place.”
Tips and Topics: Opening the Toolbox for Transforming Services and Systems” by David Mee-Lee, MD with Jennifer E. Harrison, MSW.
You can buy in two ways:
–> Go to Tips & Topics book at The Change Companies and buy online.
–> Call The Change Companies at (888) 889-8866 and ask for Dr. Mee-Lee’s Tips and Topics book.
Until next time
Thanks for reading Tips & Topics this month. See you soon again in late June.
Vol. 15 No. 10
In this issue
India ASAM Criteria Training
David Mee-Lee M.D.
In late November/early December, I made a quick trip to India to do a three day training train on The ASAM (American Society of Addiction Medicine) Criteria. I was in Pune, about 95 miles from Mumbai (formerly known or as Bombay). In November’s SOUL section I spoke about the bureaucracy of getting a visa to train in India. Tips & Topics November 2017
Since this was India’s first introduction to The ASAM Criteria, I wanted to share a brief Q&A with Ranjana Pavamani, the driving force behind bringing this training into reality:
Here is our group:
- After 1 month of TM practice, all 46 veterans with PTSD responded.
- Because of the magnitude of these results and dose-response effect, placebo effects are unlikely explanations for the results.
- Major limitations were the absence of random assignment and lack of a control group. Those who self-selected to enter this study may not be representative of all veterans who have PTSD.
- But when taking into account these results and all previous research on the TM technique in reducing psychological and physiological stress, the evidence suggests that TM practice may offer a promising adjunct or alternative method for treating PTSD.
TM has been extensively researched for other disorders like hypertension, heart attacks and other
David Mee-Lee M.D.
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