December 2006 – Tips & Topics – december-2006

TIPS & TOPICS
Volume 4, No.7
December 2006

In this issue
– SAVVY
– SKILLS
– SOUL
– STUMP THE SHRINK
– Until Next Time

Happy and Healthy New Year for 2007!

Thanks to all who responded to my request in last month’s edition for your TTT from TNT (Your Top Ten Tips from TIPS and TOPICS). It’s not too late to submit your list; read SUGGESTIONS in the Oct-Nov 2006 issue.

(more…)

January 2007

Volume 4, No.8 | January 2007
In this issue


SAVVY | SKILLS | SOUL

David Mee-Lee M.D.


Welcome to all the new readers who are joining TNT for the first time. Thanks to all the “old-timers” too as we start 2007.

 

SAVVY

A psychiatric disorder that is often associated with substance-related disorders is Attention-Deficit/ Hyperactivity Disorder (ADHD). There are certainly children, adolescents and adults for whom ADHD is concurrent with a substance disorder. However, it is also easy to get “trigger happy” with the diagnostic gun and see any impulsivity, distractibility or restlessness as ADHD. So here are a few facts, figures and philosophical issues about ADHD.

Tips

  • Attention-Deficit/ Hyperactivity Disorder (ADHD)

FACTS

-ADHD dates back to 1902 when Still, a British pediatrician, first describe symptoms of ADHD in children. (1, 2); modern psychopharmacology started in 1937 with a study of benzedrine in a mixed population of children with ADHD symptoms; methylphenidate was subsequently synthesized in 1955 with its formulations being the most commonly prescribed agents for ADHD (2)

FIGURES

-In the USA, ADHD is the most common psychiatric disorder afflicting children and adolescents with approximately 5% (3, 4) or 6%-9% of juveniles affected; and 4%-5% of adults or about 7 million adults. (5)

-ADHD can be a life-long disorder with 60% – 70% of children who have ADHD age into adulthood with impairing symptoms of the disorder, if not full- syndrome criteria of ADHD (2, 6)

-Up to 71% of adult alcoholics had childhood-onset ADHD that was persistent; and 15%-25% of adult alcoholics and drug addicted people meet criteria for ADHD (7, 8, 4)

-About one third of ADHD patients have co- occurring alcohol and other drug dependence; 60% of people with untreated ADHD have co-occurring substance use disorders. (9 )

WHAT ADHD LOOKS LIKE

-Current diagnostic criteria for ADHD describe three subtypes: hyperactive-impulsive; inattentive; and combined. (10)

-In adults, the hyperactivity can manifest adaptively as working long hours with two jobs; or in a very active job. May avoid situations requiring low activity e.g. going to the ballet. Constant activity can lead to family tension and often feel like they cannot play or work quietly. (2)

-Impulsivity may manifest as low frustration tolerance – quitting a job; ending a relationship; losing temper; driving behaviors. Makes quick decisions; interrupts. (2)

-Inattention may manifest as poor time management. Difficulty initiating or completing tasks or changing to another task when required; or difficulty with multitasking. Avoids tasks that demand attention; proscrastination. (2)

WHAT IS HAPPENING IN THE BRAIN (5)

-Neuroimaging shows structural brain abnormalities – smaller volumes in the frontal cortex, cerebellum and subcortical structures.

-Brain imaging to look at what areas are functioning normally or are too active or low activity, point to problems in the subcortical systems in the frontal area; and in the anterior cingulate activation. There is too low a level of activity in the Anterior Cingulate Cortex.

-Three subcortical structures – the caudate, putamen, and globus pallidus – are part of the neural circuitry underlying motor control, executive function, inhibition of behavior, and modulation of reward pathways – these are all critical in substance use disorders too.

-Executive functions are:

-Planning: foresight in devising multi-step strategies.
-Flexibility: capacity for quickly switching to the appropriate mental mode.
-Inhibition: the ability to withstand distraction, and internal urges.
-Anticipation: prediction based on pattern recognition.
-Critical evaluation: logical analysis.
-Working memory: capacity to hold and manipulate information in our minds in real time.
-Fuzzy logic: capacity to choose with incomplete information.
-Divided attention: ability to pay attention to more than one thing at a time.
-Decision-making: both quality and speed.

-The subcortical circuits provide feedback to the cortex to regulate behavior. ADHD is thought to use neural systems involving neurotransmitters norepinephrine and dopamine. Dopamine is also involved in the reward pathway for substance use disorders.

-Bottom line: In ADHD there is too low activity (hypoactivation) in the areas responsible for regulating behaviors and cognitive functioning like motor control, executive function, inhibition of behavior, and modulation of reward pathways.

WHAT TO DO ABOUT ADHD – Nonpharmacologic approaches (9)

-ADHD coaches who help clients identify deficits and organize and prioritize their time; identify strengths and exploit them and identify weaknesses and avoid them. A qualified ADHD coach can be found through the ADD Coach Academy’s website.

-Time management

-Patient education and advocacy groups like Children and Adults with ADHD (CHADD, www.chadd.org); the Attention Deficit Disorders Association (ADDA, www.add.org). College students with ADHD can have accommodations such as un- timed tests in noise-free rooms.

-Cognitive-behavioral therapy

-Anger-control skills

-Individual, group and family therapy

-Coaching versus counseling

WHAT TO DO ABOUT ADHD – Pharmacologic approaches (9)

Stimulant medication has been used for over 70 years but should be used carefully in the presence of preexisting structural heart defects.

-Short-acting (4-6 hours); moderate-acting (6-8 hours); long-acting (8-12 hours)

-Amphetamines (Adderall, Adderall XR= extended release, dexedrine); methylphenidate (Ritalin, Concerta, Metadate CD, Ritalin LA=long acting); D- methylphenidate (Focalin XR)

-Stimulants act on the brain’s dopamine and norepinephrine neurotransmitter systems by enhancing the release of these neurotransmitters from storage vesicles in the presynaptic neurons. Stimulants also block the reuptake of the neurotransmitters which thus increases the available amount of dopamine and norepinephrine.(4) This increase in the available quantity of neurotransmitter makes up for the hypoactivity in the relevant areas of the brain. It is thought that this then restores the low activity to more normal levels. This corrects the signs and symptoms of ADHD.

-Treating ADHD pharmacologically does not appear to exacerbate a substance use disorder e.g., stimulants have not been found to increase subjective or objective measures of cocaine use or cravings in ADHD or cocaine-substitution studies (11, 5)

-Treatment of ADHD appears to protect against the development of substance use disorders.

Nonstimulant medications are more recent. (5, 9)

-Atomoxetine (Strattera) – noradrenergic agent; two reports of liver toxicity in over 2 million exposures; and slight increase of suicidal ideation in children, but not adults.

-Buproprion (Wellbutrin) – atypical antidepressant

-Modafinil – arousal agent

-Tricyclic antidepressants – desipramine, nortriptylineAntihypertensives for adolescents – clonidine, guanfacine

Medications for co-occurring ADHD and Substance Use Disorders (5)

-Untreated ADHD worsens the ADHD and the SUD

-Atomoxetine, buproprion and extended-release stimulants are recommended for ADHD patients with very recent SUD i.e. within 3 months.

-Alpha agonists and tricyclic antidepressants are often reserved as alternate agents for ADHD with SUD – lower potential for drug-drug interactions with substances of abuse.

-Avoid amphetamines in patients with a history of amphetamine-related psychosis.

REFERENCES
1. Still GF (1902). Lancet 1:1008-1012, 1077-1082, 1163-1168.

2. Donnelly CL (2006): “History and Pathophysiology of ADHD” in “Differential Diagnosis and Treatment of Adult ADHA and Neighboring Disorders” Authors Donnelly C, Reimherr, FW, Young, JL. CNS Spectr 11:10 (Suppl 11) October 2006.

3. Faraone SV, Sergeant J, Gillberg C, Biederman J (2003): “The worldwide prevalence of ADHD: Is it an American condition?” World Psychiatry 2:104-113.

4. Donnelly CL (2006): “Treating Patients with ADHD and Coexisting Conditions”. Behavioral Healthcare Vol. 26, No. 9. pp. 40-44. September 2006.

5. Wilens TE (2006): “Attention Deficit Hyperactivity Disorder and Substance Use Disorders”. Am J Psychiatry 163(12): 2059-2063. December 2006.

6. Biederman J (2005): “Attention- deficit/hyperactivity disorder: a selective overview”. Biol Psychiatry 57(11):1215-1220.

7. Goodwin DW, Schulsinger F, Hermansen L, et al (1975): “Alcoholism and the hyperactive child syndrome”. JNerv Ment Dis 160:349-353.

8. Wilens TE (1998): “AOD use and Attention Deficit Hyperactivity Disorder” Alcohol Health Res World 22:127-130.

9. Young JL (2006): “Treatment of Adult ADHD and Comorbid Disorders” in “Differential Diagnosis and Treatment of Adult ADHA and Neighboring Disorders” Authors Donnelly C, Reimherr, FW, Young, JL. CNS Spectr 11:10 (Suppl 11) October 2006.

10. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) Washington, DC, American Psychiatric Association.

11. Grabowski J, Shearer J, Merrill J, Negus SS (2004): “Agonist-like, replacement pharmacotherapy for stimulant abuse and dependence”. Addictive Behaviors 29:1439-1464.

SKILLS

Last November I chaired a panel discussing how to improve services for teens in West Virginia. Phil Washington was telling us all about how he engages adolescents in educational but fun ways. He shared some of the tools he uses. With his permission, I am sharing a couple of exercises he uses which provokes good discussion within the group. Some are best used just with adolescents. Others can be used with any age group.

Tips

  • “Sounds Like Fun” are some thought- provoking questions to check whether using really is all fun.

Sounds Like Fun
These questions are to be asked in light of the fact that young people call getting high or drunk a good time. If it’s such a good time why do we not share it with everyone? Remind them of the times that they stuck their head in a toilet bowl to throw up. Remind them of promising God, “If you get me out of this I will never do it again.”

1. Do you ever call the police to let them know that you will be drunk and they can come pick you up at wherever?

2. Do you arrange for special lodgings at the jail in anticipation of being picked up for public intoxication?

3. Do you arrange for a special hairdo and clothing so you don’t get vomit on your good stuff?

4. Do you call your friends and family and tell them to watch the news to see you get into an altercation with the police on those special evenings?

5. Do you video yourself when you are drunk or high so you can show those special moments to your future children and grandchildren?

6. Do you let your potential boyfriend/girlfriend know that you sometimes have had unprotected sex while under the influence of drugs/alcohol?

7. Has anyone ever taken a picture of you while you were drunk or high, and you were so proud you made copies and sent them to the whole family?

8. Have you ever been with your boyfriend/girlfriend and offered them a big, wet, sloppy kiss after throwing up?

9. Have you ever checked your breath after drinking and smoking and thought, “Wow, my breath is enchanting. I think I’ll kiss someone”?

10. If not, why not? Isn’t this what we call a good time? Shouldn’t good times be shared by all?

Reference for “Sounds Like Fun” and “Would You?”
Phil Washington – Daymark Inc.
1598 C Washington St., East
Charleston, WV 25311
(304) 340-3690
phil@daymark.org

  • “Would You” helps young people and adults think through the situation and examine their values.

Would You?

1. Would you give the keys to your car to someone who was drunk or high?

2. Would you give the keys to your apartment to that same person?

3. Would you allow someone under the influence to baby-sit your children?

4. Would you allow a person who drinks and drives to take your children to an outing in their car?

5. Would you hand a person under the influence your check book?

6. Would you invite someone under the influence to fix your pipes, or electrical appliances, or your roof?

7. Would you take someone under the influence on vacation with you and your children, or family?

8. Would you take someone under the influence to meet your parents and family?

9. Would you take someone who you know will get drunk to your company picnic where there will be beer and liquor?

10. Would you recommend someone who gets high for a job at your company?

SOUL

My New Year’s resolution was about achieving balance between work, love and play. Since you will get this month’s TNT while I am playing Down Under, here are a few lighthearted quotes and tidbits to help you play a little too. Most come from the vast cyberspace:

Zen for those who take life too seriously:
–> Change is inevitable, except from vending machines
–> Plan to be spontaneous tomorrow
–> If you think nobody cares, try missing a couple of payments
–> When everything’s coming your way, you’re in the wrong lane
–> Depression is merely anger without the enthusiasm
–> Just remember – If the world did not suck, we would all fall off.

Quotes from George Carlin:
–> “Ever notice that anyone going slower than you is an idiot, but anyone going faster than you is a maniac?”
–> “Isn’t making a smoking section in a restaurant like making a peeing section in the swimming pool?”

And to end with an Aussie flavor:

-“What do you call a boomerang that doesn’t work?”
-“A stick.”

G’day mate!

Until Next Time

Thanks for joining us. See you in February.
David

Vol. 11, No. 12

In This Issue
  • SAVVY, SKILLS & STUMP THE SHRINK : A combined “conversation” on working with mandated clients
  • SOUL : Changing the context to avoid droughts and storms in helping people

Welcome to all new readers to the March edition of Tips and Topics.  Thanks to all for reading this month.

David Mee-Lee M.D.

SAVVY, SKILLS & STUMP THE SHRINK

This month, I presented a webinar on The ASAM Criteria and DSM-5.  A participant wrote to me with some follow-up questions.  We ended up having an email “conversation” as we clarified questions and responses to the initial questions.

(If you want to hear the Addiction Technology Transfer Center (ATTC) Network webinar, you can access it at www.ASAMcriteria.org.  Click on News & Events and you’ll see it there).

So forMarch, here’s a combined SAVVY, SKILLS and STUMP THE SHRINK. I will share with you the “conversation”.

My Webinar Point- about “doing time”

I made a point that treatment providers, especially when working with mandated clients, are responsible for making sure that clients are “doing treatment” not “doing time” in the program – i.e. not just going through the motions.

Question #1:

Howcan you tell if a person is just “doing time, not treatment”?

Hi David,

What other specific criteria should providers gauge to determine whether a client is just “sitting in the program” or “doing time”?  For example, say the client just wants to get a job and maintains that attitude throughout treatment – in effect, turning treatment into a vocational training program. Would you consider this one example of merely “sitting in treatment?” What should be done, in “treatment” or not? 

Response #1:

Youcan turn “doing time” into active treatment.

“Doing time” is when a person is not taking responsibility for their treatment and their treatment plan.  If your client just wants a job but is in a treatment program, it is fine to make the goal of treatment: to get a job.  That’s what he wants and is a good place to start to engage him in treatment.  Presumably however, he has been referred to an addiction program or mental health because he has an addiction and/or MH problem. Say he doesn’t see that and thinks he just has a job problem, then the treatment plan focus would be: do motivational work around helping him get a job.  At the same time examine with him how has not had a job; or when he does get a job he loses it due to addiction and/or MH problems.

Even with the focus on getting a job, he is not just involved in a vocational training program, because he would be assessing why he doesn’t have a job or can’t keep one. Treatment will emphasize:

*      His examining how he is going to keep a job if he does not address the addiction/MH problems.

*      His sharing in group why he thinks he does not have a behavioral health problem, yet he has not had a job.  OR he shares how he lost his job because he was not showing up, or was hung-over.  OR he shares that due to mental health problems he got fired, or that he couldn’t make it through a job interview because he was so depressed or unstable.

*      Executing a “discovery” plan not a “recovery” plan – discovering any connections between addiction/MH problems that interfere with getting or keeping a job.

*      Active and meaningful participation and working on a collaborative plan. This is “doing treatment”, involving stages of change work to see if the client can connect the dots: that if he is to going to land a job, at some point he will need to address his addiction and/or MH problems.

Say your client just sits there and doesn’t participate in collaborative treatment planning. Then he is not doing treatment, he is “doing time.”  We shouldn’t continue treatment.  If he is not changing his treatment plan in a positive direction, he is essentially choosing not to do treatment, and has a right to leave.

My Webinar Point – DSM-5 SUD and Homelessness

In the new DSM-5 criteria for Substance Use Disorder (SUD), there are 11 criteria with a requirement for at least 2 of the 11 to diagnose SUD.   Some of these relate to how substance use interferes with meeting life expectations like work, family and social obligations.

Question #2:

Are the homeless exempt from certain SUD criteria?

 

In working with a homeless population it seems the degree of social isolation obscures the impact of their substance use disorder given the extent and degree of social isolation. In effect, the degree of social functioning required of them is much lower in light of the lack of role obligations that they must fulfill. Does this make them “exempt” from some of the DSM-5 substance use disorder criteria?

Response #2:

Many homeless will still meet sufficient criteria to qualify for an SUD.

As you suggest, a socially isolated homeless person may not have work, family or social obligations.  Thus they may not meet the social obligation criteria. However, such a homeless person could meet the other criteria – only 2-3 of 11 are needed to have mild SUD.

Here are the first 4 they could meet:
1. Substance is often taken in larger amounts or over a longer period than was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control substance use.

3. A great deal of time is spent in activities necessary to obtain substance, use, or recover from the substance’s effects.

4. Craving or a strong desire or urge to use the substance. (DSM-5, SUD, criteria 1-4 of 11)

I hope this helps,

David

 
My Webinar Point- about “Graduation”

When I discuss program-driven treatment rather than person-centered, outcomes-driven treatment, I encourage participants to move away from “graduation” as aconcept and practice in the treatment of addiction (and actually any illness).

Question #3:

What did you mean about ‘graduating’ from the program’s policies and procedures?

Yes, this helps! If ever there was a critical thinker, it’s you, David.  I enjoyed tracking your logic and appreciate your way of explaining.

 

One last thing – in response to the question of why its erroneous to use the term graduation in the realm of addiction, you said something about clients’ graduation, but only satisfying graduation of the program’s policies and procedures…or something along those lines. This point grabbed my attention. I was hoping you could articulate it once more and perhaps expand upon it. On that point, I read your piece on RCA Ceremonies and don’t recall coming across it. (March 2011 edition of Tips and Topics)

Thank you for responding to my e-mail and making yourself accessible.

Response #3:

Focus on functional improvement not program compliance.

Thanks for your nice feedback.  Take a look at Tips and Topic (TNT) – February 2013 edition.  I raised concerns that an overemphasis on compliance to program rules, norms and assignments overshadows a person-centered, assessment-based, outcomes-driven approach. Progress in a person’s function based on their individualized treatment plan determines when they transfer to another level of care, not compliance with the program’s policies and procedures, or phases.

I think this addresses what you want, but let me know if not.

Thanks,

David

Question #4:

How do you work with a client who says the “right things”?

OK,I have one more question in response to your answer in regards to “doing time” in treatment.  Say, the legally-mandated client takes a compliant-orientated stance and “gives in.” Or perhaps he feeds the treatment staff what they want to hear by apparently acknowledging the connection between drug use and employment within the first several week ofIntensive Outpatient (IOP) treatment.  It’s not a unique or peculiar situation to have this kind of mandated client then say they have a job problem and that their drug problem is now under control. They remain “dug in” to that position by posturing as if “everything’s all good” and “I got this” type of mentality with respect to all other aspects of “treatment.” Thus would the treatment plan still be a “discovery plan” focused on the client’s need to obtain employment?

 

Would you please tell me how you might work with such a client.

Response #4:

Give your client the chance to follow his plan first. Closely monitor outcomes.

Take a look at the following editions of Tips and Topics, especially the difference between “compliance” and “adherence”.  We don’t want any client to be “compliant” and say what we want them to say (“feeds the treatment staff what they want to hear or not”).  Webster’s Dictionary defines “comply” as follows: to act in accordance with another’s wishes, or with rules and regulations.  It defines “adhere” as: to cling, cleave (to be steadfast, hold fast), stick fast.

Perhaps your client believes he has it all under control (“everything’s all good” and “I got this”.)  At that point, we can share with the client anything we see in his behavior and/or thinking and/or relationships we think would threaten his getting or keeping a job.  What if he doesn’t agree?  Then you develop a plan to track how he is doing with his job or job hunting.  Help him identify what would be the first sign(s) to recognize that he is heading in a direction of losing the job, or not even getting the job. If you track this closely with him, he/you can discover if indeed he has everything under control, or whether his plan is starting to unravel.  Close monitoring is vital.  We don’t want to wait until it all blows up before he changes his treatment plan.

For example:
If he still wants to hangout with substance-using friends, not go to AA or other support groups, and still thinks he can get or keep a job, then agree to have him try his plan: i.e. the plan to “keep hanging out with using friends; not attending AA” ‘treatment plan.’ See if his plans work.  Keep close tabs with him on recognizing the first signs that his plan is not working.

Say his treatment plan is actually working- i.e. the  “keep hanging out with using friends; no AA” treatment plan.   Maybe he’s either getting a job or keeping one. Understandably from your experience, you doubt that he will be able to sustain that stance/decision.  So what do you say in your sessions with him?  You agree to keep going with his plan; but with him you carefully watch what happens. With humility, you express that you hope you are wrong but you think his plan is a risky one.  If his plan starts to unravel, then he will be more open to trying a plan that incorporates your ideas, because his plan didn’t work.  What you did give him is the chance to make his own discoveries and decisions.

November 2007:

January 2004:

December 2006:

Hope this helps.

David

Question #5:

When do you finally discharge a person?

Thanks! David that helps. So in developing a plan to track how she/he is doing toward job obtainment this might include listing jobs of interest; applying to X number of jobs per week; listing potential barriers to employment; practicing job interviewing skills, etc?  AND what if the client consistently fails to successfully follow through–at what point would it merit a discharge?

 

You’ve shared this excellent example of MOTIVATIONAL ENHANCEMENT technique and what comes to mind is the consent forms which used to state the purpose ofthe consent to Adult Client Services was to ‘monitor compliance’.   Ever since hearing the compliance vs. adherence story, I STOPPED using the word compliance in my consent forms.

 

In speaking with Probation Officers and Intake Workers from criminal justice services who ask if a client is being compliant, I ask them if they are sure that is what they want from a client.  I then offer the explanation of how temporary and superficial “compliance” is.

Response #5:

Discharge when the person is not making positive changes in the treatment plan.

Thanks for that interesting update on your use of “compliance” versus “adherence”.  A person could be in “compliance” with a court order to do treatment, with which the person agrees to do.  But once they get to treatment, you don’t want “compliance”, you want “adherence” with the collaborative treatment plan in which the person had an integral part in developing.

Regarding:

So in developing a plan to track how she/he is doing toward job obtainment this might include listing jobs of interest; applying to X amount of jobs per week; listing potential barriers to employment; practicing job interviewing skills, etc? 

Yes, correct, as these are strategies that are Specific, Measurable, Achievable, Realistic and Time limited (SMART).  If the person does whatever they agree to do, then treatment keeps going.

Regarding:

AND what if the client consistently fails to successfully follow through–at what point would it merit a discharge?

If the person does not do what they agreed to do, assess why not.  Perhaps they said ‘yes’ too quickly when they meant ‘maybe’.  Or they really want to follow through, but it was harder to do.  Or they found a better way to get to their goal and so did that instead.  Whatever is revealed when you assess the lack of follow-through, if your client agrees to change their treatment plan in a positive direction, then continue treatment.  There is no need to discharge.

For example:

If a person did not follow through with a job interview they thought would be easy, practice role-playing the job interview process.  If they now agree to practice role-playing to prepare better for a job interview, this is a positive direction. Keep going in treatment.  (You can tell the Probation Officer that your client is in “compliance” with the court order to do treatment and is “adherent” to the collaborative treatment plan.)

What if your client does not want to adjust the treatment plan in a positive direction using role-playing or another acceptable strategy?   At that point, the client is choosing no further treatment.  This is their right and they can leave treatment.  You are not kicking them out – they are not doing treatment.  If you let them stay, then you would be “enabling” – allowing them to “do time” not “do treatment”.  They would be non-adherent (not following through) to the treatment plan they created collaboratively. But they also would be out of compliance with the court order to do treatment.  Hope you see the distinction.

*******

The decision flow makes perfect sense, David.

Thanks again for taking the time to put forth a thorough response.

References:

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Arlington, VA, American Psychiatric Association, 2013.

Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013).The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City,NV: The Change Companies.

SOUL

I am an avid reader of weather.com and the Weather page of the local newspapers.  This is not because I am finding the latest facts to have an intelligent weather conversation with the next person I meet.  It is because of two realities facing me at home and at work.

*      California had its driest year in history in 2013. This year we have so far received less than half the rain we should have by now.  We are in a drought. We have been doing our best to cut water use – collecting water in the shower while waiting for the water to warm up and using it to water the plants; not turning on garden sprinklers; and “if it’s yellow, let it mellow; if it’s brown, flush it down” (sorry for the bathroom talk).

*      At work, my commute is often an airplane ride into potentially snowy or stormy airports.  It is not good to be scheduled for a workshop or keynote presentation and be stuck at an airport in another state!  So I am always anticipating a Plan B if there is bad weather predicted en route or for my destination.

 

So this year there has been a strange phenomenon where I check every day hoping to see the weather prediction of either 100% precipitation or 0% precipitation – depending on whether I am home or on the road.

 

If I am at home, I rejoice to see 100% rain predicted because that means we are one step closer to breaking the drought.

 

If about to go on aroad trip, I want to see 0% rain or snow predicted, so I am not stressed about getting to the conference on time.

 

It’s funny how the context can totally change what we want by 100%. It’s a bit like when working with mandated clients.  You can either side with the victim-side of the client (“They made me come”) by saying something like: “Iknow you don’t want to be here, but you have to be, so suck it up and see if you can get something out of the program.”

 

Or, you can change the context and say: “Thank-you for choosing to work with me, so I can help you get people off your back and help you keep your job, or get your children back, or stay out of jail.”

 

I don’t want to be in an unproductive drought or a stressful storm.  By changing the context, you can avoid droughts and storms in your work with people too.

 

I hope it rains…well not next week when I’m traveling.

Until next time

See you again in late April.

David

November 2012 – Tips & Topics – november-2012-tips-topics

Vol. 10, No. 8 November 2012
In This Issue

SAVVY – Alternate terms for “Relapse”; ASAM’s definition of relapse
SKILLS – How to deal with substance use in residential treatment settings
SOUL – When not being chosen was good!

Welcome to the November edition of Tips and Topics. I hope you have been able to balance some family and friends time with the commercial push to have you shop till you drop.

Senior Vice President
of The Change Companies®

(more…)

July-August 2010 – Tips & Topics – july-august-2010

TIPS and TOPICS
from David Mee-Lee, M.D.

Volume 8, No. 4

July-August 2010

In this issue

SAVVY Aging by the numbers; and tips on eldercare

SKILLS Facing your fears, saying good-bye, and planning the future

SOUL What is Your Legacy?

SHAMELESS SELLING The new Tips n Topics book just released! Plus a freebie

Until Next Time

Welcome to a combined July-August edition of TIPS and TOPICS.

With summer vacation on our mind (here in the northern hemisphere at least), I took it easy these two months. But what I include in this edition is not light summer reading. It is, in fact, a topic I have not addressed before in any detail partly because it can be a sad and depressing focus for discussion. I’m speaking of aging, elder care, dying and death. Still want to read on?

(more…)

November 2007 – Tips & Topics – november-2007

TIPS & TOPICS
Volume 5, No.7
November 2007

In this issue
— SAVVY
— SKILLS
— SOUL
— Until Next Time

Welcome to the November edition; and if you are in the USA, Happy Thanksgiving. We’re glad you join us every month. But if you find yourself with too much e-mail, and want to unsubscribe, you can do that at the links at the end of this newsletter.

(more…)

June 2009 – Tips & Topics – june-2009

TIPS & TOPICS
Volume 7, No.3
June 2009

In this issue
— SAVVY
— SKILLS
— SOUL
— STUMP THE SHRINK
— SUCCESS STORY & SHARING SOLUTIONS
— Until Next Time

Welcome to the June edition of TIPS and TOPICS. I’m glad you could join us.

(more…)

April 2009 – Tips & Topics – april-2009

TIPS & TOPICS
Volume 7, No.1
April 2009

In this issue
— SAVVY
— SKILLS
— SOUL
— STUMP THE SHRINK
— SUCCESS STORIES
— SHAMELESS SELLING
— Until Next Time

Time flies when you are having fun. This month’s edition begins year seven of TIPS and TOPICS (TNT). A special welcome to those of you who have been here from the beginning with our first edition in April 2003. If you are a new subscriber, welcome too.

(more…)

February 2009 – Tips & Topics – february

TIPS & TOPICS
Volume 6, No.10
February 2009

In this issue
— SAVVY
— SKILLS
— SOUL
— STUMP THE SHRINK
— SUCCESS STORY
— Until Next Time

Welcome to all the new readers who joined us this month and to our long-term readers as well. I understand we all receive a lot of information in our inbox each day; I appreciate your taking the time to look this edition over.

(more…)