Vol. 11, No. 12
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.
Howcan you tell if a person is just “doing time, not treatment”?
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?
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.
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?
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:
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,
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).
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.
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.
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.
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.
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.
Hope this helps.
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.
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.
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.
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.
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.
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.
* 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