March 2011 – Tips & Topics – march-2011-tips-topics

TIPS & TOPICS
David Mee-Lee, M.D.

Volume 8, No. 11
March 2011

In this issue
— SAVVY – The METHODS method for discharge planning
— SKILLS – RCA ceremonies – The new treatment completion Graduation?
— SOUL – Always the right answer

— STUMP THE SHRINK – Medical necessity, ASAM PPC and what levels of care?
— Until Next Time

Welcome and thanks for joining us for the March edition of TIPS and TOPICS (TNT).

(more…)

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

Vol.12, No. 8

Welcome to the November edition of Tips and Topics (TNT). For all in the USA, a Happy Thanksgiving!

David Mee-Lee M.D.

SAVVY

Whenever I raise a sometimes controversial issue in Tips and Topics (TNT), I am never quite certain how it comes across. Fortunately I see many of you at workshops and conferences. I appreciate it when readers tell me they always seem to get something useful out of each issue. (Of course the readers who don’t get much out of TNT never come and let me know how disappointed they are. After all, TNT is free!)

The emails and verbal appreciations are gratifying.  This month however, one reader, Izaak Williams, went much further than simply read and digest a previous edition.In the March 2011 edition, I wrote in SKILLS about the sometimes negative, unintended consequences of “graduation” ceremonies in residential treatment.

http://www.tipsntopics.com/2011/03/march-2011-tips-topics/#more-1625

 

Izaak researched the topic and wrote his version in a peer reviewed paper entitled “Drug Treatment Graduation Ceremonies: It’s Time to Put This Long-Cherished Tradition to Rest” He even received permission to allow you free access to the whole paper at this link:

http://www.tandfonline.com/doi/full/10.1080/07347324.2014.952995

 

So I asked Izaak Williams to summarize his paper for the November edition. Here is how he did that (with some minor edits from me.)

 

TIP 1

Are Graduation Ceremonies a Therapeutic Celebration or Hollowed Concept? You Be the Judge

 

1. Where did substance use treatment graduation ceremonies originate?

The history of this tradition finds its roots in “early 19th century treatment institutions. It was the practice in the Keeley Leagues (KL) – (for example, the patient-led recovery mutual aid fellowship within the Keeley Institutes) for the person leaving treatment to recount their experience, receive the best wishes and guidance of other KL patients before KL members walked the departing patient to the train station in Dwight, Illinois. The function of this ritual was to reaffirm commitment to sobriety, cement the bonds of fellowship, and form a bridge between the institutional group and the Keeley League meetings in one’s own home” (Personal Correspondence, W. White, November 6, 2014).

 

2. What’s wrong with using the term graduation or commencement?

Just about any dictionary definition of “graduation” or “commencement” spells out the notion of “wholeness” that refers to completion of everything needed or required. When we talk about graduation in the education system the discussion shifts to prerequisites and credits towards a degree program—requirements that are clearly articulated.

 

For example, asking a high school or college student if he or she will graduate would invite the student to talk about how many credits they’ve completed or what classes they plan to take in the near future in order to graduate or commence. Moreover, while the meaning of commencement in the dictionary may refer to “a beginning”, this very same definition is often qualified with cross-reference to graduation. In other words, to start anew or “begin” one must first completely finish (high school or college degree program).

With this in mind, how does one commence or graduate from a substance use disorder?

Why might it not be such a Good Idea to Graduate Treatment Participants?

 

Here are Izaak’s thoughts on how graduations appear to affect participants:

  • There can be an overblown sense of confidence about their prospects of not returning to use. This reinforces a willpower stance toward addiction. It seems to foster a particular relationship with their drug of necessity which directly contributes to continued drug use or relapse.
  • For some clients who tend to reward or celebrate with drug use, a festive celebration with entertainment value may trigger a drug craving in order to enhance the fun.
  • It may foster the false belief that “cure” has occurred and that treatment support or ongoing mutual aid is no longer needed or will ever be required.
  • Treatment participants may be working on repairs or making amends while relationally cutoff from loved ones. If loved ones are not invited or refuse to participate in graduation, this can provoke client distress, anxiety, and other not-so-good feelings and negative emotions.
  • Returning to treatment after graduating would seem to provoke a sense of stigma in light of embarrassment and disappointment of having to face treatment staff and possibly other peer clients who celebrated with them.

3. What is the future for graduation ceremonies?

There are many ongoing changes in drug treatment industry standards in light of the Affordable Care Act (ACA) and Mental Health Parity and Addictions Equity Act (MHPAEA)(2008).  In the future, the existence of graduation ceremonies will hinge on the availability of empirical evidence to support it as a therapeutic practice.  This is because traditional stand-alone addiction treatment programs which perpetuate this tradition mostly aim at targeting drug use on the basis of stabilization. This is an acute care model; it’s not sophisticated enough to be effective for chronic disease management.  One emerging model of care is the patient-centered “medical home” or “Patient-Centered Primary Care Home Program” (PCPCHP) (see: http://www.oregon.gov/oha/pcpch/Pages/index.aspx for patient-centered primary care programs). In short order, here are but a few of the key standout words characterizing this model: comprehensive, integrated, coordinated, continuous, patient and family centered, collaboration.

 

As treatment industry standards encourage collaborative plans of intervention that are holistic and promote wellness, the future of both acute care model and graduation ceremony is bleak. This is because both appear antithetical to the new standards of care conforming to the medical model of drug addiction promoted by ACA and MHPAEA.

 

4. Is there another way of thinking about Graduation Ceremonies?

  • One suggestion is that the word “graduation” and its substitute or euphemism-“commencement”— be avoided in program speak. This would then permit the notion of continuum of care transition to creep into thought rather than “end of treatment”, “completion”, or “graduation.”
  • Perhaps the proverbial graduation ceremony performed in a grand ballroom could be scaled down to a more individualized patient-centered setting-an intimate meeting-  between the treatment team, client, family members, sponsor, and friends willing to offer ongoing support.  This forum would provide a structured opportunity to talk safely and formulate support roles.  Add to this: the possibility of clarifying misconceptions about addiction dynamics and facilitating ongoing treatment recovery processes.
  • As David Mee-Lee suggests, this could be called the Reflection, Celebration, and Anticipation (RCA) (seehttp://www.tipsntopics.com/2011/03/march-2011-tips-topics) stage.  At its very essence, what this entails is establishing a road map to help patients and his/her support system see where they are now and where they are headed in treatment recovery.  This might be called a ”life in recovery transition day” centered on the sharing of a solid, longitudinal, community-based Continuing Care Recovery Plan (CCRP) in supporting further stages of recovery.

 

In closing, Izaak indicated that Thomas McGovern, editor of the Journal of Alcoholism Treatment Quarterly invites comments in response to the article entitled “DrugTreatment Graduation Ceremonies: It’s Time to Put This Long-Cherished Tradition to Rest” (Vol. 32 issue 4). “We welcome critique and criticism to stimulate further dialogue, compel critical thinking, and encourage empirical scrutiny of substance use disorder treatment graduation ceremonies.”

 

Izaak L. Williams, Hawaii State Certified Substance Abuse Counselor (CSAC), was selected in the 2014 cohort of emerging leaders by the Center for Substance Abuse Treatment’s(CSAT’s) Behavioral Health Leadership Development Program. He can be reached at: izaakw@hawaii.edu

 

Reference:

Williams, Isaak L (2014): “Drug Treatment Graduation Ceremonies: It’s Time to Put This Long-Cherished Tradition to Rest” Alcoholism Treatment Quarterly Volume 32, Issue 4, pages 445-457

Published online: 06 Oct 2014http://www.tandfonline.com/doi/full/10.1080/07347324.2014.952995

SKILLS

In April of 2011, theBoard of the American Society of Addiction Medicine unanimously adopted a new definition of addiction. There is a “short version” (shown below), as well as a “long version” definition (available at http://www.asam.org/for-the-public/definition-of-addiction), which serves as more of a description of the condition.

Short version: “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.”

 

Izaak provided what he called “Stimulus” questions for you to think about. Reflect on these to see how you view graduation ceremonies in the context of your definition of addiction. I responded with a few thoughts his questions stimulated for me.

 

TIP 1

Consider the following “Stimulus Questions” about Graduation Ceremonies

 

Question:

How do graduation ceremonies provide mutual support and aid drug addiction treatment and recovery for participants?

My thoughts:

It is always a joy to see people change (if they have) in attitude, thinking and behavior from the beginning of an episode of care to their transfer or discharge. Celebrating these changes creates a sense of accomplishment that too many clients and patients have rarely experienced in their lives. However, on the path of life-long recovery, their episode of care is just one step; it is a beginning not an ending. For many clients, families and mandating agencies “graduation” sounds like cure, as if a broken leg is now fully healed and ready for weight-bearing. It may seem that the term “commencement” might be a better word, to signify a beginning process, except in people’s minds this word is still associated with graduation ceremonies.

Question:

What do such ceremonies provide to family members when their loved one is reintegrating into the community out of treatment?

My thoughts:

Many families have suffered for years from the effects of addiction in their lives and their loved one. Finally, after treatment, the family finds it wonderful to have their son, daughter, father, mother or partner back. They get back the loved one they haven’t experienced for years, due to the ravages of addiction. But I have seen so many families disappointed and hurt by expectations of “treatment completion and graduation.” They thought this would finally be the miracle.

When families think of addiction treatment as finding the best program (like researching a world expert surgeon, cancer center, miracle medication or procedure) “graduation” offers false hope. They need to understand addiction requires continuing recovery and care. Flare-ups and acute exacerbations of this ongoing disease are common, just like asthma, diabetes, hypertension, bipolar disorder or panic disorder. Families are in need of recovery help as much as their loved one. “Graduation” sends the wrong message.

 Question:

What values and perceptions about the nature of addiction are you expressing when you have graduation ceremonies?

My thoughts:
You can tell what I think. In providing your services, what do your practices, policies and procedures with clients and families communicate to them about the nature of addiction? What messages do clients and families receive, explicitly and implicitly, in how you describe your program or service? How do you speak about length of stay and program rules? How do you treat the end of a treatment episode, discharge planning, family work and graduation ceremonies?

Question:

Are such values and messages consistent with what the research says about addiction?

My thoughts:

Obviously I view addiction and treatment as an ongoing process of recovery; it needs to be viewed as chronic disease management in a flexible continuum of care. The ASAM Criteria has set out the criteria for how to do chronic disease management since 1991. Ponder your definition of addiction. How consistently do you walk the talk about addiction – its nature and its treatment.

Question:

Does participation in graduation lead to better recovery outcome?
Do “graduates” find it easier to maintain their therapeutic gains?

My thoughts:

Whether you are for or against “graduation”, we are most often speaking from tradition, personal life and work experience, and clinical opinion. The research evidence is slim to nothing. This would be a worthy research focus for an up and coming scientist in the field.

Question:

How does graduation ease the transition from treatment to longitudinal recovery care management in the community?

My thoughts:

Unfortunately, I believe the unintended negative consequences outweigh the understandable advantages of joyful celebration. I wonder, as Izaak Williams’ paper suggests, whether “It’s Time to Put This Long-Cherished Tradition to Rest”.

SOUL

I am pretty good at saving money. My father was frugal and I have been socialized to be the bread-winner and provide the best I can for my family. But when it comes to saving time, it’s a different matter. Somehow, I just never seem to have enough time.

 

Now before I go on further, let me acknowledge that this SOUL was inspired by reading Scott Provence’s “Time Robbers” in his weekly stories about superheroes and behavior change. Scott is Vice President of Product Development at The Change Companies and in his blog, Superhero is learning about the science of self-help. You’ll be entertained and educated by the antics Superhero gets up to. You can see the November 3, 2014 story I’m referring to at the website Scott calls “I’ll Save You (and other lies)”. Check out the Archives and subscribe there too if you want.

http://www.illsaveyouandotherlies.com/blog/2014/10/28/the-hero-of-time-and-money

“Time Robbers” started me thinking about parallels between money and time, and the language we use:

  • We save money to spend later. We save time by taking a shortcut on a road trip.
  • We spend a lot of money on what is important to us. We spend a lot of time on what is important to us.
  • We can waste money on ill-founded schemes or trivial pursuits. We can waste time on ill-founded schemes or trivial pursuits.
  • If you don’t watch out to keep your money safe, it can get stolen. If you don’t watch out for how life flies by, you may find on your deathbed that time can also be stolen.
  • We can be generous or stingy with our money. We can be generous or stingy with our time.
  • If you manage your budget well, you can have extra money. If you manage your schedule well, you can have extra time on your hands when you arrive early for an appointment.
  • You can worry about how much money you have and stress yourself out. You can worry about how much time you have left in life and stress yourself out.
  • Some people just never seem to enough money. Some people (looking in the mirror) just never seem to have enough time!

Well this could go on endlessly. What I realized is that I need to look at what works so well for me in having enough money, then apply the same skills to having enough time.

 

Here’s what I came up with for starters:

With money:

1. I set my priorities between retirement savings, living expenses, charity, travel and vacation.

2. I watch what I spend for quality and value.

3. I check my bank account and credit card accounts frequently to make sure expenditures and savings are in balance.

 

I do all that well.

 

Now for time, it is the same three principles:

1. What are my priorities between work, love and play?

2. How can I be more conscious about spending quality time with people, places and things of value?

3. How can I regularly check that all is in balance?

 

I’m sure my wife willbe happy to keep my feet to the fire on how I spend my time. I can see NewYear’s Resolutions gradually taking shape.

Until next time

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

David

February 2017

Vol. #14, No. 11 In this issue Words & underlying concepts; Stump the Shrink on individualized treatment; Pressing buttons David Mee-Lee M.D. SAVVY From January 29 to February 1, I participated in C4 Recovery Solutions’ Addiction Executives Industry Summit (AXIS)...

New publications on Drug Court Graduations and Discharge Categories; rethinking policies and practices; Customer service

Vol. #15, No. 3

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

David Mee-Lee M.D.

SAVVY

This is the fifteenth year of publishing Tips and Topics (TNT). It is always gratifying and meaningful when people tell me how much they appreciate receiving it. About three years ago, one of TNT’s readers introduced himself to me and has gone way beyond just being a reader of TNT. I introduced Izaak Williams to you in the November 2014 edition of TNT.  In there, he summarized a paper he had written which was prompted by my writing on graduation ceremonies, which had appeared in a 2011 TNT edition.

If you missed his paper entitled “Drug Treatment Graduation Ceremonies: It’s Time to Put This Long-Cherished Tradition to Rest,” here is a link to that paper:

November 2014 Tips & Topics

This June, Izaak published another paper as principal author.  I was a co-author, along with two others. This new one built on Izaak’s previous paper and expanded into graduations in Drug Courts. I will get to that in a minute.

Before that, here is some backdrop. Below is part of an exchange between Izaak and myself about: * how he came to be on the TNT mailing list in the first place and what resonated with him to read them so extensively?

Izaak Williams: “Years ago I was working on the frontlines of an outpatient addiction service, when my well-regarded Interim supervisor and colleague forwarded me their edition of Tips & Topics (If I may digress into a brief aside, I do not believe it coincidence that my professional relationship with these two former colleagues, who were both eager and avid readers of Tips and Topics at the time, would years later blossom into a personal friendship). As an addiction counselor, I was gradually becoming aware that there were areas of addiction treatment that needed improvement. Tips & Topics seemed to articulate a set of values and beliefs that really resonated with me. Since then I have used Tips & Topics as a bedrock to form a foundation upon which to build addiction services. Tips & Topics has become a prevailing medium to both highlight and inspire changes in treatment programs and to help fundamentally shift anachronistic paradigms. With Tips & Topics, I have drawn on the 14 years of Archives to address a variety of core initiatives that could very well make addiction treatment a better quality system in terms of its integrity, efficacy and effectiveness.”

Izaak L. Williams, Hawaii State Certified Substance Abuse Counselor (CSAC), was selected in the 2014 cohort of emerging leaders by the Center for Substance Abuse Treatment’s(CSAT’s) Behavioral Health Leadership Development Program. He can be reached at: izaakw@hawaii.edu.

 

TIP 1

Rethink Drug Court graduation ceremonies; consider a possible alternative approach

“Rethinking Court-Sanctioned Reintegration Processes: Redemption Rituals as an Alternative to the Drug Court Graduation” was published this month in the Howard Journal of Crime and Justice.

Here are some highlights:

  1. On Drug Court (DC) graduation day, participants receive a certificate signifying completion of treatment for their substance use disorders and compliance with DC requirements. Having satisfied the conditions of DC by staying drug free and not engaging in criminal behavior, graduation signifies successful compliance.

 

  1. Graduation ceremonies can, however, create the perception among DC participants and families that graduation represents the end of treatment, and that little, or no further support will be necessary to prepare DC participants for their future.

 

  1. This article offers an alternative perspective. It explores what it means to graduate from DC, and how DC graduation might be reconfigured and reoriented to preserve validation and accomplishment, while guarding against the impression of a cure.

 

  1. Our conceptual framework is grounded in both re-integrative shaming theory, as well as the idea of redemption rituals. The latter is a form of ceremony to facilitate the offender re-entry process. In this approach, the offender is “shamed” by their community by being held accountable for their actions, but also provided with the support to enable them to make the changes necessary for successful reintegration.

 

  1. Redemption ceremonies feature reward and celebration, evoke positive emotion, and involve the public. However, in contrast with conventional graduation ceremonies, redemption rituals are intended to be restorative in their outcomes.

 

  1. Redemption ceremonies offer alternative meanings and symbolism for graduation from DC. These represent much more than just a participant’s compliance with court orders, treatment programming, and drug testing expectations.

 

  1. Redemption ceremonies emphasize a number of key factors: achievement, coordination of care, status elevation, and moral inclusion.
  • Achievement“: refers to long-term positive changes in the behavior of DC graduates rather than just compliance with program requirements of abstinence; promotes sustainable change and treatment matching.
  • Coordination of care“: ensures that the overall care provided is sufficiently comprehensive and coordinated to address the diverse and specific needs of individuals pre/post-graduation. Major differences in the characteristics and needs of DC participants means that there needs to be coordinated, integrated services from a variety of providers.
  • Status elevation“: involves effectively elevating the status of DC graduates so they can be fully accepted by, and integrated into, the social community without ongoing stigma and discrimination.
  • Moral inclusion“: addresses the process of welcoming the DC participant as a full member of a moral community rather than as a stigmatized person; it highlights the role of community acceptance in promoting sustainable change among DC graduates.

“Redemption entails identifying clients who are doing time versus doing treatment and change, and ensuring that adequate treatment resources are made available to successfully engage the former category of participants in an ongoing process that requires more than the DC phase from which they have now graduated.” (Page 263)

How to access the full article:

I am not permitted to post the full paper, but here’s the link to the Abstract: http://onlinelibrary.wiley.com/doi/10.1111/hojo.12203/full

If you want to read the whole paper you can contact me at dmeelee@changecompanies.net. I can “transmit individual copies of this PDF to colleagues upon their specific request provided no fee is charged, and further-provided that there is no systematic distribution of the Contribution, e.g. posting on a listserv, website or automated delivery.”

 

TIP 2

Consider the underlying assumptions, attitudes and practices driving the structure and naming of Discharge Categories.

Back in 2005 (February and March editions of TNT), I wrote about Discharge categories and the hidden philosophy, values and attitudes underlying many agencies’ categories.

February 2005 Tips & Topics

March 2005 Tips & Topics 

Now 12 years later, Izaak and I formalized an article named:
“Co-participative Adherence: The Reconstruction of Discharge Categories in the Treatment of Substance Use Disorders”. It was just published this month online in Alcoholism Treatment Quarterly (ATQ).

Here are some highlights:

  1. Every program and agency has a variety of discharge categories classifying whether a client was successfully discharged or not.

 

  1. We suggested that a “moral-choice-compliance” (MCC) model of addiction and treatment underpins current discharge categories.

 

  1. Many providers advocate a “disease model of addiction”, but actually practice from the perspective of an MCC model. That model embraces practices and policies that sees substance use as willful misconduct, a moral problem where clients choose to pick up a drink or drug and therefore:
  • Should have “consequences” for their use
  • Be suspended from treatment for the day until sober
  • Be discharged from residential care and sometimes banned from reapplying for treatment until 30 days have passed
  • Be removed from mixing with other clients lest they trigger use for others.
  1. Rather than conducting treatment in recovery-oriented systems of care that values client empowerment, each client is expected to comply with treatment recommendations. Treatment progress is then measured by the client’s quality of compliance with program rules and counselor recommendations. Non-compliance can be met with “loss of privileges”, set back a level in a phase-based program; and even Administrative Discharge or Discharged for Non-compliance.

 

  1. To contrast a compliance, program-driven philosophy implied in the MCC model,we suggested a “coparticipative adherence” model to drive discharge terminology.

 

  1. Such a model values client autonomy in the administrative and clinical program systems. Clients participate and collaborate on goals and treatment plans, and participate in self-fueled adherence and committed effort in treatment. Coparticipative adherence thus facilitates a self change process rather than program-driven change.

 

  1. We offered contrasting and alternative discharge categories based on a “coparticipative adherence” model.

 

Here’s link to the Abstract:

http://www.tandfonline.com/doi/full/10.1080/07347324.2017.1322432

How to download the full article:

  • There are a limited number of free downloads at these two links to see the full paper:

http://www.tandfonline.com/eprint/eq3aFhfwTzK5BXaS7U8p/full              

http://www.tandfonline.com/eprint/yzyTQFmjskwUVeR3ZrKx/full

  • Check the Addiction Professional website around the middle of July to read Gary Enos’ online cover story of a Williams – Mee-Lee interview about this paper. For 30 days once that Addiction Professional article is posted, you can access the link for a free copy of the article https://www.addictionpro.com

 

References

Williams IL, Mee-Lee D, Gallagher JR, Irwin K (2017): “Rethinking Court-Sanctioned Reintegration Processes: Redemption Rituals as an Alternative to the Drug Court Graduation” The Howard Journal of Crime and Justice. Volume 56, Issue 2 June 2017 Pages 244-267.

Williams IL, Mee-Lee D (2017): “Co-participative Adherence: The Reconstruction of Discharge Categories in the Treatment of Substance Use Disorders” Alcoholism Treatment Quarterly. Vol. 35, Issue 3, June 2017 Pages: 279-297. Published online: 16 Jun 2017, Pages 1-19

http://dx.doi.org/10.1080/07347324.2017.1322432

 

SKILLS

Here are a few Skills tips to help rethink graduation ceremonies and promote sustainable self-change in the people we serve.

TIP 1

How to move from graduation to commencement ceremonies. 

  1. In the March 2011 edition of TNT, I suggested we develop RCA – the Reflection, Celebration and Anticipation ceremony.

March 2011 Tips & Topics

 

  1. Some drug courts and treatment courts have literally shifted terminology from “graduation” to “commencement” ceremonies. This encourages viewing recovery as a process just started, not completed.

 

  1. Talk to clients and participants in terms of having done an important “piece of work” in their treatment process, which is to be appreciated and honored. However, it is just a “piece” of the process of recovery, if sustainable change is to be achieved.

 

  1. Pay attention to clients who are just going through the motions of treatment.  Make sure you don’t give the impression that just complying with rules and regulations will bring lasting results. I was reviewing with a care manager about her client who was eager to know what his drug court graduation date was going to be.

Why was it important to him to know the exact date?

He wanted to plan his wedding date after graduation. That way he could drink alcohol at his wedding without fear of consequences from drug court. His drug court graduation date was pushed back, so he promptly changed his wedding date to a later date. You can see where his priorities were.

TIP 2

How to enhance “coparticipative adherence” 

What was the rationale behind coining the term “coparticipative adherence”?
The term emphasizes the true meaning of “adherence”; this encompasses collaboration, client empowerment for shared decision-making, and client choice in treatment decisions affecting their life. It isn’t an exercise in political correctness to replace “compliance” with “adherence”.

 

  1. Is the client actually a co-partner in defining overall and specific goals in their treatment? If you feel like you are doing more work than the client, then something has gone wrong with the co-partnering process.

 

  1. Are they actively participating in treatment or passively going along with treatment? If you feel like you are doing all the talking and making all the arguments (e.g. why attending self/mutual help groups is important; why medication adherence is necessary; why staying away from those friends is advisable) then your client is watching treatment, not doing it.

 

  1. Is your client adhering to the treatment plan – clinging to, steadfast, sticking to it – with the same energy and commitment they had in their active addiction days.  If they knew they could have whatever drugs, whatever quantity, so long as they met their dealer promptly at 4 PM, how many of your clients would say “I don’t think I can make it at 4 PM.  How about 5 PM?  Or feel a little flu coming on, can I go next week?”  However when it comes to treatment, if your client can’t seem to make it to appointments until 15 minutes late or not even show up or call, their adherence quotient is low.

Finally, if your client is not adhering, don’t look at the pathology of the client and think about Discharging them for Non-Compliance. Take a look first at the treatment plan and how well -or not- you have engaged the client.  It may well be your treatment plan not a coparticipative plan.

SOUL

Because I travel so much, I notice the hospitality and travel industries continually innovating to be more and more customer-friendly.

For example, renting a car?

  • If you are enrolled in a loyalty program, you can bypass the lines at the rental counter and go straight to your car in space A9.
  • How can you be sure A9 is your car? Either you receive a text or email telling you what car to look for in what space, or, their TV monitor lists your name and car space.
  • What if you don’t like the assigned car and want to choose yourself? Some companies allow you to choose any car in your rental rate category. Since we are a Toyota RAV-4, Prius family, it’s nice to select a car with familiar dials and settings.

How about hotels?

  • Many hotels now have phone apps. This enables you to check in ahead of time. When you arrive at the hotel, you simply pick up your key and go to your room.
  • In a few hotels it is possible to even bypass the key-pickup-process and use your smartphone to enter your room. I haven’t tried that yet.
  • Checking out is just as easy. Before leaving the room, just review your emailed bill, check out on your phone or laptop. You can now bypass the front desk.

Then there’s Uber

  • As soon as I type in my destination in the Uber app I love seeing the price, how many minutes my ride is away, the driver’s name, car brand and license plate number. Now I know what to look out for.
  • How great is it to be able to track the car’s path on the map and exactly how many minutes s/he is away, so there is no confusion who and where your ride is?
  • Have you tried Uber (or Lyft)? When you do, I think you’ll see, like me, that you’d never choose to use a taxicab again.

Healthcare and addiction and mental health treatment all serve people too. Yet, I have to think hard to churn out m/any bullet points of innovation:

  • I do like the easy access to my medical record online where I can make an appointment, ask my doctor a question, check my lab test results all without being placed on a phone hold.

However there are a lot of “unfriendly” practices which come to mind:

  • When I visit the doctor’s office, I am handed a clipboard with a request to update any changes to my medical history.  However the form is a brand new form as if I am a brand new patient.

Why not offer me a printout of my current history, then I can indicate any updates or changes on that ‘existing information’ form?

  • Often an anxious person or family member is given an intake appointment in 2 days, 2 weeks and even 2 months.

Why not establish and offer an orientation, service-overview group available in 2 hours? If no one turns up, the leader can do paperwork. If 10 people show up, engagement and support can start that day.

  • We still offer care and treatment services only in face to face appointments.

Why not provide phone apps, online education, treatment sessions, disease management, chat groups and support networks in the privacy of the person’s own home by phone or online?

Of course, innovations are already happening in healthcare.  Practices and policies are indeed becoming “friendlier”.  But maybe we could pick up the pace!  Surely people’s health and well-being are just as important as renting a car, booking a hotel room or catching a ride.

Until next time