Year 15 of Tips & Topics; Spirituality & ASAM Criteria; Heart, patience and empathy

Vol. #15, No. 1

Welcome to start of our 15th year of publishing Tips and Topics. It is hard to believe there are now 14 years of back issues in the Archives at Tips & Topics.

David Mee-Lee M.D.

SAVVY

Several months ago, I started a conversation with Rev. Jack Abel, M.Div., MBA, Senior Director of Spiritual Care at Caron Treatment Centers. Caron, a leading not-for-profit addiction treatment center, is headquartered in Wernersville, Pennsylvania, and is not a religious organization. Jack leads a team of spiritual counselors, and adapts the historic model for Clinical Pastoral Education (CPE) common in hospitals and end-of-life care. He and his team are intentional about work in the practice gap of spirituality. They have refined a formal model of spiritual assessment and care as an integrated discipline of addiction treatment.
The ASAM Criteria editors have always believed in the importance of spirituality in addiction treatment. However we have not articulated well in The ASAM Criteria how to integrate spirituality into multidimensional assessment and treatment. On page 54 of The ASAM Criteria (2013) there is a section on spirituality: “By assessing if and when spirituality has been meaningful for the individual in any or all of the assessment dimensions, strengths, skills, and resources can be identified to be incorporated into the service plan.”
Jack Abel agreed to lay out for Tips & Topics how he and his team at Caron Treatment Centers uses the structure of The ASAM Criteria assessment dimensions to integrate spirituality into the care at Caron. Spirituality is like comedian Rodney Dangerfield’s joke that he gets “no respect”. So here’s what Jack wrote. I reconfigured his content to fit with the style of Tips & Topics, but it is Jack’s work:

 

“The Chaplain Gets No Respect”:
Caron Treatment Centers uniquely integrates professional spiritual care
This month we take a close look at how one treatment provider is moving into this area in a way that draws heavily upon the ASAM Criteria.

 

TIP 1
Spirituality may or may not play a role in how we think about placement and ongoing care – but it can and should!
 
Many behavioral health facilities offer some access to persons who are trained in pastoral care, spirituality, or chaplaincy services. The provider may be a pastor, priest, rabbi, or shaman that comes in from the surrounding community. It might be someone on staff who brings mindfulness, grief counseling, visitation, or a “chapel” component to our care. There’s no uniform standard, and few formal models for how spiritual care is delivered, but it’s also something we see experimentation with, and a good bit of talk about.
Spirituality in Six Dimensions
The 2013 Third Edition of The ASAM Criteria notes, “many have asked why there is not a Dimension 7 on spirituality.” The paragraphs on page 54 go on to suggest a few examples of how spirituality can be integrated across the six dimensions. At the same time, “specific criteria have not been written incorporating the role of spirituality in placement or treatment decisions explicitly.”
The current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) also offers:
  • A new “Cultural Formulation Interview” (CFI) among several proposals for further research.
  • It is one of several assessment and monitoring tools “for which we determined that the scientific evidence is not yet available to support widespread clinical use” (p. 23f).
  • The introduction to the CFI chapter explains, “Culture includes language, religion and spirituality, family structures, life-cycle stages, ceremonial rituals, and customs, as well as moral and legal systems” (p. 749).
So, spirituality, faith, religion, and culture: these are on the “radar” for ASAM and DSM-5, but also lacking clarity in terms of specific models and methods. Hence the title of our tip, “the Chaplain gets no respect.”

 

TIP 2
How a spiritual care provider interfaces with the rest of the treatment team
  
A Respectable Chaplain’s Work Day
In some settings, the role of the chaplain may be quite ancillary or quite integrated. A small hospital without a formal program may allow clergy from outside to visit, with little or no documentation. On the other hand, a hospice program may include chaplains in treatment planning with patient and family involved.
What makes sense for addiction care at various levels?
Caron’s approach to the integration of spiritual care is on the more formalized end of this continuum.
  • Patients are assigned a spiritual counselor who is a member of their treatment team, and automatically scheduled for a formal spiritual interview, which typically occurs between the 3rd and 7th day of treatment (depending on availability and readiness, given the complexities of addiction withdrawal).
  • The assessment interview is captured in an extended narrative that becomes a part of the patient’s medical record, and is frequently referred to by other members of the treatment team.
  • Any action steps or interventions devised in the assessment are incorporated in relevant goal areas in their written treatment plan. Thus, the team and patient are engaged collaboratively in spiritual work as an integrated part of treatment goals.
The spiritual counselor then remains an engaged member of the patient’s treatment experience.
  • He or she provides lectures, small groups, specialty groups (e.g. grief and loss)
  • May collaborate in these components with other disciplines.
  • Patients with significant areas to explore that were identified in the initial assessment may benefit from an individual follow-up consultation if time and resources allow.
  • The spiritual counselor is a partner in the dialogue as the team provides ongoing treatment plan updates and works to author a plan for next level of care.

 

TIP 3
The Importance of Story
  
For each assessment, a variety of tools are woven into a foundational portrait of the recovery process as narrative and journey.
  • How can the individual and family move toward greater connectedness?
  • What are the barriers that impede this movement?

Story or “narrative” plays an important role in theology, philosophy, and social psychology. One of the central resources in Caron’s spiritual care training program focuses on the work of Arthur Frank, and his text, “The Wounded Storyteller”. It may not be obvious to persons who are unfamiliar with this material, but Frank looks masterfully at the types of stories people use to navigate through illness, and emphasizes the role of an “epic” story style in circumstances of serious illness and personal or family crisis.

 

As the continuum of care unfolds from initial inquiry through residential treatment to aftercare, a patient and their family members may tell the story of their journey in different ways.
  • It is not uncommon for people to adopt a “restorative” narrative, one that sees the treatment episode as brief and compartmentalized, a kind of ‘penalty box’ experience after which the ‘player’ returns to the ‘game’ of life.
  • At other points, the sense of having a coherent narrative may fall away, leaving a person in a “chaos” or un-utterable phase – a time when no story seems to make sense.
It is not surprising that 12-step recovery communities are largely story-based.
  • Ultimately, successful recovery is generally accompanied with a different kind of story, a story that often has classic features of epic narratives or “heroic” journey.
  • The traveler embarks upon a quest, entering the ‘sick world’ where a combination of helps and challenges shape movement towards a new, hoped-for outcome.
  • Connectedness, a fundamental aspect of spirituality, is central to every phase of the quest journey.
Saying yes, making alliances, facing trials, learning lessons: these are ways in which the spiritual counselor helps the patient and family tell the story of their experience, hopes, and challenges.

SKILLS

TIP 1
The Nuts and Bolts of Spiritual Assessment
 
One of Caron’s innovations involves elucidating spiritual needs in parallel with the ASAM Criteria dimensional framework. This enhances collaboration with interdisciplinary partners in the treatment process, and supports the involvement of patients and families in understanding this model of the recovery journey. This SKILLS segment explores in some detail:
  • What spiritual assessment and interventions may consist of
  • Some of the models most useful for designing them
  • How differing personal and cultural backgrounds are taken into account.
Spiritual Assessments
1. In general, the spiritual counselor’s assessment presents findings about the patient’s suffering and its impact on their connection to self, others, the natural world, and to universality, faith, or transcendence as they may conceive it. Pastoral, theological, and clinical frameworks can, and should, be referenced to provide context and support for the assessment.
2. These frameworks are a foundation of clinical chaplain training. Different spiritual care clinicians will bring different preferences and experience. Typical models through which a patient is viewed include stage-based models of human development, grief and loss, or trauma.
3. Another aspect of assessment is the patient’s cultural or personal history – how does their tradition or exposure to none or many influence their negotiation of the recovery journey? Twelve-step recovery concepts and models are often in view as well, for example addressing self-reliance through sponsorship and “higher power” relationships, addressing resentments with an inventory and reconciliation process, or coping with distress through prayer and meditation.
Theological and pastoral care training prepares the spiritual care practitioner for this task. A rich pastoral care education includes various stage-based models like:
  • Phil Rich’s formulation of grieving
  • Judith Herman’s stages for trauma recovery
  • James Fowler’s identification of five “stages of faith”
  • Paul Pruyser’s work on ministerial diagnosis.
In addition, the team at Caron is trained:
  • To be mindful of learning styles and cultural and religious frameworks which inform the expectations and struggles of each person and family.
  • Howard Gardner’s theory of multiple intelligences and the DSM’s CFI are key resources.
  • Each spiritual care clinician has their own identity, formation, and belonging. They are accountable for understanding how this informs their experience of the spiritual care encounter, attending to projection, transference, and counter-transference as these occur.
As is the case with other target areas:
  • Identified spiritual care concerns may be mild, moderate, or severe.
  • In certain instances, strengths are identified rather than areas of need or focus.
  • While not equating to formal diagnoses of other disciplines, spiritual care findings often correlate with medical and psychological diagnoses identified by other practitioners – and should.
 
TIP 2
Formulate spiritual care assessments using the ASAM Criteria dimensions, and increase compatibility and integration with other practitioners in the multidisciplinary care team.
 
Treatment assignments, designed collaboratively with the patient, become part of the written care plan. Spirituality is also a focus area in their family program, and throughout the treatment continuum: in preparation dialogues and in next steps after residential care.
Examples in Six Dimensions
In reporting findings to the treatment team, the spiritual counselor writes to one or more of the six ASAM Criteria dimensions.
Dimension 1, Acute Intoxication and/or Withdrawal Potential
Exploring an individual’s past and current experiences of substance use and withdrawal.” The discipline of spiritual care attends to tremors, eye contact, and ability to focus, and even emotional elements of withdrawal like homesickness. Some patients will invite comment in this area; others merit no observation on Dimension 1. Consider a patient in early withdrawal, whose emotions are characterized by fear and loneliness, perhaps having “burned bridges” and sought treatment multiple times previously. This Dimension 1 lamentation, with aspects of fear and loneliness, constitutes an aspect of their spiritual assessment or “diagnosis.”
Dimension 2, Biomedical Conditions and Complications
Exploring an individual’s health history and current physical condition.” Spiritual care attends to the chart and patient’s presentation, and explores how biomedical conditions contribute to the patient’s self-understanding and negotiation of the challenges of existence. A patient with chronic migraines sees their unrelenting pain not only as a medical affliction, but as a cause for despair. Other examples of particularly significant Dimension 2 presentations might include HIV positive status, an amputation, or a history of cancer.
Dimension 3, Emotional, Behavioral, or Cognitive Conditions and Complications
Exploring an individual’s thoughts, emotions, and mental health issues.” What is the patient’s suffering? How does their suffering affect their connection to self, others, the natural world, and to the transcendent – the “God of their understanding?” Dimension 3 is often the most significant area of findings for spiritual assessment. Shame is a frequent challenge for those with use disorders in Dimension 3, and religion, culture, or spiritual outlook often layer this with a narrative of brokenness that seeks forgiveness or redemption. Grief, trauma, and life meaning or purpose are also central to this Dimension. Multiple keywords may apply, for example faith and trust, grief, or woundedness and healing (trauma). It is helpful not only to identify areas of focus but to provide insight into severity and staging.
Dimension 4, Readiness to Change
Exploring an individual’s readiness and interest in changing.” The discipline of spiritual care explores change in varied terms including fear, developmental processes, ritual theory, religious or spiritual conversion, and 12 step recovery. Appropriate findings here are based on the data described in an interview summary and might include observation of patient’s difficulty with surrender in part or whole, fear in relation to specific issues like care planning, or an inability to conceive of a new paradigm.
Dimension 5, Relapse, Continued Use, or Continued Problem Potential
Exploring an individual’s unique relationship with relapse or continued use or problems.” The spiritual counselor helps identify obstacles and risk factors for the achievement or maintenance of a sustained recovery. Apathy and self-reliance are frequent concerns. The patient’s cultural or religious context may contribute positively or as caution. This dimension may simply highlight findings in other areas, which present the greatest concern, but simple redundancy should be avoided.
Dimension 6, Recovery/Living Environment
Exploring an individual’s recovery or living situation, and the surrounding people, places, and things.” The discipline of spiritual care may be especially interested in the network of relationships or meaningful attachments and their status. Distrust, alienation, and resentment are frequent keywords. Examples would be marital discord, strained parent-child relations, hostility or risk in friendship and work settings, and the loss or reduction of any sense of “home” and “belonging.”
 
TIP 3
Spiritual Treatment in Action
 
1. Documented Action Steps. Beyond spiritual “diagnosis,” a compelling area of spiritual interest involves action steps toward identified treatment goals – what are often called clinical “interventions.” At Caron, the initial assessment includes a “disposition” which summarizes any assigned interventions, recommendations, and collaborative engagement of the multidisciplinary team. This might include suggestions for specific approaches to prayer or meditation, reading or writing assignments, art projects, attendance at Chapel or other services, etc.
In the same way interventions can become “boiler plate” in other disciplines, there are core spiritual care practices that frequently are proposed. These often include:
  • Breathing and other mindfulness practices
  • Specific readings from classic recovery texts
  • Observance of customary faith practices (e.g. Sabbath)
  • Grief processing is often aided by the writing of therapeutic letters
  • Resentments in recovery are often processed through AA’s “fourth step” columnar exercises.
The items mentioned above are supported as “evidence-based” in the classic sense.
There is also historic evidence provided by the witness of faith traditions, recovery communities, and the archetypal role of the priest/minister/shaman in our diverse human heritage. Prayer, meditation, ritual, calendar, study, mentorship, and more structured spiritual roles and rites of passage are all tools that can contribute meaning, hope, help, and transformation in the journey of recovery.
2. Contextualization. The spiritual care professional can aid in grounding identified treatment goals within the context of a client or family’s cultural, religious, and personal thought-world.
  • While mindfulness exercises in the generic sense appeal to many, others may be interested in the meditation practices of their family of origin faith experience.
  • A learning style limitation or preference may suggest music or collage as better methods over reading or letter-writing.
3. Collaborative Care. It is important to recognize that significant interventions should be brought to the attention of the primary counselor, and often also the psychologist and unit coordinator – possibly through case consultation beyond documentation in the chart.
  • Any follow-up intention or scheduling should be noted.
  • The spiritual counselor is a regular attendee at treatment team meetings, so that progress towards the fulfillment of action plans and larger objectives can be assessed and the treatment plan updated on an ongoing basis.
  • The treatment plan is then a ‘living’ document, rather than a snapshot, which may quickly lose relevance.
TIP 4
Respecting the Spiritual in Your Context
 
Caron’s deployment of a spiritual care team as an integrated component of residential addiction treatment makes a comprehensive program like this possible. Satisfaction surveys indicate spiritual care content adds significant value to the patient’s perceptions of treatment. Caron’s outcome measures consider an individual’s overall health and wellness, which includes spirituality.
1. Depending on your level of care and other factors, there may or may not be possibilities for full-time spiritual care providers as a component of treatment.
2. The factors raised here, though, and the associated skills for spiritual assessment and treatment planning, are ones that may be beneficial.
3. Consider who may be functioning in this kind of role in an informal or supplemental way. Often there are specific providers who incorporate spiritual aspects in their mental health or medical evaluation and treatment.
4. There may even be administrative and support staff who are providing a spiritual care component not easily recognized. It may have no “footprint” in the medical record.
In whatever way spiritual issues are addressed in your setting, the next time someone mentions “that guy” or “that woman” who “does the spiritual stuff,” don’t disregard the role they may be able to play in assisting your clients to wellness and flourishing. Respect them. The thought may be a great one after all!
References:
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA, American Psychiatric Association, 2013.
Fowler, James. Stages of Faith: The Psychology of Human Development and the Quest for Meaning. 2nd ed. New York, NY: HarperCollins, 1995.
Frank, Arthur. The Wounded Storyteller: Body, Illness, and Ethics. 2nd ed. Chicago, IL: University of Chicago Press, 2013.
Gardner, Howard. Frames of Mind: The Theory of Multiple Intelligences. 2nd ed. New York, NY: Basic Books, 2011.
Herman, Judith. Trauma and Recovery: The Aftermath of Violence-from Domestic Abuse to Political Terror. 1R ed. New York, NY: Basic Books, 2015).
Mee-Lee D, Shulman GD, Fishman MJ, Gastfriend DR, Miller MM, eds. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. 3rd ed. Carson City, NV: The Change Companies®, 2013.
Pruyser, Paul. The Minister as Diagnostician: Personal Problems in Pastoral Perspective. Philadelphia, PA: Westminster Press, 1976.
Rich, Phil. The Healing Journey through Grief: Your Journal for Reflection and Recovery. New York, JY: John Wiley & Sons, 1999.

SOUL

I read an article on April 24 by Julie Pace, Associated Press White House Correspondent. I was intrigued by her report that President Trump “acknowledged that being Commander-in-Chief brings with it a “human responsibility” he didn’t much bother with in business, requiring him to think through the consequences his decisions have on people and not simply the financial implications for his company’s bottom line.”
Here, everything, pretty much everything you do in government involves heart, whereas in business most things don’t involve heart,” he said. “In fact, in business you’re actually better off without it.” (I added italics)
Yes, President Trump is so right …..”everything…..involves heart”.
  

 

 

  • “Heart” is what the staff on the United Airlines flight forgot about (or lacked) when Dr. David Dao didn’t want to give up his seat on the plane, concerned about getting back home to see his patients the next day. If you missed the video of his being dragged up the plane aisle:  United Airlines and Dr. Dao
It took United Airlines too long to get President Trump’s message that “everything involves heart”. United CEO Oscar Munoz eventually said the airline won’t allow law enforcement officers to haul seated paying passengers off its flights again “unless it is a matter of safety and security.”
(Don’t get me wrong. There are always two sides to the story and I fly United whenever I can.  But if United’s culture was ‘person-centered’, there would have been an easy fix to the problem.  For example- ask if anyone else, less concerned about their seat, would give up their seat for $1,000, $2,000 or whatever it took.  Even $10,000 would have saved United millions in lost image, revenue and stock price.)
 

 

 

  • “Heart” is what the flight attendant on American Airlines forgot about when he grabbed the stroller from the distraught and crying mother carrying 15-month-old twins.
“What we see on this video does not reflect our values or how we care for our customers,” the airline said in a statement. “The actions of our team member captured here do not appear to reflect patience or empathy, two values necessary for customer care. In short, we are disappointed by these actions.” (I added italics)
Heart, patience and empathy.
You would think addiction and mental health professionals would be the first people to know about heart, patience and empathy. However it hasn’t been too far back in behavioral health treatment history that we were more focused on rule breaking, behavior control and sticking to our policies. We did this:
  • Discharged people for having a flare-up of addiction and drank alcohol or used other drugs.
  • Heavily confronted clients with profane language, punishments and re-traumatizing practices to strip a person of their defenses.
  • Blacklisted clients – barring them from treatment for months, after three poor outcomes in the program.
  • Used physical restraints and leather straps to tie down psychiatric patients to their beds.
Heart, patience and empathy.

Until next time

Thanks for joining us the start our 15th year of Tips & Topics.  See you in late May.
David

Vol. 12, No. 5

Welcome to all the new readers of Tips and Topics and to all our longtime readers as well. Thanks for joining us for the August edition.

David Mee-Lee M.D.

SAVVY

I recently was in a rush and jumped in the car to get to an appointment. Once on the road, I reached down to my cell phone belt holder and realized I had left my cellphone on my desk at home. I noticed a little twinge of panic…..somewhat like when you suddenly realize your wallet, with all your money and credit cards, is not in your pocket. Have I dropped it? Did I leave it on the store counter?

 

But this is just my mobile phone. I know where it is. If I miss a call or a text, my voice mail and the message will still be there. So no big issue…right? Well it is worth taking a look at your own reactions if you find yourselves without your mobile device or smartphone. Or, even if you have it with you, what is your usual behavior?

  • Can you sit alone at a restaurant, bus stop or airport departure gate without picking up your phone to check messages or email?
  • For that matter, can you sit anywhere even with friends, partners and loved ones and not look at your phone’s screen?
  • Even if you don’t look at your phone, look around. Observe how many people have heads down, fingers tappingthe little screens on the device cupped in their hand.

A group of young, passionate, mission-driven young adults has recently been challenging the relationship we have with our digital devices.  Take a look at what “digital detox” is all about at http://thedigitaldetox.org. They’ve been getting a lot of attention in the mainstream press. There’s a shift in the culture…a little shift. They don’t just blog about it; they’ve been introducing people to the experience of digital detox at what they call Camp Grounded (and other such device-free events.) Take a look at http://blog.thedigitaldetox.org/camp-grounded-official-video/

By the way, catch a glimpse of my son, Taylor in the box titled “Talent Show. ” It is one of a collage of images halfway down the page, with the main title- “CAMP GROUNDED IS.”  At Camp, he leads singing, songwriting and a capella groups (proud father speaking).

 

TIP 1

What’s So Bad About Being Alone With Your Thoughts?

 

This is the title of a July 11, 2014, segment on Public Radio International’s Science Friday radio program. “Researchers at the University of Virginia were recently amazed to discover that many people would rather self-administer painful shocks than sit quietly with their own thoughts for 15 minutes. They also found that men were significantly more likely to shock themselves than women. So what’s so bad about sitting alone and thinking? One of the study authors, Erin Westgate, talked about a fascinating experiment you can hear more about at:

http://www.sciencefriday.com/segment/07/11/2014/what-s-so-bad-about-being-alone-with-your-thoughts.html

 

It is worth the 10 minutes to listen to. If you don’t have the time right now, here are a few excerpts from that program and other news items about this study:

 

Excerpts and Tidbits

In the year 1654, scientist and philosopher Blaise Pascal said “All of humanities problems stem from man’s inability to sit quietly in a room alone.” This age long premise was tested in experiments that were published in the journal Science. Here is the Abstract of that published paper:

 

“In 11 studies, we found that participants typically did not enjoy spending 6 to 15 minutes in a room by themselves with nothing to do but think, that they enjoyed doing mundane external activities much more, and that many preferred to administer electric shocks to themselves instead of being left alone with their thoughts. Most people seem to prefer to be doing something rather than nothing, even if that something is negative.”

 

“Now the big question is, ‘Why would someone do this?’” Erin says. “Why is it so hard to entertain ourselves with our thoughts that we’re willing to turn to almost anything, it seems, to avoid it?”

 

College Students in a study

Studies at universities often start with college students. College volunteers were asked to sit alone in a bare laboratory room and spend six to 15 minutes doing nothing but thinking or daydreaming. They were not allowed to have a cellphone, music player, reading material or writing implements and were asked to remain in their seats and stay awake. Most reported they did not enjoy the task and found it hard to concentrate.

 

The researchers experimented to see if the student volunteers would even do an unpleasant task rather than just sit and think:

  • In one of the studies they offered students a chance to rate various stimuli:ranging from seeing attractive photographs to the feeling of being given an electric shock about as strong as one that might come from dragging one’s feet on a carpet.
  • After the participants felt the shock (which Westgate described as a mild shock of the intensity of static electricity) some even said they would prefer to pay $5 rather than feel it again.
  • Volunteers were asked whether, if given $5, they would spend some of it to avoid getting shocked again. The ones who said they would be willing to pay to avoid another shock became a subject in the experiment.
  • Each subject went into a room for 15 minutes of thinking time alone. They were told they had the opportunity to shock themselves, if desired, by simply pushing a button.

College Students- The Results

  • Two-thirds of the male subjects — 12 out of 18 — gave themselves at least one shock while they were alone.
  • Most of the men shocked themselves between one and four times. However, one “outlier” shocked himself 190 times.
  • A quarter of the women, six out of 24, decided to shock themselves, each between one and nine times.
  • All of those who shocked themselves had previously said they would have paid to avoid it.

Next: Different subjects- not college students

The researchers wondered: were the young college subjects just overly fidgety, not being allowed to tweet or text or check their e-mail? So they reached out to the wider community for non-college volunteers. New subjects ranged in age from 18 -77, recruited from a church and farmers’ market.

  • Researchers asked them to sit alone in an unadorned room in their home – without the shock, since “we weren’t there to supervise them.” They were asked to do the same thing: just sit there at a time of their own choosing, with no mobile phone, reading or writing materials. They were to report back on what it was like to entertain themselves with their thoughts for between six and 15 minutes.   The researchers got pretty much the same results.
    “These were adults,far past college age,” Westgate says, “and again they were terrible at it!”
  • 57percent found it hard to concentrate; 89 percent said their minds wandered.
  • Over half of the participants confessed to cheating. They weren’t supposed to get on their phones or talk to other people, but over half said they had. “And those were just the ones who were honest with us,” Westgate says.
  • About half found the experience was unpleasant.

Thoughts from the researchers- Westgate & Wilson 

Erin Westgate said she is still astounded by those findings.
“I think we just vastly underestimated both how hard it is to purposely engage in pleasant thoughts and how strongly we desire external stimulation from the world around us, even when that stimulation is actively unpleasant.”

 

She added that the research showed, by and large, that people prefer some positive stimulation, like reading a book or playing a video game.

“Many people find it difficult to use their own minds to entertain themselves, at least when asked to do it on the spot,” said University of Virginia psychology professor Timothy Wilson, who led the study. “In this modern age, with all the gadgets we have, people seem to fill up every moment with some external activity.”

 

“I think they just wanted to shock themselves out of the boredom,” Wilson said. “Sometimes negative stimulation is preferable to no stimulation.”

 

Whether the effects seen in the experiment are a product of today’s digital culture or not is a matter of debate.

 

So try this experiment at home!
All you need is a timer and an empty room.  Tell your friends and loved ones how you did. You could lie (if you want) that you sat perfectly calm and serenely.

 

Reference:

Timothy D. Wilson, David A. Reinhard, Erin C. Westgate, Daniel T. Gilbert, Nicole Ellerbeck, Cheryl Hahn, Casey L. Brown, Adi Shaked: “Just think: The challenges of the disengaged mind” Science 4 July 2014: Vol. 345 no. 6192 pp. 75-77

SKILLS & STUMP THE SHRINK

Here is a combined Stump the Shrink question and Skills section this month.

 

Kurt Snyder, Executive Director of Heartview Foundation in Bismarck, North Dakota asked about treatment planning and The ASAM Criteria assessment dimensions.

 

Question:

“We are wanting to list random drug and alcohol screens as a method and strategy on the treatment plan. Our treatment plans are organized using the structure of the ASAM Criteria six Dimensions. We develop goals and objectives for the high severity dimensions. So as people progress through treatment the severity risk scores tend to fall in Dimensions 1, 2, and 3. Would you suggest we list the random tests in Dimension 1 or Dimension 5?”

 

Kurt

 

Now for readers unfamiliar with The ASAM Criteria six assessment dimensions, here is a brief overview (The ASAM Criteria 2013, pp 43-53):

 

Assessment Dimensions

Assessment and Treatment Planning Focus

1. Acute Intoxication and/or Withdrawal Potential  Assessment for intoxication and/or withdrawal management. Withdrawal management in a variety of levels of care and preparation for continued addiction services 
2. Biomedical Conditions and Complications Assess and treat co-occurring physical health conditions or complications. Treatment provided within the level of care or through coordination of physical health services 
3. Emotional, Behavioral or Cognitive Conditions and Complications Assess and treat co-occurring diagnostic or sub-diagnostic mental health conditions or complications. Treatment provided within the level of care or through coordination of mental health services 
4. Readiness to Change Assess stage of readiness to change. If not ready to commit to full recovery, engage into treatment using motivational enhancement strategies. If ready for recovery, consolidate and expand action for change 
5. Relapse, Continued Use or Continued Problem Potential Assess readiness for relapse prevention services and teach where appropriate. If still at early stages of change, focus on raising consciousness of consequences of continued use or problems with motivational strategies. 
6. Recovery Environment

 

Assess need for specific individualized family or significant other, housing, financial, vocational, educational, legal, transportation, childcare services

 

You can obtain a great working knowledge of The ASAM Criteria dimensions by doing the eTraining module for continuing credit “Multidimensional Assessment”. See http://www.ASAMcriteria.org and click on Resources & Training.

 

TIP 1

Determine why the drug and alcohol testing is needed. Then decide which ASAM Criteria dimension the random testing strategy relates to.

 

As regards your question, Kurt: Let’s look at all the possibilities when random drug and alcohol testing might be used.

 

Dimension 1, Acute Intoxication and/or Withdrawal Potential
If you want to verify what drugs a person may be intoxicated with, or go into withdrawal from, then the random testing would be under Dimension 1.

If you want to be sure a client is taking their maintenance medication to prevent going into withdrawal (methadone or buprenorphine), then random testing can check and monitor that. These are 2 examples of Dimension 1 strategies.

 

Dimension 2, Biomedical Conditions and Complications

Perhaps you have concerns about the drug interaction with a client’s physical health medications- e.g. drinking while taking anti-hypertensive or diabetes medication. Or you have concern about a person using heroin while also on chronic pain narcotics. This would put the random testing under Dimension 2.

 

Dimension 3, Emotional, Behavioral or Cognitive Conditions and Complications

As with Dimension 2, you might have concerns with the person drinking and drugging along with their psychotropic medication. In assessing whether a patient’s psychosis or depression is substance-induced, random testing would be a diagnostic strategy under Dimension 3.

 

Dimension 4, Readiness to Change

Clients will often say: “I can stop anytime, I don’t have an addiction problem.” In trying to engage the person, you might try a motivational “Discovery” plan. Such an approach would have the client try the “I can stop any time” plan. Random testing would track and monitor the client’s success or not.

 

Dimension 5, Relapse, Continued Use or Continued Problem Potential

In a Relapse Prevention plan, random testing would track how well a person’s coping skills are working. Are they maintaining abstinence or not?

 

Dimension 6, Recovery Environment

The Department of Transportation (DOT) and other employers require everyone to be drug-free. Random testing in this situation would be a Dimension 6 example.

Perhaps someone is enrolled in a Drug Court program where random testing is part of the Court expectations.

Some parents have children who are playing high-level sports with costly equipment and travel expenses. As a condition for ongoing financial and emotional support, they require their child to be drug-free. Using random home-testing kits would be another Dimension 6 example. This is the same expectation as in professional and college sports.

 

So drug and alcohol screening has many purposes. It is a lab test to help track the effectiveness of treatment. It is not a “gotcha” spying activity as part of an adversarial relationship based on mistrust and suspicion.

SOUL

What a tragedy that Robin Williams is dead. This month he killed himself in his home about two hours from my home. It is a grim reminder that celebrities, so talented and creative, are nevertheless people who can suffer the same addiction and mental health problems, of which we are all vulnerable. But their very celebrity status can be a curse, aggravating their vulnerabilities and even inhibiting reaching out for help.

 

I have gotten a glimpse of how celebrity can be a blessing and a curse, not because I consider myself a celebrity, but because I travel a lot. I have been on planes for over 18 years due to my full-time training and consulting work.

 

Here’s what I get just because I travel a lot:

  • Priority boarding at the front of the line because I am approaching 3 million lifetime miles on United Airlines.  I have flown over 100,000 miles every year with them for 20 years.
  • Free upgrades to first class domestically and business class internationally – oh it is such a let down to be on another airline and be up the back with all the “common” people! (LOL)
  • Even the Transportation Security Administration (TSA) often lets me skip the long lines and zip through TSA PreCheck. I can keep my shoes, belt and coat on and just show them my computer, wallet and cellphone. No stripping down and going through those big fancy security machines.
  • When I hit 2 million miles with United Airlines, I received an engraved 160 gigabyte Apple iPod and lifetime membership in the United Clubs at airports around the world. I wonder what I’ll get when I hit 3 million miles next year….a new BMW car?
  • On some trips, the pilot has even come to greet me by name. On occasion I have received a personalized note from the pilot thanking me for my loyalty. All I’ve done is buy airline tickets, not entertained millions of people like Robin Williams.

Anyway, you get the picture.

 

The problem with all this ‘special treatment’ is it’s easy to start thinking you arespecial and deserve this all the time.   You can see why celebrities start acting like entitled celebrities. (My wife quickly reminds me I am not a celebrity, so there isn’t too much danger.)

 

This is so insidious for real celebrities who are always in the public eye, with fans and swooning groupies paying homage to them. And their money can buy almost any material desire or best seat in the restaurant……

 

Reality starts to become very distorted. So have some sympathy for celebrities. For many it is a curse that can kill you. Who knows, for Robin Williams, it just may have.

Vol.12, No. 9

Welcome to the September edition of Tips and Topics (TNT). I’m glad that we have many new subscribers to join our longtime TNT community.

David Mee-Lee M.D.

SAVVY

It is difficult to work in the mental health and addiction treatment field without interfacing with clients involved in the criminal justice system. Some addiction treatment programs receive 90% or more of their clients from the criminal justice system.

 

“In a 2006 Special Report, the Bureau of Justice Statistics (BJS) estimated that 705,600 mentally ill adults were incarcerated in State prisons, 78,800 in Federal prisons and 479,900 in local jails. In addition, research suggests that “people with mental illnesses are overrepresented in probation and parole populations at estimated rates ranging from two to four time the general population” (Prins and Draper, 2009). Growing numbers of mentally ill offenders have strained correctional systems.”

http://nicic.gov/mentalillness

 

Here’s another headline from the Bureau of Justice:

 

STUDY FINDS MORE THAN HALF OF ALL PRISON AND JAIL INMATES HAVE MENTAL HEALTH PROBLEMS

“More than half of all prison and jail inmates, including 56 percent of state prisoners, 45 percent of federal prisoners and 64 percent of local jail inmates, were found to have a mental health problem”. This was according to the 2006 study published by the Justice Department’s Bureau of Justice Statistics (BJS).

http://www.bjs.gov/content/pub/press/mhppjipr.cfm

 

And now, note this headline on addiction and criminal justice:

 

NEW CASA REPORT FINDS: 65% OF ALL U.S. INMATES MEET MEDICAL CRITERIA FOR SUBSTANCE ABUSE ADDICTION, ONLY 11% RECEIVE ANY TREATMENT

NEW YORK, N.Y., FEBRUARY 26, 2010

 

The National Center on Addiction and Substance Abuse at Columbia University, a

drug policy organization, found that “of the 2.3 million inmates crowding our nation’s prisons and jails, 1.5 million meet the DSM-IV medical criteria for substance abuse or addiction, and another 458,000, while not meeting the strict DSM-IV criteria, had histories of substance abuse; were under the influence of alcohol or other drugs at the time of their crime; committed their offense to get money to buy drugs; were incarcerated for an alcohol or drug law violation;or shared some combination of these characteristics, according to Behind Bars II: Substance Abuse and America’s Prison Population. Combined, these two groups constitute 85% of the U.S. prison population.”

http://www.casacolumbia.org/newsroom/press-releases/2010-behind-bars-II

 

Any way you cut it, in clinical work it is increasingly important to understand Drug Courts, Mental Health/Behavioral Health Courts, other Problem-Solving Courts, and how to interface with Probation and Parole officers, Judges and their court teams.

 

TIP 1

What Are Problem-Solving Courts?

 

Here’s how the Center for Program Evaluation and Performance Measurement explains these courts:

 

“Problem-solving courts began in the 1990s to accommodate offenders with specific needs and problems that were not, or could not be adequately addressed in traditional courts. Problem-solving courts seek to promote outcomes that will benefit not only the offender, but the victim and society as well. Thus problem-solving courts were developed as an innovative response to deal with offenders’ problems, including drug abuse, mental illness, and domestic violence. Although most problem-solving court models are relatively new, early results from studies show that these types of courts are having a positive impact on the lives of offenders and victims and, in some instances, are saving jail and prison costs.

 

In general, problem-solving courts share some common elements:

  • Focus on Outcomes Problem-solving courts are designed to provide positive case outcomes for victims, society and the offender (e.g., reducing recidivism or creating safer communities).
  • System Change Problem-solving courts promote reform in how the government responds to problems such as drug addiction and mental illness.
  • Judicial Involvement Judges take a more hands-on approach to addressing problems and changing behaviors of defendants.
  • Collaboration Problem-solving courts work with external parties to achieve certain goals (e.g., developing partnerships with mental health providers).
  • Non-traditional Roles.These courts and their personnel take on roles or processes not common in traditional courts. For example, some problem-solving courts are less adversarial than traditional criminal justice processing.
  • Screening and Assessment Use of screening and assessment tools to identify appropriate individuals for the court is common.
  • Early identification of potential candidates Use of screening and assessment tools to determine a defendant’s eligibility for the problem-solving court usually occurs early in a defendant’s involvement with criminal justice processing.”

https://www.bja.gov/evaluation/program-adjudication/problem-solving-courts.htm

 

 

TIP 2

Access “A Technical Assistance Guide For Drug Court Judges on Drug Court Treatment Services

 

The Justice Programs Office, School of Public Affairs at American University, Washington D.C. http://www.american.edu/justice has published a very useful guide that helps judges understand what is addiction treatment. It helps treatment providers understand Drug Courts. You can Google the guide (paste in “A Technical Assistance Guide For Drug Court Judges on Drug Court Treatment Services“)and it should come right up.

 

There is even a small section on The ASAM Criteria (2013) which I was privileged to contribute.

SKILLS

In May this year, I gave a presentation on The ASAM Criteria at the National Association of DrugCourt Professionals in Anaheim, California. It was such a learning experience for me to be around so many judges, attorneys, court team professionals and treatment providers. In a session I attended on Judicial Leadership principles, I was struck by something one of the judge panelists said when speaking of client outcomes (sorry, I didn’t note which judge it was):

 

“People don’t failDrug Court, Drug Court fails them by not meeting their needs.”

 

Problem-Solving courts are focused on outcomes. But knowing how easy it is to blame the offender and participant in Drug and other Problem-Solving Courts for any poor outcome, that statement really got my attention………and got me thinking:

  • How should Drug Court, the judge, court team and treatment provider work together to meet the needs of participants?
  • How do we collaborate to get the outcomes of increased public and community safety and decreased legal recidivism and crime that we all want?
  • When client outcomes are not going well, what is the balance between client accountability and the treatment provider’s responsibility to improve assessment and treatment planning?
  • What is the role of court sanctions and incentives in holding offenders accountable for treatment adherence?
  • What is the role of treatment providers to keep the court informed about the participant’s threat to public safety?

Some judges are rightly concerned that treatment providers are not watching public safety closely enough.  Not sure that they trust treatment providers’ reports, judges sometimes take treatment into their own hands. This can result in judges working outside their scope of practice and issuing sanctions or mandates that are not clinically assessment based.  Here are some examples:

  • Mandating 90 days of residential level of care
  • 90 Alcoholics Anonymous meetings in 90 days
  • Ordering sanctions that may be ineffective in producing improved treatment engagement and real client functional change.

 

TIP 1

Consider these thoughts on how to deal with sanctions and incentives in Drug Court (and other Problem Saving Courts)

 

Drug court participants are varied and can present with addiction, mental health and physical health complexity. These diverse clinical presentations highlight the need for individualized approaches to sanctions that are:

 

1. Based on assessment of each client’s multidimensional needs as per The ASAM Criteria six dimensions (I’m biased of course, and there are other assessment tools and parameters that address high risk and high need).  So assessing if a person is developmentally disabled and suffers from an intellectual developmental disorder (previously called Mental Retardation) is important compared with a person who has antisocial personality disorder or lifestyle and is very institutionalized and used to incarceration. The intellectually developmental disordered person has deficits in reasoning, problem solving, abstract thinking, judgment, learning from instruction and experience etc.  The institutionalized antisocial person experiences sanctions like water on a duck’s back.

 

2. Based on treatment engagement and good faith effort of the client in treatment. Participants with co-occurring mental and addiction issues will have more difficulty with engagement and have needs that require awareness of their multiple vulnerabilities. Treatment plans need to be assessment-based and person-centered not program and compliance based. Because of different client learning styles and their array of needs, any manualized and evidence-based curriculum may require adaptation to fit each client’s problems and progress/outcomes.

 

This calls for a level of clinical sophistication to use Evidence-Based Practices (EBPs) in a person-centered and outcomes driven manner rather than a compliance and one-size-fits-all manner.  Interactive Journaling is an evidence-based method to facilitate self-change using Motivational Interviewing, stages of change work and CBT.  The Change Companies has a Drug Court journal that can be used along with other journals designed for criminal justice populations used by Federal Bureau of Prisons and many others.

 

3. Based on outcomes in treatment.  Is the client making progress in real accountable change? Are they demonstrating improved functioning that will increase public safety, decrease legal recidivism and crime and increase safety for children and families?  Active credible treatment is not just about compliance with attendance and negative drug screens.  Is the client invested in a change process at a pace that fits their assessed abilities and vulnerabilities? Or is the client merely passively complying, which does not translate into lasting change and increased safety?  How do we impact the revolving door of repeated episodes of treatment and incarceration, which wastes resources and does not produce the outcomes we all want?

 

TIP 2

What is the “bottom line” on how to move from punishment to accountability for lasting change – implications for sanctions and incentives?

 

A. Sanction for lack of good faith effort andadherence in treatment based on the clinical assessment of the person’s needs, strengths, skills and resources.  Don’t sanction for signs and symptoms of their addiction and/or mental illness in a formulaic manner that is one-size-fits-all.

 

B. The treatment provider is responsible for careful assessment and person-centered services and to keep the court apprised of any risk to public safety. The court should be informed about the client’s level of good faith effort in treatment; and whether the client is improving in function at a pace consistent with their assessed needs, strengths, skills and resources. The provider should not just report on passive compliance with attendance and production of positive or negative drug screens….passive compliance is not functional change.

 

C. If the client is not changing their treatment plan in a positive direction when outcomes are poor e.g., positive drug screens, attendance problems, passive participation, no change in peer group activities and support groups like AA etc., then the client is “doing time” not “doing treatment and change.” Providers need to then inform the judge that the client is out of compliance with the court order todo treatment.  The client consented to do treatment not just do time and should be held accountable for their individualized treatment plan. If the client is substantively modifying their treatment plan in a positive direction in response to poor outcomes; and adhering to the new direction in the treatment plan, then the client should continue in treatment and not be sanctioned for signs and symptoms of their illness(es).

 

D. Incentives for clients can be explored and matched to what is most meaningful to them.  For example, incentives that allow a client to choose a gift certificate or coupon for a restaurant may be meaningful for some clients.  But others may find assistance in seeing their children; or receiving help with housing; or advocacy to change group attendance times to fit better their work schedule to be more meaningful incentives to be used.  This requires an individualized approach recommended to the court by providers who should know their client’s needs, skills, strengths and resources.  It is too much to expect the judge can work all this out in a busy schedule of court appearances.

 

E. A close working relationship between the client, judge, court team and treatment providers is needed to actualize this approach.

 

These ideas come from my clinical bias and experience, but they are offered with awareness:

  • That we need more discussion to make this work in the world of courts and criminal justice.
  • That to achieve the public safety outcomes we all want, we have to move treatment from a passive compliance and a ‘jumping through the hoops’ mentality that allows many clients to “do time” in treatment instead of “doing treatment and change”.
  • That treatment providers will need to rise to the occasion and improve assessment and person-centered treatment planning that values outcomes-driven services.
  • That judges and court personnel can expect treatment providers to design and deliver individualized care; and to keep them well-informed on any threats to public safety. Reports need to be on functional improvement not just compliance with attendance and drug screens.

SOUL

Recently a colleague was to meet up for dinner but had to cancel because he strained his back and was in a lot of pain. I know what that is like. Over 20 years ago, I reached up to place my roll aboard suitcase in the overhead bin on the plane only to be shocked by a sharp back pain that left me walking like a 120 year old.

 

Hopping out of a car is a quick turn to the side, swinging your legs to the outside and rising out of the car seat….right? Not when you have back pain. Even in slow motion, each of those maneuvers can be excruciating. If you think back pain is mind over matter, let me know after you get your first attack.

 

On the other hand, it is true that people can milk back pain for all kinds of advantages: “I’d help you move those tissue boxes, but I have a bad back.” “Sorry I can’t come to the volunteer community park cleanup, I have a bad back (and by the way, the game is on TV).” I’d help with the dishes, but you know my back is bad today.”

 

Twenty years ago, I had almost crippling back pain in Greece on vacation, in Australia on vacation and when I moved to California. But I haven’t had an acute episode in nearly 18 years!

 

Lucky streak of good health? I don’t think so. On that bad back attack in Australia, I saw a musculo-skeletal physician who was quick to prescribe not narcotic analgesics,but rather muscle strengthening exercises. They take less than five minutes a day and I swear by this preventive remedy.

 

Here’s the three sets of exercises the Aussie doctor taught me:

1. Modified windshield wipers – I lie on my back with knees bent and feet flat on the floor. Arms are by my side and I sway my legs back and forth like windshield wipers. This seems to loosen up the back and spinal muscles.

 

If you want to do the real thing, you can check out:

How to do Windshield Wipers

http://www.health.com/health/video/0,,20732158,00.html

http://workouttrends.com/how-to-do-windshield-wipers

 

2. Next, do Pelvic tilt exercises. Same position on my back, feet flat on the floor, arms by my side. Then I tilt my pelvis up and down repetitively.

 

If you want to see a professional teach this, go to:

How to Do Pelvic TiltExercises -YouTube

https://www.youtube.com/watch?v=lTX15Qk1xTM

 

3. The third exerciseinvolves abdominal crunches. Same position on my back, but this time, I raise my legs and rest my feet on a stool or chair. Keeping the neck in line with your spine, not bent forward with chin touching your chest, do some crunches to strengthen abdominal muscles. I cross my arms across my chest butyou can check out a couple of ways here:

How to Do Crunches

https://www.youtube.com/watch?v=Xyd_fa5zoEU

http://www.wikihow.com/Do-Crunches

 

How many repetitions of these are necessary? I don’t know what works for you, but at first, if the back pain is still acute, just do a few to get the idea…maybe five each. But I have worked up to do 3 sets of 20 windshield wipers and pelvic tilts and 2 sets of 20 crunches in sequence: wipers, tilts, crunches to tilts,wipers and crunches and ending with tilts and wipers.

 

I talked to another colleague today. He is going for an MRI in preparation for back surgery, hopefully to fix his chronic back pain.

 

I feel bad for him and I know I don’t want to get anywhere near that. I better do my wipers, tilts and crunches.

Until next time

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

David

January 2011

Volume 8, No. 9 In this issue SAVVY ASAM multidimensional assessment for mental health and addiction SKILLS Evaluating immediate needs in 5 minutes or less; 10 questions or less SOUL Jump-starting recovery SHAMELESS SELLING DAPPER and LOCI-2R David Mee-Lee M.D.  ...

January 2012

Vol. 9, No. 10 In This Issue SAVVY – What do you do when a severely mentally ill person keeps using substances? SKILLS – Clinical and systems questions, suggestions and solutions SOUL Politics of personal destruction STUMP the SHRINK Addiction relapse and...

Vol. 11, No. 2

In This Issue
  • SAVVY : Getting closer to payment for outcomes and preventing harm
  • SKILLS : Be prepared for healthcare reform, use The ASAM Criteria

Thank-you for celebrating with me the 10th anniversary of Tips and Topics (TNT) last month and to all of you who bought the Tips and Topics book. You still have until May 31 to keep celebrating with this special anniversary price.

David Mee-Lee M.D.

SAVVY

A small proportion of Tips and Topics readers receive the American Medical Association News. When reading some recent editions, two headlines caught my attention. I’ll share them with you and address the implications for addiction and mental health clinicians and services.

Our overseas readers will, I expect, find the first headline less relevant unless you are curious (amused?) by how the USA still struggles to provide universal health care to its citizens. Where you live, you likely have solved this years ago.

Despite the fact that we spend more per person on healthcare than you do, we have poorer quality results. The Institute of Medicine (IOM) reports that the “the panel analyzed US health conditions against 16 nations: Australia, Austria, Canada, Denmark, Finland, France, Germany, Italy, Japan, Norway, Portugal, Spain, Sweden, Switzerland, the Netherlands and the UK.” The report explains: the “disadvantage exists even though the US spends more per capita on health care than any other nation, partly because of a large uninsured population and inaccessible or unaffordable medical care.”)

TIP 1

“Volume, not quality, still decides most doctor pay”

This was a headline in the April 22, 2013 edition of American Medical News, page 5.

While this talks about how doctors get paid for their services, it’s also true for how just about every other counselor, clinician and behavioral health program and agency is paid – the more patients and clients you serve, the more money and funding you get.

–> The more services you provide – (individual and group sessions, family therapy, medications and recreational therapy etc.) – the more you can charge (unless you are funded with a fixed case rate.) That is why it has been said the USA has a sick-care system not a health-care system. The incentives are to fill beds or treatment slots with sick people. If the population is well and don’t need you, you’re out of business.

Why is this important if you live and work in the USA? The Affordable Care Act (ACA) is coming into full force in just over 7 months. The shift in how you will be paid for services will continue to change and pick up pace. It has already started. Hospitals are already being penalized for quality issues like readmission of patients within 30 days. For patients, it was bad if they were quickly released from hospital, became destabilized and then needed to return for readmission. But….it was not bad for hospitals. That kept hospitals’ censuses up, helped pay their bills, maybe even increased their profits.

–> Everyone says they are interested in quality outcomes and excellence. But you have to follow the money. Check with your institution’s budget and finance person. Ask how much your program spends on measuring and tracking outcomes. Then check how much is spent on marketing and expanding services to increase the volume of new clients and increase revenues. My guess is that the budget for the first is a fraction of the budget for the second.

–> I’m not saying marketing and expansion is “bad”. It’s just that the shift in healthcare has already started where quality outcomes will increasingly determine your funding, referrals and revenues than just volume.

TIP 2
“Top 10 ways to improve patient safety NOW!”
This was a headline in the April 22, 2013 edition of American Medical News, page 12.

The article talked about newly-released evidence on the best areas to prevent harm to patients – things hospitals should be doing to prevent harm. In that setting, this involved things like:

  • Improved hand hygiene compliance – to prevent health-care associated infections.
  • Use of barrier precautions to stop the spread of infections – by wearing gowns and gloves when providing care.
  • Employing pre-operative checklists to reduce surgical complications – the checklist prompts communication among members of the surgical team.

So I asked myself:
What are the equivalent areas to prevent harm in behavioral health treatment?

A few came to mind, drawing from the first 5 of 13 research-based Principles of Effective Addiction Treatment from the National Institute on Drug Abuse (NIDA):

Principle 1.
“Addiction is a complex but treatable disease that affects brain function and behavior.” – “Drugs of abuse alter the brain’s function, resulting in changes that persist long after drug use has ceased. This may explain why drug abusers are at risk for relapse even after long periods of abstinence…”

In relation to this principle, how do we prevent harm to our clients?

  • We design and deliver chronic disease management of addiction.
    When you “graduate” people from treatment and talk of “treatment completion,” it sounds like you don’t believe addiction is a chronic disease. It creates potential harm if the client and others believe they are “cured” and done with treatment altogether. Patients don’t complete treatment and “graduate” from diabetes, bipolar disorder or asthma care.

Principle 2.
“No single treatment is appropriate for everyone.” – “Matching treatment settings, interventions, and services to an individual’s particular problems and needs is critical…”

In relation to this principle, how do we prevent harm to our clients?

  • We “walk the talk” about true individualized and person-centered services.
    No longer will it make sense to answer, “How long do I have to be here?” with a number of weeks, months or sessions. Then perhaps we can avoid potential harm when the client spends more time focused on their treatment plan, rather than the calendar/ treatment time!

Principle 3.
“Treatment needs to be readily available.” – “Potential patients can be lost if treatment is not immediately available or readily accessible. As with other chronic diseases, the earlier treatment is offered in the disease process, the greater the likelihood of positive outcomes.”

In relation to this principle, how do we prevent harm to our clients?

  • We work to eliminate waiting lists and any barriers to access to care.
    Other areas of healthcare are streets ahead of behavioral health in screening, early intervention and immediate access to care. Certainly they do not have it all resolved; however we could learn from approaches like “no appointment necessary” experiments, telemedicine and in-home consultations etc. When clients are not moved flexibly through seamless continuums of care (often due to long fixed lengths of stay and lack of community resources for housing and care management), what happens? Waiting lists lengthen, access diminishes and harm increases.

Principle 4.
“Effective treatment attends to multiple needs of the individual, not just his or her drug abuse.” – “To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems….”

In relation to this principle, how do we prevent harm to our clients?

  • We provide assessment-driven services rather than program-driven care. Using the structure of multidimensional assessment like the 6 ASAM Criteria dimensions, the individualized service plan covers all client needs.
    (See January 2011 for more on the 6 ASAM dimensions)
    Treatment is not about compliance with a certain program model. It is the development of services to match each person’s unique multidimensional needs. It would be harmful for every patient to get the same medication dose for withdrawal management, diabetes treatment; the same type and intensity of therapy for trauma work; the same vocational counseling regardless of assessed needs. Worse still, outcomes are poorer if housing needs are unaddressed; family and significant other treatment is ignored; and trauma and co-occurring disorders are not detected. It is much more than “don’t drink or drug.”

Principle 5.
“Remaining in treatment for an adequate period of time is critical.” – “The appropriate duration for an individual depends on the type and degree of his or her problems and needs. Research indicates that most addicted individuals need at least 3 months in treatment to significantly reduce or stop their drug use and that the best outcomes occur with longer durations of treatment….As with other chronic illnesses, relapses to drug abuse can occur and should signal a need for treatment to be reinstated or adjusted. Because individuals often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment.”

In relation to this principle, how do we prevent harm to our clients?

  • We engage and attract people into recovery. We use the whole continuum of care to increase access to, and lengths of, treatment. Treat relapse, don’t discharge for relapse.
    People with addiction rarely seek treatment spontaneously without any external family, work, school or legal pressure. Typical readiness to change issues, slips and recurrences of addictive behavior will always show up. We need to assess them, not harmfully exclude and discharge from treatment. How can we call addiction a disease and then exclude people from treatment for recurrences of their signs and symptoms?
That’s my two cents’ worth. So it’s your turn now. What’s on your Top 10 list of ways to improve patient safety and behavioral health care NOW!? Send me one or two of
your Top 10, especially if you have any supporting evidence or data.

References:

  1. Institute of Medicine: U.S. Health in International Perspective- Shorter Live, Poorer Health. Report Brief, January 2013.(http://www.iom.edu/Reports/2013/US-Health-in-International-Perspective-Shorter-Lives-Poorer-Health/Report-Brief010913.aspx)
  2. National Institute on Drug Abuse: Principles of drug addiction treatment: a research-based guide (NIH Publ No 09-4180). Rockville, MD: National Institute on Drug Abuse, 2009

SKILLS

This month, two major publications will affect addiction and mental health treatment providers and programs:

  1. The Fifth edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, DSM-5. (DSM-5 is now released.)
  2. A new edition of The ASAM Criteria.(The ASAM Criteria will be released in October, 2013) (See SHARING SOLUTIONS for how to Preorder the new edition.)

For most clinicians and programs in the USA, you will need to use DSM-5 to get paid.

The ASAM Criteria will not only help you provide and manage care which prevents harm to your clients and patients, but also get you ready for healthcare reform, if you truly implement the spirit and content of The ASAM Criteria.

TIP 1
Compare how the new edition of The ASAM Criteria addresses all the issues in SAVVY above and more – the goal being to “do no harm”.

Ways to improve patient safety and care

How The ASAM Criteria helps design/deliver services

 

 Design and deliver chronic disease management of addiction.

Current & Continuing

New & Additional

The Criteria have always had multiple levels of care to promote a seamless continuum. The new edition expands Level 1

  • It emphasizes outpatient services for ongoing disease management and recovery monitoring.
  • Level 1 isn’t just a treatment level at the beginning of recovery.
“Walk the talk” about true individualized and person-centered services. Since first published, The ASAM Criteria has advocated for a shift from program-driven services to person-centered, individualized care. The new edition has a brand new layout.

  • There is a logical sequence from assessment to service planning to level of care placement and continuing care.
  • It will guide you better to the Dimensional Admission Criteria for each level of care.
Work to eliminate waiting lists and any barriers to access to care. It has always been the spirit of The ASAM Criteria, to increase access to care. Clients move flexibly through the levels of care, receiving whatever length of treatment they need. This helps eliminate waiting lists if coupled with more Dimension 6, Recovery Environment community support services.
There is a new section on working effectively with managed care and healthcare reform.
  • This will also help everyone manage care to be good stewards of resources and increase access to care.
Provide assessment-driven services rather than program-driven care. Use the structure of multidimensional assessment (6 ASAM Criteria dimensions) to cover all client needs. The six assessment dimensions of The ASAM Criteria provide the common language of holistic assessment.
The new edition expands the discussion of co-occurring disorders.
  • Integration with general health treatment is highlighted for the first time in this edition.
  • Across all health systems, the six dimensions are a common language of behavioral health assessment.
Engage and attract people into recovery. Use the whole continuum of care to increase access to, and lengths of, treatment. Dimension 4, Readiness to Change:
Assessing stage of change is as important   as assessing withdrawal and mental health needs.Dimension 5, Relapse, Continued Use, or Continued Problem Potential:
This is used to treat recurrences, not used as a discharge policy.
There is an expanded section on Dimension 5.

  • This will guide programs on dealing with relapse as a treatment issue.

 

If we fund and use the full continuum of care in The ASAM Criteria, we’ll realize the vision of:

  • Increasing access to care
  • Stretching resources to give people longer lengths of stay in the continuum of services
  • Improving engagement, ongoing monitoring and outcomes.

SOUL

If you think there are a lot of changes coming to healthcare you haven’t seen anything about changing systems until you see what’s happening in places like Myanmar (Burma). Well I haven’t seen it yet either, but I will….and very soon.

By the time you read this edition of TNT, I will be in Myanmar for an up-close and personal look at astounding scenery, temples, cultural transition and sights, sounds and smells so new to me. I’m going for a week of touristing – a new experience for Marcia and me as we meet up with Taylor, our son, for his last week traveling in SE Asia.

Our travel agent sent us a list of DOs and DON’Ts. It’s a quick lesson in cultural competence. Here are some off the list that fascinated me. I’ll add my comments in italics:

Typical Character

  • Friendly, helpful, honest, but proud.
  • Treat everyone with respect and you will be respected. (That’s good advice in any country)

Speaking

  • When addressing people, don’t leave out U (which stand for Mr) or Daw (which stand for Ms/Mrs)
  • Speak slowly and clearly. (But will they understand an Australian-Chinese-39 years in the USA accent?!)

Manners

  • Not always necessary to shake hands.
  • Don’t hug or kiss in public. (No PDAs = Public Displays of Affection)
  • Don’t touch any adult on the head. (I’m not one of those TV preacher healers and can’t think when I would touch anyone on the head in the USA, so that shouldn’t be hard)
  • Don’t step over any part of a person, as it is considered rude.(Imagination runs wild thinking about what that situation would be like)
  • Accept or give things with your right hand.
  • In Myanmar, unlike the Indian continent, nodding mean YES, and shaking head means NO. (Phew, that’s familiar)

Eating

  • Let the oldest be served first. (That’s good, since I’ll be the oldest)
  • Myanmar food is often complained about as ‘oily’.

Safety

  • Beware of cheats, swindlers, imposters. (I’m glad we don’t have any people like this in the USA!!)

Health

  • Stay away from narcotic drugs. (Now that’s good advice for a lot of people worldwide)
  • Health insurance is not available. (Just like the 45 to 50 million people in the USA)

Traveling

  • Accept that facilities may not be the best. (Serenity Prayer time)
  • Carry toilet paper in your bag. (Serenity Prayer time)

Religion

  • At religious places, remove footwear, but to remove headwear is not necessary.
  • Avoid shouting or laughing. (No loud Americans here please)
  • Tread Buddha images with respect.
  • Tuck away your feet. Don’t point it toward the pagoda or a monk.
  • Don’t play loud music in these areas. Note that Buddhist monks are not allowed to listen to music. (No booming, thumping music coming from the car beside you. Maybe this should be a rule in the USA)
  • Do not put Buddha statues or images on the floor or somewhere inappropriate.
  • Don’t touch sacred objects with disrespect. Hold them in your right- hand, or with both hands.
  • Leave a donation when possible. (At least the need for money is worldwide)
  • Show respect to monks, nuns, and novices (even if they are children). (“Even if they are children” – Now that’s different)
  • Don’t offer your hand to shake hands with a monk.
  • Sit lower than a monk and elders. (Don’t make your patients and clients do this with your treatment sessions)
  • Don’t offer food to a monk, nun, or a novice after noon time.
  • A woman should not touch a monk. (No women’s lib here)

This is going to be some experience. Can’t wait.

 

There’s still time for the special 10th anniversary celebration. The Tips and Topics book for $10 total (shipping and handling free) – that’s $1 for each year. After May 31, it will revert to regular pricing of $19.95 plus shipping.

Get selected relevant clinical and systems tips from the years of Tips and Topics all in one place.”Tips and Topics: Opening the Toolbox for Transforming Services and Systems” by David Mee-Lee, MD with Jennifer E. Harrison, MSW. (158 pages; usually sells for $19.95 plus shipping but through May 31, $10 all-inclusive, except for international orders)

You can buy in two ways:

  1. Go to http://www.changecompanies.net/products/product.php?id=TNT and buy online; or
  2. call The Change Companies at (888) 889-8866 and ask for the anniversary deal for the Tips and Topics book.

The special runs through May 31, 2013.

Preorder The ASAM Criteria and get more than the book

The new edition of The ASAM Criteria is coming in October.
If you preorder now, you receive 3 months of free access to the enhanced, web-based version when it releases. Find out more and preorder at http://www.ASAMcriteria.org

  • See video clips where I explain what’s new and what’s coming in the new edition.
  • Opt-in and sign up there to be kept in the loop on the new edition even before it releases in October.
  • See FAQs on The ASAM Criteria.
  • We’ll keep adding more at http://www.ASAMcriteria.org for all things ASAM criteria.

Until next time

Until next time

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

David

Vol. 11, No. 6

In This Issue
  • SAVVY & STUMP THE SHRINK : How to work with angry, frustrating clients
  • SKILLS : Emotional intelligence and creating a learning environment
  • SOUL : No talk, No relationship
  • SHARING SOLUTIONS : ASAM Criteria eLearnings
Welcome to all the new readers and longtime subscribers to Tips and Topics.
Thanks for joining us for the September issue.

David Mee-Lee M.D.

SAVVY & STUMP THE SHRINK

I always enjoy and appreciate it when readers send their feedback about eLearnings, webinars, Tips and Topics or presentations I have done.

This month I received the following message which combines words of appreciation along with a “meaty” and substantive question I know is shared by many other clinicians, supervisors and clinical directors.

So I have combined SAVVY and STUMP THE SHRINK this month. Here’s the email:

Dear Dr. Mee-Lee:

I hope this email finds you well. I have a “stump the shrink” question I’d love to get your take on, if you have the time/interest. I find questions/struggles exemplified by this scenario have a tendency to show up again and again. I think our staff has a hard time in these situations because they are confronted by feelings of frustration, anger, annoyance, ineffectiveness and, if they’re willing to go there, their own expectations and values that they’d like our clients to adopt . . .

I recently attended case conference at our inpatient substance use rehabilitation center (length of stay is based on assessed need, however,28 days is still the accepted target) and the team was consulting regarding a client with whom they were extremely frustrated. The client is a middle-aged man who presents with mixed personality disorder traits (cluster B -antisocial, borderline, histrionic, narcissistic).

The client had been at our inpatient centre for 6 days and, during that time:
  • repeatedly violated house rules around pay phone and cell phone use, as well as daily living structure. 
  • He also had a tendency to tell the staff that our programming was “stupid” and that he had nothing to learn from them or our programming, especially since this was his 2nd treatment episode with us.
  • The staff was growing weary from constantly reminding him of the house rules and, at this point, were asking me permission to place him on a tight behavior contract (e.g., if we have to remind him X more times about the pay phone or cell phone rules, then he will be considered non-compliant and choosing to engage in treatment-interfering behavior, which may warrant an administrative discharge).
The staff were clearly tired, exasperated, and approaching the limit of being willing to work with this client.
  • I tried to balance empathizing with their frustration and feelings of ineffectiveness,
  • while also engaging them in a discussion about our mandate, realistic and reasonable expectations (especially given the enduring nature of personality disorders, learning & behavior, and the brief nature of our treatment),
  • empathy for the client, his own expectations and values,
  • and the difference between behaviors we absolutely cannot tolerate (e.g., verbal or physical aggression toward other clients or staff) and behaviors that require us to stand solid and yet have the capacity to bend in the wind, if you will.

I won`t give you all of the details (because I am eager to hear what type of recommendations you would give to a team that was tired, frustrated, and understandably reverting to hard nosed methods), but I will say that by the end of the discussion they agreed that the behavior contract they were proposing was unlikely to accomplish anything other than giving us a reason to discharge the client.

Given the lack of evidence-based or efficacious brief treatments/approaches with personality disorders, I find that it becomes increasingly difficult to advise/inspire our staff in their work with co-occurring Axis I and Personality Disorders. In all of your busy-ness, if you have the time and interest to give your take and how you would approach such a scenario (in the shoes of the therapist and floor staff working with this client), it would be greatly appreciated — especially since you are a bit of a celebrity around here

I circulate your Tips & Topics each month (with a bit of commenting and orienting on my part) and a common question we like to throw around is, “What would David Mee-Lee say/do?” lol.

Thank you so much for your time, and for the extremely useful and engaging Tips & Topics — I truly believe it is the staff’s favorite email that I send out!

Warmest regards,

Phuong-Anh

Phuong-Anh Urga, Ph.D.

Montreal, Quebec, Canada

My response (supplemented by Tips in SKILLS):

Hello Phuong-Anh:

 

Thank-you for that nice feedback. It is really gratifying to know that Tips and Topics is helping make a difference to you and your team.

As regards your Stump the Shrink question, indeed this is an often-heard issue.  It has come up a lot over the years, but especially with some programs in Alabama and Louisiana where I am currently doing teleconference supervision.

Take another look at SKILLS in the Feb., 2013 edition.  This link should get you there.  Especially note numbers 2 and 3 in SKILLS tip#1.
Most importantly, help staff begin to reframe how to use the behavioral problems and “rule-breaking” etc., as an opportunity:
  • To recognize that treatment progress and outcomes are not going well.  As with any poor outcome – whether stabilizing someone’s blood pressure or blood sugar, their asthma, their depression – their addiction is really the same.
  • After that, the next step is to assess what is not going well.
  • Then collaborate with the client on a modified treatment plan. Then watch if things improve.
We wouldn’t just criticize a patient for having their blood pressure go up. We wouldn’t expect them to contract to control their blood pressure on their own. We would explore with them what’s going wrong, and how we can help them fix it. The same with anger, outbursts and rule-breaking…….

 

In the case of this client, we would be asking these questions and assessing along with him:
  • Why is he even in the program?
  • What does he want?
  • What is so important to be on the phone all the time?
  • What does he feel is stupid about the program?
  • What made him decide to choose to be in the program in the first place?
  • Is he getting what he wants? And if not, what can we do together to reach his goal?
Use the six ASAM Criteria dimensions to re-assess:
  • Dimension 1, Acute Intoxication and/or Withdrawal Potential

Is he acting up because he is in some withdrawal or even using on the side?

  • Dimension 2, BiomedicalConditions and Complications
Are there some physical health problems making him more frustrated -e.g. pain or migraine headaches or something else going around a co-occurring physical health problem?
  • Dimension 3, Emotional,Behavioral or Cognitive Conditions and Complications
Similarly are there issues that are stressing him?  Anger over something going on at home – or whomever he is talking to all the time on the phone? (Dimension 6, Recovery Environment).  Does he have an unstable concurrent mental health diagnosis?
  • Dimension 4, Readiness to Change
Readiness to change -or not- is an important area of focus. When I hear cases like this, the first thing I want to check is:
…What is the treatment contract?
…What made the client decide to be in treatment?
…What does he want?
Many behavior problems arise when we clinicians try to do “Recovery, relapse prevention” when our client is actually at “Precontemplation” for recovery, but at “Action” perhaps for other things like: getting someone off their back, or keeping a job or a relationship, or for staying out of jail or getting off Probation?
  • Dimension 5, Relapse, Continued Use or Continued Problem Potential
Is it possible your client is having addiction cravings to use and doesn’t know how to handle those?  Are there mental health flare-ups? He is possibly exhibiting in your program all kinds of struggles that he similarly gets into at home or work?  All of this comesback to the central question: Why is he in treatment? What does he want?
  • Dimension 6, Recovery Environment

Your client may have some family, work or other recovery environment pressures – e.g., money, housing, legal issues frustrating him. That could be contributing to his negativity about being there.

—-> So what is the staff’s goal? 
  • What can he (the client) and we (the staff) learn from how he handles frustration here in our program, which also happens outside in the ‘real world’? (Assessment)
  • What alternate strategies and skills can we help him learn and practice in the program, which he can also apply outside? Then he won’t have to come to these “stupid” programs. (Skills)

 

—–> It isn’t about our just trying to clamp down and stop the behavior. 
  • How can we relate to clients in an Adult-Adult interaction (Transactional Analysis) rather than a Parent-Child relationship?
  • Behavioral contracts and the like just perpetuate a victim, Parent-Child interaction. This doesn’t help him, or the staff, learn from this microcosm of the real world.
 
Bottom Line 
…When there is “rule breaking,” assess what is not going well.
…Tie the behaviors to the client’s treatment plan.
…Don’t make separate behavioral contracts.
…Create programs to be a safe, supportive environment where clients can understand and practice new ways of being.

… The same frustrations and behaviors that happen ‘out there’ also happen in the program.

Thanks for being a faithful reader and spreading it around.
David

SKILLS

So… What do we do about clients’ behavioral and emotional outbursts, especially in residential treatment programs?

 

On August 9, 2013 National Public Radio’s Science Friday interviewed two experts in social-emotional learning: Marc Brackett, Director of Yale University’s Center for Emotional Intelligence; and Maurice Elias, Professor, Psychology Director of Rutgers University’s Social and Emotional Learning Lab.

http://www.sciencefriday.com/topics/body-brain/segment/08/09/2013/reading-writing-rithmetic-and-respect.html

 

The program’s theme was on emotional intelligence. While the focus was on what schools and teachers should be doing in educational settings, the conversation referred to many principles applicable to treatment settings. In behavioral health, we also create an environment of learning, to facilitate lasting positive self-change.

 

TIP 1

Consider these points about schools. How can we relate them to our daily work in behavioral health?

 

1. Emotional intelligence is our way of being smart in the world.
We develop the set of skills needed to get along in our interpersonal relationships.

  • People in treatment have often been raised in families who themselves were never taught about emotional intelligence.
  • Many have never developed the skills to be smart in the world. They are not skilled about negotiating relationships. Our clients need us to create a safe and healing environment to learn emotional intelligence.
  • What they don’t need is a “school” where the focus is on behavior control, rule-breaking and “punishments.”

 

2. Schools and teachers do not do direct instruction of these skills.
Yet these skills are teachable. Students can be helped to develop a sophisticated emotional vocabulary and research-based strategies to regulate their emotions. Many people can only identify a few emotions; many have no emotional vocabulary to make sense of what is bubbling up inside them.

  • Clients can often have defiant outbursts and don’t comply with house rules. They probably have a very limited understanding of what they are feeling, and what they are reacting to. They are not skilled at acting differently and constructively, since they most likely have a limited repertoire of emotions and behaviors.
  • What is our job in treatment? To help our client become an explorer of his/her own feelings and behaviors – to think through what is going on and how to thrive.
  • What must we watch out for? That we do not perpetuate our clients’ externally- oriented perspectives where others are blamed for what is going wrong. We can reinforce this by responding to outbursts with rules and procedures. This then puts the responsibility for controlling emotions and keeping the peace on the staff! It is our clinical challenge to harness the teachable moment of an outburst.

 

3. Ability to learn at school is affected by a student’s emotional state while they are learning.

  • Students can’t learn if preoccupied with feelings and fears they don’t have a good handle on.
  • It is the same in treatment. When clients struggle to understand what they are feeling, thinking and why they are, it is doubly hard to figure out what to do about it.
  • In treatment, we must create a therapeutic environment to promote learning, not compliance.

 

4. Teach students how to calm themselves down when stressed or even when they are elated.

  • We must help clients find strategies they can use themselves,not just in the program, but more importantly when they are on their own in their outside world.
  • Simply expecting clients to manage interpersonal disputes effectively when they have never been taught is like teachers expecting students to know calculus just because they have enrolled in the class.

 

5. Teachers need to pay attention to the students’ emotional cues and create an engaging learning environment.

  • Clients frequently behave in exasperating and frustrating ways. For the staff, that’s a signal that the client is out of their depth in emotional intelligence.
  • The clinician is now alerted to the need for engaging the client in a learning process, not a disciplinary process.

 

TIP 2

Help people “name their emotions to tame their emotions.

Marc Brackett coined RULER to develop critical and inter-related emotional skills. Whena person creates a mental model of what an experience is, then it’s possible to figure out what one’s feelings and needs.   This helps you regulate them.

Here is what the acronym RULER means:

 

Recognize emotions in oneself and others.

Understand where emotions come from and the causes of emotions.

Label emotions and increase your emotional vocabulary.

Express emotions rather than holding them in.

Regulate emotions so as to get needs met, be smart in the world to get along in interpersonal relationships.

 

Help clients identify and explore their RULER. Focus the therapeutic community and staff energies on learning and growing, not compliance and discharge.

SOUL

The headline in the Sacramento Bee newspaper on Saturday, September 28read: “
Obama, Rouhani break ice on phone” FIRST DIRECT TOP-LEVEL TALKS SINCE 1979 – “Barack Obama and Hassan Rouhani spoke Friday by telephone in the first conversation between the presidents of the United States and Iran in more than 30 years.

Experts on Iran used a wide range of superlatives to discuss the call: “hugely positive,” “historic but long-overdue moment,” a “groundbreaking event.” “The phone call lasted only 15 minutes, but it offered the best hope in years for the two countries to settle their disagreements.”

 

I know I am politically naive. But it seems to me that if you don’t talk to people, it’s hard to form any kind of working relationship, let alone hope to settle disagreements. So, yes, maybe in the world of politics, talking to someone for 15 minutes after 30 years is pretty amazing. But on another level, you don’t have to be a rocket scientist to figure out that if you:

  • don’t talk for 30 years
  • don’t try to give each side some mutual respect
  • don’t use any methods other than the threat of bombs, sanctions, force and violence

………….that the chance of settling disagreements might seem a little far off!

 

The world of international politics is way over my head and outside of my expertise. But what is amazing to me much closer to my area of expertise is that we do our own version of the “no talk, no relationship” method in behavioral health and criminal justice settings.

 

As we just discussed in SAVVY and SKILLS this month, it is too easy to stick to “behavior control” methods to manage behavioral and emotional outbursts rather than to talk and build a “working alliance” method to create a learning experience for our clients.

 

Worse still are how high-risk inmates of prisons are housed with very little human contact and relationship. They are allowed only an hour out of their cell, with all their comings and goings controlled electronically via switches and gates.

 

Some forward-thinking prisons have discovered that respectful human interaction works wonders. Previously out-of-control inmates have shown dramatic improvements in the health and safety of inmates, correctional officers and the overall facility.

 

So maybe there are some places and world regions where the “no talk, no relationship”, power and control methods work well to settle disagreements.  I just know I don’t want to be anywhere near those countries or politicians – oops, I take that back.

 

I don’t want to move away from the USA. (I wonder when politicians in the USA will discover talking and relationship to settle disagreements?) I guess I’ll just have to enjoy the Government shutdown looming this week.

SHARING SOLUTIONS

Here is Dr. Phuong-Anh Urga again:

Firstly, I’d like to congratulate you–and The Change Companies–on your work that has resulted in the ASAM (American Society of Addiction Medicine) e-learning modules.I have completed them myself and have piloted them with some newly hired clinicians. Based on the feedback, I intend to incorporate them into my organization’s training and integration of new staff (it will be much more cost efficient and effective than providing the trainings myself, which I have done for the past few years now). I wonder how/if the modules will change with the launch of the revised criteria — any insight you might be able to provide without violating top security clearance would be appreciated before I purchase the site licenses.

 

My response:

I’m so glad you appreciated the ASAM eLearning modules.  We will have a new eLearning module on the new edition; it will be about an hour long. Also we are updating the two original modules to take into account some terminology changes from the new edition. However the essential principles and content will be the same as what you took, just updated for the 2013 edition.  I’ll certainly announce that in Tips and Topics, but you can also keep up to date at www.ASAMcriteria.org and check out the special preorder offer for the new edition of The ASAM Criteria that is running out.

Until next time

Thanks for joining us this month. I’ll be back in late October.

David

Vol. 11, No. 7

In This Issue
  • SAVVY : What’s new in The ASAM Criteria?
  • SKILLS : Integrated care and managing care
  • SOUL : Malala Yousafzai – the inspiring 16 year old
  • SHARING SOLUTIONS : Final days for special ASAM Criteria preorder offer

Welcome to the October edition of Tips and Topics. Thanks for reading.

David Mee-Lee M.D.

SAVVY

This week, the American Society of Addiction Medicine (ASAM) will release the new edition of ASAM’s criteria: “The ASAM Criteria – Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions.” As Chief Editor, I am especially excited as October 24, 2013 culminates over two years of direct work on the new edition. (It has been 12 years since the last edition of ASAM’s criteria.)

 

For those of you familiar with The ASAM Criteria, you’ll be pleasantly surprised once you get your hands on the new manual. It is attractive, user-friendly and leaps and bounds ahead of previous editions. There is new content and it helps you apply the criteria in a variety of clinical settings and for different populations.

 

Both for long-time Criteria users and for readers who do not know The ASAM Criteria, here are highlights of what you will see in the new edition. (There is also more information about what’s new in this year’s May 2013 edition of Tips and Topics.


TIP 1

Expand your knowledge about multidimensional assessment and the levels of care.

*Changes in Dimension 1, Acute Intoxication and/or Withdrawal Potential
Instead of detoxification services, the new edition now refers to withdrawal management services.This is because the liver “detoxifies” but clinicians “manage withdrawal.”

This isn’t just playing with words. There are good reasons to think about managing a patient’s withdrawal rather than just “detoxifying” the patient.

Common Case Scenario

  • Patients are often placed in high-intensity, high-cost hospital levels of care for detoxification to make sure they don’t have a withdrawal seizure.
  • However, they are discharged after 3-4 days or whenever the seizure danger has passed, only to find some people use again even within a week or two.
  • Why does this happen when we already detoxified them? The answer is that we hospitalized the person until the danger of seizures passed, but didn’tmanage the person’s withdrawal, which can take much longer than the few days of seizure danger.
  • There are 5 levels of withdrawal management in the adult criteria.
    Too often treatment occurs just in Level 4-WM (Medically Managed Intensive Inpatient Withdrawal Management). This can cost $600, $800 or even $1,000 per day. If all 5 levels are used, as needed, a patient can receive close to 2 weeks
    of withdrawal management support, for what it costs for a few days in Level 4-WM.
  • By contrast, one day in a 24 hour supportive Level 3.2-WM (Clinically Managed Residential Withdrawal Management) can cost $100 or $200 per day. Do the math: a patient can receive 5-6 days of 24-hour withdrawal management support for everyday in a high intensity hospital-based service.

 

 

*Level 1, Outpatient Services

Outpatient services are often used as the entry point at the beginning of recovery, or a brief “aftercare” level for people who have “graduated” from intensive addiction treatment. In the new edition, we emphasize that addiction is a chronic illness, and many clients need ongoing disease management in Level 1 – indefinitely.
  • How often does a patient need to be seen for ongoing recovery monitoring? Short answer: it depends on that individual’s current severity of illness and level of function. If the person’s addiction is unstable and they need closer monitoring, then the “dose”, frequency and intensity of Level 1 care may require that- at first- the patient be seen weekly or even twice weekly. After that, as the person stabilizes, the intervals between appointments can be lengthened.
  • Level 1 now becomes a level of care to help clients maintain their recovery for successful wellness and health.
  • Again, how do I understand the levels of care in the new edition?
    Consider these parallels. How does your doctor manage hypertension, or asthma or diabetes? How does a psychiatrist manage schizophrenia, bipolar disorder or chronic panic disorder or major depression? Disease management does not mean closing the case after 10 aftercare sessions.

 

*Level 3, Residential Services

This level is fundamentally the same in the new edition of The ASAM Criteria, but there are 2 levels worth highlighting. One is Level 3.1, and its difference from the other residential levels; and the other is Level 3.3 with its new name.

Level 3.1. Clinically Managed Low Intensity Residential

  • It is qualitatively different from Levels 3.3, 3.5 and 3.7.
  • Level 3.1 is 24 hour supportive living mixed with some intensity of outpatient services
  • In contrast, the other level 3 programs are 24 hour treatment settings for those in imminent danger.
  • The new edition explains further “imminent danger” in Dimensions 4, 5 & 6.
  • For example–
    An individual may not even think he has an addiction problem. Even though he is intoxicated, and not in withdrawal, he is intent on driving when it is obvious he is impaired. He needs 24-hour stabilization in a residential setting.
  • Another example–
    A client has overwhelming impulses to continue drinking or drugging. He has existing liver or psychotic illness. Continued heavy use with acute signs and symptoms places him in imminent danger of severe liver or psychotic problems. This calls for 24 hour treatment to prevent an acute flare-up.

 

Level 3.3: “Clinically Managed Population-Specific High-Intensity Residential Services

  • This is a new name for Level 3.3 and here’s why:
  • The PURPOSE of Level 3.3 programs has always been: to deliver high-intensity services and to provide them in a deliberately repetitive fashion.
  • Which populations does this level serve? The special needs of individuals such as the elderly, the cognitively-impaired or developmentally-delayed.
  • Another population is patients with chronic and Intense disease who require a program which allows sufficient time – to integrate the lessons and experiences of treatment into their daily lives.
  • Typically, level 3.3 clients need a slower pace of treatment because of mental health problems or reduced cognitive functioning (Dimension 3), or because of the chronicity of their illness (Dimensions 4 and 5).
  • Summary: this level is for specific populations; high intensity work still is needed; treatment is conducted at a slower pace.
Learn about the ASAM Criteria Dimensions

If you are not familiar with the ASAM Criteria dimensions, take a look at last month’s edition: http://changecompanies.net/tipsntopics/?s=The+ASAM+Criteria+six+dimensions

 

Notice the change in the numbering system
The old edition used Roman numerals.
The new edition uses regular Arabic numerals- for Levels of Care.

So Level III is now Level3. Level IV is now Level 4 etc.

TIP 2

Broaden your perspectives on addiction treatment

There are 2 new chapters in The ASAM Criteria, 3rd edition which move into areas which have not gained much respect in addiction treatment in the past:

Tobacco Use Disorder

Gambling Disorder

 

In fact, a significant number of programs still view nicotine addiction as one drug addiction which can wait until later: “You can’t expect a person to quit everything at once. We don’t allow smoking in the groups or in the building, but we do have a smoking gazebo on the grounds where patients can smoke in predesigned breaks.”

 

–> I’m still looking for the program that has the cocaine, heroin, marijuana or Xanax gazebo for the patients not ready to quit all those drugs at once!! <–

 

For both Gambling and Tobacco Use Disorders, the new edition makes the case for a continuum of levels of care for these types of addiction, just as we have had for other substance use disorders.

 

 

TIP 3

Apply the criteria to special populations

The editors have responded to feedback from counselors and clinicians who have expressed difficulty applying the criteria to special populations:
—-older adults

—-parents or prospective parents receiving addiction treatment concurrently with their children

—-those in safety-sensitive occupations like physicians and pilots

—-clients in criminal justice settings.

 

Mandated Clients
Many clients come from criminal justice drug courts, probation and parole or even still reside in prison treatment settings.
For example…
A judge often mandates a client to a specific level of care and length of stay, not based on an assessment of what will achieve good outcomes, but rather concerned about public safety. The ASAM Criteria recommends that a judge mandates assessment and treatment adherence which places the responsibility on clients to “do treatment and change,” rather than give the impression that the client can “do time” in a program for a fixed length of stay.

 

What does the judge’s mandate require from the clinicians and programs involved with this particular client?
–> To carefully monitor the person’s risk to public safety

–> Inform the judge, probation and parole officer when a mandated client is not doing treatment and simply sitting in a program.

SKILLS

TIP 1

Cultivate interdisciplinary relationships with other health systems

Here are the facts:

  • There are millions more people who after January 1, 2014will now be covered by health insurance and have access to addiction treatment
  • 23.1 million people 12 years and older needed treatment for an illicit drug or alcohol use problem and only 2.5 million receive specialty addiction treatment (2012 National Survey on Drug Use and Health, NSDUH, September 2013)

How will addiction treatment agencies increase access to care when we already have waiting lists and can’t even meet treatment-on-demand?

 

The new edition addresses the need to reach out to other health systems where most people withaddiction first show up:

  •  Integration of addiction treatment services with mental health- co-occurring capable; co-occurring enhanced; complexity capable programs
  • Increasing Screening, Brief Intervention, Referral and Treatment (SBIRT) in Level 0.5, Early Intervention
  • Integration of addiction and general healthcare services – Patient Centered Health Care Homes
  • Integration of primary care into addiction treatment settings


TIP 2

Learn how to manage care yourself

A new section on working effectively with managed care and healthcare reform helps everyone manage care to “bend the cost curve” – meaning reducing the rate of healthcare inflation and costs.  This is a responsibility of ALL if we are to eliminate waiting lists and make way for the millions of potential new patients who deserve and need addiction treatment.

 

When asking a managed care utilization reviewer to authorize payment for your treatment services, go over in your clinical head the following steps in the information and be ready to communicate/convey them to the care manager on the phone:

 

1. What are the problems and priorities you are concerned about?

2. Which ASAM Criteria dimensions do they belong to?

3. What are you going to do in the treatment plan for those problems? What services?  How much and how frequently does the client need those services?

4. What is the level of care that is the least intensive, but safe level to provide the treatment plan?

 

Here is an example that follows those steps: (Clinician response in italics)  

 

Q1.  What are the problems and priorities you are concerned about?
” The patient has impulses and cravings to continue using.”

 

Q2. Which ASAM Criteria dimensions do they belong to? –
“Dimension 5, Relapse, Continued Use or Continued Problem Potential”

 

Q3. What are you going to do in the treatment plan for those problems? What services?  How much & how frequently does the client need those services? “Cognitive behavioral therapy, peer refusal skill building, medication management and relaxation and contingency management strategies – throughout the day, on a daily basis, for several hours a day, because the client’s cravings and impulses are intense, frequent and daily. Without this dose and frequency of services, my client will have a significant flare-up of liver problems and psychosis.”

 

Q4. What is the level of care that is the least intensive, but safe level to provide the treatment plan?
“Level 2.5 partial hospital combined with Level 3.1 supportive living”

 

Some clinicians request payment authorization by saying such things as:
“We need another week because the patient is at high relapse potential.”  Such clinicians will need to be prepared to answer some more searching questions from the authorizer like:
What do you mean by “high relapse potential”?
What are you doing in the treatment plan for the high relapse potential?
What about the relapse prevention plan you say you are developing with the patient can only be done in your level of care?
Why cannot those same strategies be delivered safely in a less intensive setting?
If all a clinician can say is to repeat the statement that the patient’s potential for relapse is very high, then you can be assured that the managed care utilization reviewer will consider that as inadequate information to explain why further treatment is needed in your program.  Most likely payment for those services will be denied.

 

Learning to manage care yourself means:

  •     To be good stewards of resources so we can increase access to care
  •      Stretching limited resources to provide all the levels of care a person needs for recovery

SOUL

Malala Yousafzai is now 16 years old. She teaches and travels the globe talking about the importance of education, especially for girls and women. The Pakistani girl, shot by the Taliban for her efforts, has been hailed as the youngest person ever nominated for the Nobel Peace Prize.

http://www.utsandiego.com/news/2013/Oct/10/malala-yousafzai-pakistan-nobel-peace-prize/

 

When I was a 11 year old boy in Australia, I was writing little stories for the Sunday paper trying to win a prize.  I even got to go on television to receive my prize of a watch for my essay.  Malala blogged for the BBC in 2009 as she defied a Taliban edict banning girls from going to school.  She was also 11.

 

Malala was targeted and shot in the head and neck October 9, 2012 – a year ago this month – following all the publicity she received for opposing that Taliban campaign to close schools.  She continues to speak out eloquently and courageously.

 

I am proud to speak out and advocate for a broad range of effective and efficient services for people with addiction and co-occurring conditions, which I have trumpeted since the 1980’s. I will be especially gratified to hold the new edition of The ASAM Criteria and introduce it to everyone on Thursday, October 24.

 

Then I think of Malala Yousafzai.

SHARING SOLUTIONS

No pressure – but I really don’t want you to miss out on the special preorder offer when you buy the new edition of The ASAM Criteria. Go to www.ASAMcriteria.org to order and get the offer that is in it last days until the end of October.

Until next time

See you again in late November.  Thanks for reading.

David

Vol.12 , No. 7

Welcome to the October edition of Tips and Topics (TNT). I’m glad you could join us.

David Mee-Lee M.D.

SAVVY

It was a year ago this month the latest edition of The ASAM Criteria was released. If you haven’t been briefed on what’s new in the 2013 edition, you can take a look at the October 2013 edition of Tips and Topics http://www.tipsntopics.com/2013/10/

or even do a two-hour eTraining module for continuing education credits on an “Introduction to The ASAM Criteria”. Check it out at http://www.asamcriteria.org and click on Resources & Training. There’s lots of other resources on bringing you up to speed.

 

I am often asked whether The ASAM Criteria can be used in mental health treatment systems as well as for addiction treatment. I’m biased of course. Not only is it useful in mental health, but also in this era of healthcare reform where integratedcare is increasingly necessary, The ASAM Criteria can help general health teams as well.

 

TIP 1

The ASAM Criteria six dimensional assessment provides a comprehensive structure to provide and manage addiction, mental and general health care.

 

Here is an update on what I reviewed in the Volume 4, No. 10 edition in March 2007 http://www.tipsntopics.com/2007/03/march-2007/#more-81

 

The common language of the six assessment dimensions of The ASAM Criteria can be used to determine multidimensional assessment (MDA) of severity and level of function of any health care client. Here are the six assessment dimensions of the MDA:

 

1. Acute intoxication and/or withdrawal potential

2. Biomedical conditions and complications

3. Emotional/behavioral/cognitive conditions and complications

4. Readiness to Change

5. Relapse/Continued Use/Continued Problem potential

6. Recovery environment

(The ASAM Criteria 2013, pp 43-53)

 

For each dimension, I’ll outline how why it is useful and important to consider each assessment dimension if you are:

  • A general health clinician – whether in the emergency room, primary care, health clinic or specialty practice
  • A mental health clinician – whether in emergency psychiatric services, private practice or a mental health clinic
  • An addiction treatment counselor or clinician – whether in outpatient or residential services or private practice
  • A care manager – whether in a managed care company or treatment agency

 

Dimension 1: Acute intoxication and/or withdrawal potential

  • Emergency room personnel too often treat the complications of addiction and take care of the broken leg or head trauma from a drunk driving accident, but don’t link the patient to needed addiction treatment. They would never simply stabilize a patient’s asthma attack or diabetic coma without linking them to ongoing asthma or diabetes care.
  • Surgeons may do a successful appendectomy for acute appendicitis only to find the patient agitated and in delirium tremens (DTs) three days later. Nobody checked the patient’s alcohol history to discover he/she is a daily heavy drinker and needed withdrawal management along with the appendectomy.
  • Mental health professionals should be checking: Is this major depression? Or is the person crashing from cocaine or other stimulants? Is this really anxiety disorder, or is the client in benzodiazepine or alcohol withdrawal? Is this really bipolar disorder, or is the person using uppers and downers and having mood swings as part of an addiction problem?
  • Addiction clinicians are checking the person’s recent substance use history to assess the need for withdrawal management; and in ongoing care using urine drug screen monitoring and other tests to check for use and intoxication.
  • Care managers can use the five levels of withdrawal management (WM) to provide and pay for a flexible continuum of WM services that not only uses resources efficiently, but can provide at least two weeks of WM support for what is often spent in 3-4 days at an acute care “detox” unit.

 

Dimension 2: Biomedical conditions and complications

  • All clinicians assess a person’s physical health needs, which are the focus of this dimension.
  • But emergency personnel and primary care workers can easily become entangled in a chronic pain patient’s use of medication, which may now have crossed the line into addiction.
  • Mental health and addiction clinicians also often struggle with the interface between a person’s chronic pain and their depression, anxiety or substance use disorder. How much does the patient’s pain need better pain management? Or are the frequent requests for more pain medication simply addiction?
  • Care managers in managed care companies will frequently authorize huge sums of money for expensive medications, physical health tests or procedures while micromanaging and denying payment for needed outpatient sessions or inpatient and residential levels of care in addiction treatment.
  • Care managers in treatment now work in an era of healthcare reform that now requires good linkage with primary care physicians and ongoing disease management.

 

Dimension 3: Emotional/behavioral/cognitive conditions and complications

  • Mental illness suffers nearly the same discrimination and stigma as addiction. Emergency room personnel can easily treat the acute suicidal overdose or self-inflicted cutting lacerations, but fall down on linking the patient to ongoing mental health services.
  • Primary care physicians prescribe the majority of antidepressants and anti-anxiety medications more than psychiatrists. But what about the psychosocial aspects? How well can they collaborate with therapists to provide whole care?
  • What about all those family members who present with somatic complaints when what is really fueling the headaches, stomach upsets and pain are family behavioral health problems?
  • There is now more attention on co-occurring disorders. Both mental health and addiction personnel are more fully embracing at least the need to ask questions about addiction and mental health, as well as coordinate care for any co-occurring disorders.
  • If not already doing this, Care managers in managed care should support funding for integrated care rather than create the dilemma clinicians have traditionally faced: Which diagnosis to make the primary one to ensure payment – mental disorder or substance use disorder?

 

Dimension 4: Readiness to Change

  • For many health care workers this is the less understood and more neglected assessment dimension of all. This dimension is as important to assess and treat as whether a patient is having a withdrawal seizure, bleeding to death,or suicidal or homicidal.
  • Millions of dollars are wasted in unfilled or partially used prescriptions. No client will adhere to a medication, lifestyle or cognitive change if the treatment plan is driven only by what the clinician, counselor or doctor wants for them.
  • Even in general health care, the rhetoric has shifted to the importance of patient-centered care and shared decision-making. What are the person’s priorities and goals? What quality of life do they want? What treatment strategies are a good fit for them and what ones are not?
  • Alliance building, engagement, and motivational enhancement is critical not just in addiction treatment, but also in mental health and healthcare in general.

 

Dimension 5: Relapse/Continued Use/Continued Problem potential

  • Dimension 5 is not just about drinking and drugging relapse or continued use.Oncologists, internists, and family physicians, focus on how to prevent a cancer recurrence; or another diabetic coma or heart attack. Judges, probation and parole officers, and police are concerned with how to prevent another arrest, probation violation or some illegal activity.
  • Addiction and mental health too often see treatment as isolated episodes of acute care for withdrawal management or crisis intervention.
  • Nowadays mental health clinicians however are thinking more about how to prevent that psychotic or manic episode, or another suicidal or self-mutilation injury, or another domestic violence situation. Increasingly the focus is on such methods as a Wellness Recovery Action Plan (WRAP).
  • The addiction field has long talked about relapse prevention. Where addiction treatment still struggles is in what to do with flare-ups of addiction and substance use while a person is in treatment. I have written about this before- most recently in the July 2014 edition of Tips and Topics. Check it out if you missed it at http://www.tipsntopics.com/2014/07/
  • Care managers in addiction managed care and treatment could learn more from chronic disease management of physical health and of severe mental illness. Much can be learned from community-oriented supports and outreach, which proactively prevents deterioration or intervenes early with flare-ups and worsening outcomes.

 

Dimension 6: Recovery Environment

  • With changes in how healthcare is being financed, hospitals are now penalized if a patient returns for readmission within 30 days. Previously, a returning patient filled a bed and generated revenue. What is critical now is that a patient’s family supports, living situation and environmental vulnerabilities and resources are assessed and addressed. This is part of the shift from acute care to ongoing disease management and health and wellness.
  • Addiction and mental health professionals are well aware of the following recovery environment issues: Who does a person live with? Is there even a place to live? Who is the financial and emotional support -or not? Are there transportation, childcare, criminal justice, work, school or financial problems? It is important to assess and service these issues.
  • Even general healthcare knows that when a patient is recovering from a heart attack, the person who has family and supportive friends around will do better than the isolated person.
  • The environment makes a big difference to patient comfort and recovery. Birthing centers now look more like a hotel suite than a cold sterile labor and delivery room.
  • Care managers in managed care companies and insurance benefit plans still don’t give the financial support and respect for the necessary recovery support services inherent in Dimension 6. Care managers on treatment teams too often can feel like second-class citizens on the treatment team hierarchy.In fact their work is so critical to success. Fortunately also peer specialists are now joining the team.

 

TIP 2

What about the LOCUS (Level of Care Utilization System) versus The ASAM Criteria?

 

This is a question I hear from time to time. The LOCUS evaluation parameters were influenced by the ASAM multidimensional assessment and other placement tools. In 1998 the LOCUS was introduced by the American Association of Community Psychiatrists (AACP) and was designed more specifically for mental health treatment systems.

 

The ASAM Second Revised Edition (ASAM PPC-2R) was published in 2001 containing criteria for co-occurring disorders. It was specifically broadened and updated to allow the assessment dimensions to apply to both mental health and addiction.

 

Both sets of criteria focus on a multidimensional assessment of the client. Both assess severity and level of function in a variety of important clinical and psychosocial areas. If this is a question that your treatment system is facing, you can see more about this in the March 2008 edition of Tips and Topics.

http://www.tipsntopics.com/2008/03/march-2008/#more-56

 

Reference:

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.

SKILLS

The field has had no standardized assessment tool to implement the ASAM Criteria. The multidimensional assessment is a powerful structure and clinical guide as discussed in SAVVY above. Furthermore, coming in 2015 will be a whole new opportunity for the field to unite around The ASAM Criteria Software.

 

Arising out of the research of David Gastfriend, M.D. (when he was Associate Professor of Psychiatry, Harvard Medical School and led millions of dollars of research on the ASAM Patient Placement Criteria for over a decade) the ASAM Criteria Software fills an important void.

 

The new software is based on research software extensively tested in Norway, other countries and US agencies.The Substance Abuse and Mental Health Services Administration (SAMHSA) invested millions of dollars to make the software compatible with all the major Electronic Healthcare Record systems.

 

TIP 1

Get acquainted with what is coming in 2015 to provide a standardized assessment to implement The ASAM Criteria.

 

The ASAM Criteria Software provides counselors, clinicians and other treatment team members with a computer-guided, structured interview for assessing and caring for adult patients with addictive, substance-related and co-occurring conditions.While the research has been done with adults, there is nothing to stop its being used with youth.

 

The software offers:

  • Data entry screens
  • Data management and clinical decision support (CDS) software
  • Outputs of an electronic and hard copy of treatment priorities and the least intensive, but safe, efficient and effective placement setting.
  • Research-quality questions (including tools such as the Addiction Severity Index (ASI), the Clinical Institute Withdrawal Assessment for AlcoholRevised, CIWA-Ar, and the Clinical Institute Narcotic Assessment, CINA instruments) and extensive algorithmic branching
  • An output of a 3-5 page report detailing a patient’s Diagnostic and Statistical Manual (DSM) substance use disorder diagnoses, severity and imminent risks and the recommended levels of care.

 

How does The ASAM Criteria book relate to The ASAM Criteria Software?

The ASAM Criteria book and The ASAM Criteria Software are companion text and application.

  • The book delineates the dimensions, requirements and decision rules that comprise ASAM’s criteria.
  • The software provides the approved structured interview to guide the assessment and calculate the complex decision tree to yield suggested levels of care.
  • The book and the software should be used in tandem, the book to provide the background and guidance for proper use of the software, and the software to enable comprehensive, standardized evaluation.
  • Effective, reliable treatment planning for adults is enhanced by using the book and software together.

Stay tuned at http://www.ASAMcriteria.org and click on the Software tab. We’ll let you know as soon as there are more specifics on how to access The ASAM Criteria Software. It won’t be free, but it will be affordable.

SOUL

 

70

There was absolutely no doubt what I would write for SOUL this month. I was getting ready to complete this month’s edition when the message from my very pregnant daughter was that contractions had started and were intensifying.

 

It was SUNday morning as the SUN was rising when Miya and Paulo scurried to the hospital – contractions now spiking every three minutes. Even with all their preparation for a calm, all natural birth event, labor pains are just what they’re called….labor.

 

Two hours after arriving at the hospital Miya’s labor of love was successful and we are all blessed to have grandchild and granddaughter #2 to beam about. Big sister, Luna, now two and a half welcomed her baby sister, not yet fully aware that she will now have to share the attention.

 

It is always curious as to what inspires parents to name their children. One day I’ll explain why we named our three children Miya, Taylor and Mackenzie. But for SOUL this month the spotlight is on Luna and baby Sol – our own Moon and Sun.

 

At the risk of being too cute, it was auspicious that:

  • Sol arrived on a SUNday
  • As the SUN was rising – what would have really been a surprise was if Sol wasn’t a daughter but a son!
  • Just earlier in the month I clicked this photo knowing that Sol was the intended name
  • In Portuguese Sol is pronounced SOUL

And to top it off, the rental car I was assigned on my business trip this week was an Hyundai Soul model.

 

Here comes the sun…welcome to the world, Sol.

Until next time

I’m glad you could join us this month. See you again in late November.
Thanks for reading.

David

SAVVY & STUMP THE SHRINK

Recently, a reader raised the issue of how to balance clinical thinking and judgment with strict interpretations of criteria and guidelines. “Criteria” refers to both placement and diagnostic types of criteria- for example, The ASAM Criteria or other utilization management criteria (placement) and DSM-5 (the Diagnostic and Statistical Manual of the American Psychiatric Association (diagnostic). There are also other sets of “Guidelines” like best practices or evidence-based practice protocols.Here is the STUMP THE SHRINK question I edited for clarity: 

“I was hoping you could provide some feedback on a recent discussion I had with colleagues regarding ASAM Criteria assessment Dimension 4, Readiness to Change for Level1, Outpatient Services. My co-worker was asking for input regarding a client who met Level 1 placement criteria in every dimension except for criterion “a” in Dimension 4.

(Criterion “a” in Dimension 4, Level 1 states: “The patient expresses willingness to participate in treatment planning and to attend all scheduled activities mutually agreed upon in the treatment plan.” Page 192-  this is my insertion for those not familiar with The ASAM Criteria 2013).

 

The client walked out at the end of the assessment unwilling to enter treatment. She was in denial that she had an alcohol problem that required treatment and had come to the assessment to avoid legal consequences.

 

The focus of the discussion with my colleagues was on the fact that the patient doesn’t fit Level 1 because she is not willing and walked out towards the end of the assessment. I thought the focus should be more on how do we motivate her to become willing. I would appreciate your thoughts.”

 

TIP 1

Compare and contrast strict interpretations of criteria with using clinical thinking and judgment

 

Case #1

Strict interpretation: Criterion “a” says the patient expresses willingness to participate and attend treatment. She walked out at the end of the assessment unwilling to enter treatment. End of story. No further thinking required. Patient does not meet criterion “a” and can’t be admitted to Level 1 Outpatient Services.

 

Clinical thinking and judgment: The client showed up and stayed until the end of the assessment. She clearly wants something.If she didn’t, she wouldn’t have shown up in the first place. She appears to want to avoid legal consequences but doesn’t see she has an alcohol problem. That is a critical Dimension 4, Readiness to Change treatment priority- to engage her into treatment around what she wants: to avoid legal consequences.

 

Strict interpretation: The client is “in denial” and doesn’t want treatment for sobriety and recovery; and is not willing to enter treatment. I can’t make her be willing and stop her from walking out, so she can’t be in Level 1 because she didn’t meet Dimension 4, criterion “a”.

 

Clinical thinking and judgment: This client is a prime candidate for motivational enhancement and interviewing strategies. She is at ‘Action’ stage for avoiding legal consequences. At the same time, she is in ‘Precontemplation’ stage for working on alcohol abstinence and sobriety. If I proceed and present treatment as though she showed up for sobriety, recovery and relapse prevention, I will not be on the right path. This focus does not match her stage of change. My focus is not important to her, and I’ll fail to engage her in treatment. She is likely to be turned off treatment altogether, and encourage her to walk away. (Alternatively she may enter treatment, but just sit there and passively comply, instead of focus on change.)

 

Strict interpretation: The client does not meet all criteria listed for Level 1 in The ASAM Criteria. Case closed.

 

Clinical thinking and judgment: This woman certainly meets all criteria for Level 1 if I develop a “mutually agreed upon…treatment plan” focused on avoiding legal consequences not focused on abstinence, sobriety and recovery.

 

In each dimension and level of care, The ASAM Criteria is meant to guide clinical thinking. Using the criteria is not meant to shackle counselors and clinicians to check off a criteria checklist. They should not bypass clinical thinking in how to engage a client and how to collaborate on treatment goals which makes sense to the client.

 

 

TIP 2

Note what the American Psychiatric Association says about diagnostic criteria and clinical judgment

Diagnostic Criteria Sets 

“For each disorder included in DSM, a set of diagnostic criteria indicate what symptoms must be present (and for how long) as well as symptoms, disorders, and conditions that must not be present in order to qualify for a particular diagnosis. Many users of DSM find these diagnostic criteria particularly useful because they provide a concise description of each disorder. Furthermore, use of diagnostic criteria has been shown to increase diagnostic reliability (i.e., likelihood that different users will assign the same diagnosis to an individual). However, it is important to remember that these criteria are meant to be used as guidelines informed by clinical judgment and are not meant to be used in a cookbook fashion” (italics added for emphasis).

http://www.psychiatry.org/practice/dsm

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.

For more information on the new edition: www.ASAMcriteria.org

SKILLS

Case #2

Another agency that also “uses” The ASAM Criteria provided documentation on a client case. They believed their paperwork explained and justified why their client needed Level 3.5, Clinically-Managed High Intensity Residential Services.

 

Below you can read excerpts from this counselor’s paperwork. It is an example of simply quoting from the Criteria book to justify a level of care. The “Clinical Observation” data does not support the criteria they quoted.

 

This case is especially relevant because the client had already been in their Level 3.5 service for over four months when she was discharged to outpatient services. Within a day of discharge, the client used alcohol. Now the treatment program readmitted her for more weeks in their residential program. In addition, the agency’s program is often represented to clients as being a six-month program, which is inconsistent with the spirit and content of The ASAM Criteria.

 

Here is the documentation on Dimension 4 assessment:

Dimension 4: Readiness to Change:

According to ASAM Criteria, the client meets criteria (d) Client requires structured therapy and 24-hour programmatic milieu to promote treatment progress and recovery,because motivational interventions have failed at less intensive level of care and are assessed as not likely to succeed in the future at a less intensive level of care.

(e) Client’s perspective impairs his/her ability to make behavior changes without repeated, structured, clinically directed motivational interventions, delivered in a 24 hour milieu. Interventions are judged as not likely to succeed at a less intensive level of care.

 

Clinical Observation: Client has acknowledged that she does have a drug problem and has verbalized that her desire for treatment is externally motivated. Client has not internalized motivation for change, and the causes of her addiction. She needs to internalize her motivation for treatment, and identify her relapse triggers. Client needs to continue to remain in Level 3.5 so that she learns to internalize her motivation and identify the reasons for her continued use.

 

TIP 1

Explaining why a client needs a certain level of care is much more than simply quoting the criteria from The ASAM Criteria book or any otherguidelines. You must demonstrate how the clinical assessment data and observations match the criteria quoted.

 

In Case #2, there was no clinical observation data in any of the six dimensions that demonstrated the client was in imminent danger needing 24-hour care in a residential setting. The criteria quoted for Dimension 4, Readiness to Change were referenced from page 258, criteria (d) and (e) in The ASAM Criteria (2013).

 

Here’s how the “clinical observations” do not match the criteria:

  • The client had been admitted to Level 3.5, residential services for five months and no motivational interventions at a less intensive level of care were considered or attempted.
  • Nor was there any clinical data provided indicating that motivational interventions would be unsuccessful in a less intensive level of care.
  • The client acknowledged having a drug problem even though her desire for treatment was externally motivated for legal problems.
  • Helping the client to internalize a connection between her drinking and the external motivators requires motivational strategies, which can be provided safely in an outpatient level of care.
  • There was no clinical data demonstrating that motivational strategies could only be delivered in a 24-hour treatment setting.
  • Readmitting the client to Level 3.5 residential treatment for even more weeks only further shelters the client away from developing the skills necessary for community reintegration.

Utilization management criteria such as in The ASAM Criteria are to help guide clinical decision-making and judgment…….not the other way around. In other words,clinical thinking and decision-making comes first and then that guides what criteria are chosen and used to explain decisions about treatment and level of care.

 

It is not the printed criteria (quoted from the book) which explains how to assign the level of care. It is the clinical decision-making about the client’s severity and needs that point to which criteria apply.

SOUL

This month I worked and touristed in Hong Kong after my last visit 20 years ago. It was a fascinating experience as you can imagine. It wasn’t exactly getting in touch with my roots even though my ancestors did originate in southern China, not far from Hong Kong. After all, I was born and raised in Australia; so were my parents; and my mother’s mother too. So I am more familiar with CrocodileDundee than Chinese Dragons.

 

But since Chinese NewYear was just February 19, SOUL this month should be about some things Chinese!

 

Over the last few years, I have had my awareness and knowledge upgraded regarding a very Chinese art and science called Feng shui. Here are a couple of explanations:

  • “Feng shui is a Chinese philosophical system of harmonizing everyone with the surrounding environment. The term feng shui literally translates as “wind-water” in English. The feng shui practice discusses architecture in metaphoric terms of “invisible forces” that bind the universe, earth, and humanity together, known as qi.” http://en.wikipedia.org/wiki/Feng_shui
  • “Feng shui is an ancient art and science developed over 3,000years ago in China. It is a complex body of knowledge that reveals how to balance the energies of any given space to assure the health and good fortune for people inhabiting it.” http://fengshui.about.com/od/fengshuiglossary/

Our home has been transformed with the help of our Feng shui consultant who has opened my skeptical, Western-ingrained eyes to come to respect some ancient wisdom.

 

Here is just one example which might give you an idea of how this works:

For 17 years, we have had a TV and media cabinet in our bedroom. (True feng shui prinicples discourage TVs in bedrooms as it does not harmonize with the intention of the bedroom as a place for rest, rejuvenation and romance.) This cabinet had doors which allowed us to close them so the TV, DVD player would not dominate the room. It wasn’t especially large, but it did certainly jut out a bit so there wasn’t an easy flow walking by it. It also somewhat obstructed a peaceful view out to the trees and greenery n the backyard. For years, though,we had just become accustomed to moving around it. One day last month, it dawned on us that with flat screen TVs now, we didn’t need as large a space for such a cabinet. We moved it out of the room. Amazing!

 

This is where Feng shui “eyes” come in.

 

It was a surprisingly happy, satisfying feeling to suddenly experience what now felt like a spacious path from the bedroom door to the master bathroom. It wasn’t like we had to squeeze by the cabinet before, but for years the qi (or flow) had been blocked or at least impeded. Now the space flows beautifully. We can feel, see and enjoy it.

 

You might want to get in touch with any Chinese wisdom hiding within your being and take a look at the furniture arrangement in your home. You might just open up the qi to transform your space too.

Belated Happy Chinese New Year!

SHARING SOLUTIONS & STORIES

1. Do you want an easy way to see the current edition of Tips and Topics? Would you like to explore the Archives of 12 years of back issues? Have you been forwarding Tips and Topics to friends and colleagues? You can point them to sign up so they directly receive each edition in their inbox. Now you can access directly at http://www.tipsntopics.com

 

2. Here’s an opportunity to pause in the middle of each week – to evaluate and recognize how your daily choices can bring joy to your life. Check out the free weekly storytelling of Don Kuhl, Founder of The Change Companies.
Go straight to: http://www.mindfulmidweek.com

 

3. Now for something fun, intriguing yet stimulating. Check out the antics of the world’s most powerful superhero! He is learning the science of self-help. His stories are based on actual theories of behavior change; they reveal how supernatural abilities are no match for how everyday people make changes in their lives. Scott Provence, Vice President of Product Development at The Change Companies is the inventor.
Go to: http://www.illsaveyouandotherlies.com

Until next time

I’m glad you could join us this month. See you again in late March.

David

Vol.12, No.12

Welcome to the many new subscribers to Tips and Topics. Hello to all for the March edition. 

David Mee-Lee M.D.

SAVVY

Last week, I had lunch with Laura and some of her care management team. Laura is a 46-year-old transgender person (not her real name nor age) who from a very early age was aware that she was not in sync with her assigned gender identity. While born with male sex characteristics and assigned a male identity as Larry (not his real name), Laura, for most of her life, assumed the outside presentation as a male gender. She sometimes felt like she was acting as a male identity for her work and public persona, however was not really stressed or impaired by those gender identity issues.

 

What Laura was more interested in talking about was how she was doing well with her substance use disorder and recovery while also doing well as a transgender woman – a transgender individual who identifies as a woman.

 

Before I met Laura, I was not sure she really was as untroubled by the combination of her addiction and her gender identity issues as was reported to me by the care management team. After hearing her story of addiction and recovery, I was persuaded she indeed did not suffer from Gender Dysphoria as presented in DSM-5 (2013). The previous relevant diagnosis in DSM-IV-TR was Gender Identity Disorder. But not all people who assume a gender opposite to what was assigned at birth are distressed.  So in DSM-5 the focus of the new diagnosis, Gender Dysphoria, is on people who are impaired and in pain over their gender identity. This dysphoria is what creates the designation as a disorder, rather than the identity issues themselves.

 

TIP 1

Distinguish between gender dysphoria and gender identity issues

Gender Dsyphoria in adolescents and adults is a diagnosis characterized by “a marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least 2 of six criteria.”(DSM-5, 2013, page 452). The diagnostic criteria revolve around a strong desire to assume a gender identity, expression or behavior different from those of the opposite gender assigned at birth.

 

What makes the difference between the current diagnosis (Gender Dsyphoria) and the previous Gender Identity Disorder? The current diagnosis points to the presence of: “clinically significant distress or impairment in social, occupational, or other important areas of functioning.” Laura certainly has a strong desire to be “of the other gender” and “to be treated as the other gender.” She has very understanding and supportive parents. Her personality style is one that’s engaging and she radiates resilience. In addition, she lives in a more accepting environment. Due to these factors, Laura has rarely been distressed or impaired in any way by gender identity clashes.

 

Even with supportive parents, it is understandable how Gender Dysphoria develops. Listen to the compelling story of “A Mother Comes To Terms With Her Transgender Child” in a March 16, 2015 segment of National Public Radio’s Here & Now program. You will hear how the dysphoria develops and then is resolved, as Mimi Lemay struggled with the journey of her daughter Mia towards becoming her son, Jacob.

http://hereandnow.wbur.org/2015/03/16/trans-son-letter 

 

TIP 2

Become familiar with current Transgender Terminology

 

The National Center for Transgender Equality updated terminology in their January 2014 glossary of terms.

http://transequality.org/issues/resources/transgender-terminology 

 

Here are a few highlights to note:

  • “Transgender is correctly used as an adjective, not a noun.” e.g., “transgender people” is appropriate but “transgenders” is often viewed as disrespectful.”
  • “Trans” is shorthand for “transgender”.
  • “Transgender Man: A term for a transgender individual who currently identifies as a man (see also “FTM”).”
  • “Transgender Woman: A term for a transgender individual who currently identifies as a woman (see also “MTF”).”
  • “Gender Identity: An individual’s internal sense of being male, female, or something else. Since gender identity is internal, one’s gender identity is not necessarily visible to others.”
  • “Transsexual: An older term for people whose gender identity is different from their assigned sex at birth who seeks to transition from male to female or female to male. Many do not prefer this term because it is thought to sound overly clinical.”
  • “Cross-dresser: A term for people who dress in clothing traditionally or stereotypically worn by the other sex, but who generally have no intent to live full-time as the other gender. The older term “transvestite” is considered derogatory by many in the United States.”

References:

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

 

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

 

Gee, Beck: “Treating Trans” Addiction Professional, March 2, 105

Access at: http://www.addictionpro.com/blogs/nalgap/treating-trans

 

Transgender Terminology, National Center for Transgender Equality. Up dated January 2014.

Access at: http://transequality.org/issues/resources/transgender-terminology

SKILLS

Have you noticed how there is more in the media about transgender individuals -whether that be the journey of Chaz Bono, the only child of American entertainers Sonny and Cher. She was born Chastity Bono and is now a transgender man. Or more recently Bruce Jenner, the former U.S. track and field athlete and current television figure, as he transitions to be a transgender woman.

 

Transparent is an American comedy-drama television series produced for Amazon Studios that debuted on February 6, 2014. The story revolves around a Los Angeles family and their lives following the discovery that the person they knew as their father, Mort, is a transgender individual. (Wikipedia).

 

TIP 1

When treating transgender people in addiction treatment, are your policies and procedures designed with “understanding the humanity of Trans individuals”?

 

In his article, Beck Gee emphasizes the need to see Trans people as “individuals who struggle with addiction just as any other person.”

http://www.addictionpro.com/blogs/nalgap/treating-trans 

 

Here are some of the points his article raises:

  • Does your paperwork assume that the sex the client was assigned at birth equals their gender? Does the gender box indicate male or female? Or is there room for a person to define their own identity?
  • When deciding where to place a person – in the male or female section of the program, could you let the transgender person decide where they feel most comfortable?
  • How safe do Trans people feel in your services? Do all clients feel safe and accepted, including Trans people? “Do you have gender-neutral bathrooms…Is your staff trained properly, from facility maintenance to Nurses to Techs to CEOs?”

 

TIP 2

The ASAM Criteria’s multidimensional assessment provides a good “review of systems” to include all relevant clinical factors in treating transgender individuals.

 

In finding the balance between the focus on addiction recovery and transgender considerations, clinical issues in each Dimension include, but are not limited to:

 

Dimension 1: Acute intoxication and/or withdrawal potential    

  • Does the Trans individual use alcohol and other drugs to cope with any dysphoria over transgender issues and/or is the client’s use simply addiction in a person who happens to be a transgender individual? (Laura said clearly that her addiction was causally unrelated to her transgender issues and I discovered that I agreed with her.)

Dimension 2: Biomedical conditions and complications

  • Is the person contemplating or undergoing Sex Reassignment Surgery or hormonal therapy to develop sex characteristics of the gender to which they are transitioning?
  • If hormonal therapy, is it affecting other physical health areas? (Laura joked about how initially the hormonal therapy she was taking gave her an intimate understanding of “PMS – premenstrual syndrome”.)

Dimension 3: Emotional/behavioral/cognitive conditions and complications

  • Distinguish between gender identity issues and gender dysphoria. Not everyone who faces the incongruence between their assigned gender at birth and the gender they feel most drawn to be, are distressed to the degree of meeting diagnostic criteria for a disorder.
  • Review the following with the transgender person: What needs and problems are arising due their gender identity issues? What strengths, skills and resources might a client have which protects them from dysphoria? (Laura had temperament and resilience along with supportive parents and an accepting environment which explained her non-distress in her transgender journey.)

Dimension 4: Readiness to Change

  • At what stage of change is the transgender individual at regarding their addiction versus their gender identity issues?
  • How much are they able to focus on addiction recovery versus their stage of transgender transition?
  • How does the treatment team balance a focus on transgender issues versus addiction recovery? (Laura was ready to focus on addiction recovery after some initial ambivalence; she was not feeling a need to focus on transgender issues. It is easy for treatment teams to get distracted by the transgender issues.)

Dimension 5: Relapse/Continued Use/Continued Problem potential

  • To what degree does gender dysphoria contribute to relapse or continued use or problem potential?
  • As with any co-occurring disorder, can the individual and team treat both disorders as primary disorders needing ongoing monitoring to reduce flare-ups?

Dimension 6: Recovery Environment

  • Are there any family members or significant others who are helpful to the transgender individual in their addiction recovery? Are family or significant others problematic to the transgender person?
  • Are there any school, work and other social concerns related to transgender issues? (Before Laura openly declared her female identity, she said that dressing as Larry  in men’s suits and ties at work felt incongruous and like she was “acting” for many years.)
  • How understanding are self-help/mutual help groups to transgender individuals in addiction recovery?

Whether you use The ASAM Criteria or not, these dimensions structure a holistic perspective of all people, including transgender individuals.

 

References:

Gee, Beck: “Treating Trans” Addiction Professional, March 2, 105

Access at: http://www.addictionpro.com/blogs/nalgap/treating-trans

 

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’ll have to check the Archives of 12 years of Tips & Topics (TNT) editions to see if I have ever written a SOUL section on Sex before. I don’t think I have. Some readers tell me that when they receive TNT in their inbox, the first section they skip to is SOUL. (With “Sex” in the Subject line of this month’s email, I expect a lot more skipping!)

 

It’s satisfying that readers enjoy this section, because SOUL is probably the part I enjoy writing the most…..I can just let it flow, without the requirement to be too academic, checking author references, articles, papers and the scientific literature.

 

But back to sex. Having talked to Laura about her transgender journey, I began thinking how sex, gender identity, gay rights, same-sex marriage, transgender, cross-dressing and on and on are so much in the media all the time.

 

Sex in advertising has been a long-held tradition that still keeps on working to capture most people’s attention. A skimpily-clad woman has nothing to do with gas mileage and engine capacity of an automobile, but somehow they always seem to be present (or draped around) cars at the auto show or in car advertisements.

 

Like religion and politics, sex is one of those topics tricky to maneuver in social intercourse….that’s “social” intercourse, not “sexual” intercourse. Everyone has had experience and knows what you are referring to. Yet it is a topic we all tiptoe around with everyone, except your most trusted friend, lover or ally.

 

Some male politicians have been known to denounce the evils of homosexuality, only to be caught being intimate with a male staff member. Or after declaring their support for family values and faithfulness, it is discovered they are having a baby with their journalist lover. Governors have lost face and their positions over sex. Presidents have damaged relationships and trust over sex, not to mention millions of marriages languishing in barrenness or ending in divorce over sex.

 

I haven’t talked about the wonders of sex and the joys and ecstasy of sex. I wonder if you’ll have to wait another 12 years for that edition of SOUL.

 

Enjoy.

Until next time

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

David

March 2016

Vol. #13, No. 12


In this issue

Criminal justice reform; treatment and functional change; sanctions and incentives

David Mee-Lee M.D.


(more…)

Upcoming conference; 14 minutes at Longwood University; Stump the Shrink

Vol. #14, No. 7

David Mee-Lee M.D.

SAVVY AND CONFERENCE ANNOUNCEMENT

Upcoming Conference:

If you’d like to come to sunny California soon for the 7th Western US Journal Training Conference October 24-26 2016, in Newport Beach, CA, The Change Companies is featuring a “Justice Services Track” for all those who work directly within the Justice System. I will be speaking and attending. And there is much more – take a look at

http://www.usjt.com/Conferences/2016/7th-Annual-Western-Conference-on-Behavioral-Health-and-Addictive-Disorders/ 

Hope to see you there.

David

Earlier this month, I got an email from Kevin Doyle, Ed.D., LPC, LSATP., who is a “longtime counselor in substance use disorder treatment, now Assistant Professor in Counselor Education at Longwood University in Farmville, Virginia. If “Longwood University” sounds familiar, but you aren’t quite sure why you remember the name, it is because it was the site of the October 4 Vice-Presidential Debate.

Kevin was asked to give one of about 10 faculty talks that afternoon as part of Longwood University’s debate-related activities. He talked about “Addiction and Public Policy” and covered many topics that I have written and spoken about before – only he covered them not in a day’s workshop, but in 14 minutes. You can see his presentation at: https://youtu.be/5UP5njyders

Since the Presidential election is heating up to a fever pitch, I thought a summary of Kevin’s points would keep us in the election mood, since he was up close and personal to at least the VP candidates. And by the way, Kevin is an “avid reader of Tips and Topics, which I enjoy very much.”

TIP 1

Review how attitudes and terminology about addiction, perpetuates stigma

Kevin reviewed many points about stigma and the way the public, payers and providers view addiction treatment. Here is his list with some comments I added:

1. How we perpetuate stigma – we talk of “addict” and “alcoholic” instead of saying “a person with addiction or a substance use disorder” – Use person-first language

The most recent Tips and Topics on this is September 2015:

https://www.changecompanies.net/blogs/tipsntopics/2015/09/

2. When a person goes for help for treatment, we say they were “sent to rehab” instead of “they are seeking help for a condition or a particular problem.”

The public, payers and policy makers and even treatment providers think addiction treatment is doing a set length of stay in “rehab” – a residential program from which the person will graduate and complete. Some insurance benefit plans then limit the number of “rehab” admissions to two, 30-day episodes a year, instead of understanding an addiction treatment continuum of care.

3. Families and clients sometimes say “We tried treatment and it didn’t work”. But if a cancer patient tried chemotherapy and the cancer recurred, most would try it again or certainly not give up on treatment and dismiss it.

With addiction, families and even physicians feel that if treatment hasn’t cured the person, then treatment doesn’t work and it’s no use going back to treatment.

4. “Treatment is a waste of time unless the person really wants it” – few people wake up and spontaneously say this is the day for recovery. Most people getting into addiction treatment have some external pressure or loss that prompts them to seek treatment and may even say “I don’t need this. I’m no worse than anyone else. I can stop any time I want.”

Expecting people to show up fully ready for recovery from day one before treatment is available, is a good way to decrease case loads and not help people. Treatment’s job is to attract people into a change process and recovery by using motivational enhancement methods.

5. “We need to lock those people up and they can learn their lesson that way” – Society responds to addiction with a criminal justice, punishment perspective.

Happily there is a bipartisan recognition and effort to see addiction treatment as a cost-effective way to increase public safety and decrease legal recidivism and crime rather than to just incarcerate those with addiction.

 6. When a person gets a urine drug screen result that is positive for a substance(s), we say they have “dirty urine” – We would never say a patient had “dirty cholesterol” and scold or sanction them for their laboratory result.

If a person’s urine is “dirty”, what does that imply? They are “dirty” too and we perpetuate stigma and discrimination.

 

TIP 2

Note how payers perpetuate stigma by policies that don’t see addiction as a disease

Payers’ policies often don’t treat addiction as a chronic disease process needing treatment.

1. “We can’t pay for residential treatment until there has been an outpatient treatment failure.” Instead of allowing a person to go immediately into a level of care that is needed, such a “fail first” policy expects a clinically inappropriate level of care to be used first.

We would never expect a person with diabetic coma to try outpatient diabetic dietary changes before admitting them for a diabetic crisis. We would never expect a patient with a heart attack to try weight loss, exercise and stopping smoking before admission to the cardiac care unit. It is true that if a person is safe to do treatment in an outpatient setting, that level of care should be tried first rather than residential care. But if they need residential treatment from day 1, then they should not need a “treatment failure” in outpatient first.

2. “Sometimes people are penalized for doing well”.  If a client is progressing well, payers expect the person to be transferred to a less intensive level of care and limit further reimbursement for care. Providers feel it is then necessary to play games by reporting their client is not doing well in order to assure ongoing payment for treatment. 

The solution is to explain honestly, the progress a person is making. But then the provider has to convey what clinical severity still exists that needs services that can only safely be delivered by more time in the current level of care before transferring them.

3. “Burdensome processes for accessing benefits that lead to longer waiting times and put barriers in place to get someone into treatment.” When someone is ready to access treatment, waiting lists and appointments several days and even weeks away work against treating addiction as the disease it is.

 

TIP 3

Now note how providers perpetuate stigma by policies that don’t treat addiction as a disease

1. “Length of stay is not individualized according to the needs of the client.” – 28 day programs based on insurance coverage, not based on severity of illness and progress in treatment. Adolescent treatment program design has added 2 weeks for a 42 day program because adolescents can be difficult to treat; and cookie cutter programing expects all clients to need and do the same interventions e.g., everyone has to go to Alcoholics Anonymous. For some it might not be the best fit for a mutual help group as powerful and effective as it is for others. 

2. “Kick people out for violating the rules and boundaries of the program.” For example discharging people for using substances on a pass when addiction is characterized by loss of control of use – that is what addiction is that needs more treatment, not discharge. 

3. “Inappropriate contact between clients can get clients thrown out because of a moralistic sense instead of this being a disease process” e.g., clients found holding hands – “Should we discharge them?” Kevin’s staff once asked. 

4. “Treatment programs may be only open from 9 -5 in OP; or only open Monday-Friday.” This doesn’t fit the needs of people with addiction who are using at all hours of the day and week. This is another example of how providers do not adhere to a therapeutically-based approach.

5. “Even people in recovery can perpetuate stigma by using terms like “sober”, “clean” or “straight.” These are “good and bad” and “positive and negative” stigmatizing moralistic terms rather than empowering terms like “I am a person in long-term recovery” (“Anonymous People” film). Such terms work against a public health and treatment approach to addiction.

 

TIP 4

Consider these Addiction and Public Policy Issues

Public policy implications:

1. Be aware of these stigmatizing terms and avoid using them.

2. Treat addiction like the chronic disease that it is and compare with what we do for other chronic diseases like diabetes, asthma, heart disease and hypertension. Some say “but addiction is different because there is choice involved in using substances.” But with other chronic diseases people make diet and lifestyle choices all the time that affect the progression of their disease and their recovery. For example, 70% of cardiovascular disease can be prevented or delayed with dietary choices and lifestyle modifications (Forman D, Bulwer BE, Curr Treat Options Cardiovasc Med. 2006;8:47-57) 

For more facts and figures on lifestyle change, see the October 2015 edition of Tips and Topics:

https://www.changecompanies.net/blogs/tipsntopics/2015/10/

3. Individualize treatment for the variety of needs that people present with.

4. Eliminate waiting lists.

5. Respond to relapse from a treatment perspective not punitively. 

6. Negative consequences can motivate change e.g., an encounter with the legal system can motivate a person to seek help, so there is no need to pamper people or not hold them accountable for their behavior. But treatment is the response for someone who has addiction that results in illegal or bad behavior, not punishment.

“From uncomfortability comes change” said one of Kevin’s mentors. 

SKILLS AND STUMP THE SHRINK

More and more states are looking to The ASAM Criteria to help reorganize their addiction treatment system. I wrote about these changing forces in the August 2015 edition of Tips and Topics

https://www.changecompanies.net/blogs/tipsntopics/2015/08/

TIP 1

Understand ASAM Criteria Level 3.1 and 3.5 and Moving from Program-Driven Services

Here are some excerpts from questions about New Hampshire’s residential levels of care and my response about the true content and spirit of The ASAM Criteria levels of care.

Dr. Mee-Lee,

Hello, my name is Paul Kiernan. I am the clinical services specialist at the Division of Behavioral Health for the State of New Hampshire. You and I had exchange emails some time ago regarding helping us better define the clinical requirements for level 3.1, Clinically Managed Low Intensity Residential, a level of care provided by several agencies that are contracted with us. We are having a bit of difficulty that I was hoping you could shed some light on.

The contracted agencies we work with are required to provide services consistent with ASAM Levels of Care. The problem we are encountering is determining what services fall under the scope of the level of care (these issues are being encountered in levels 3.1 and 3.5 primarily) and what services are above and beyond this and therefore can be billed as separate services. Many of the agencies are providing Recovery Support Services with groups such as Smoking Cessation, Managing Anxiety, Importance of Self-Care, Money Management, jewelry Making, Designing a resume and Self-Empowerment to name a few. Recovery support services are listed under both levels of care but frequency is not defined.   The contracts state that the contractor will provide services in accordance with ASAM Criteria, which leaves us with a bit of ambiguity. Any support or direction you could offer would be greatly appreciated.

Paul Kiernan, LADC Clinical Services Specialist

Division for Behavioral Health

Bureau of Drug and Alcohol Services

Clinical Services Unit

Concord, NH

Email address: paul.kiernan@dhhs.nh.gov

 

My response:

In Level 3.1, the person is getting at least 5 hours of clinical services per week. Since 3.1 is more of a 24 hour living support level, I can see that any formal individual or group clinical services could be charged separately because a person could be living in 3.1 but getting services in an outpatient (OP) agency separate from the 3.1 site.

The kind of 24 hour counseling support that is part of 3.1 would be provided under the 3.1 daily fee, because there should be trained staff there on a 24 hour basis, who can handle informal counseling support to someone who is having, for example, cravings to use at 11 PM or 2 AM and needs someone to talk to. But if there are formal clinical services like a group or individual session in 3.1, then that can be provided onsite or in collaboration with another OP service agency.

Recovery support services are not referring to Jewelry making. Helping with money management, resumes and vocational counseling if needed by the client on their treatment plan could qualify as a clinical service for Dimension 6, Recovery Environment, needs and be counted in the five hours or more of clinical services.

The daily fee for Level 3.1 would be lower than 3.5, Clinically Managed High Intensity Residential, which is for people who need 24-hour services because of imminent danger and instability. Sessions like Money Management, Jewelry making, Designing a Resume would not be in a Level 3.5 treatment plan that should be focused more on stabilization of imminent danger and preparation for continued care in less intensive levels of care. Because 3.5 is 24 hour care, the daily fee should be higher and include any formal individual and/or groups clinical sessions in the daily fee and not unbundled as in Level 3.1.

So the frequency of clinical services is not defined in the ASAM Criteria book for either level 3.1 or 3.5 as in 3.1, it depends on the severity and function of the person and the needs in their individualized plan. In 3.1 it has to be at least 5 hours/week to distinguish 3.1 from a general recovery home, halfway house or Oxford House. 3.1 clients are more severe needing the availability of 24 hour living and counseling support plus at least five hours of formal clinical services.

In 3.5, clients need 24-hour care and therefore formal and informal counseling sessions and supports all included in the daily fee. Again, frequency of sessions in 3.5 depends on the level of instability of the client and what they need to be stabilized sufficiently to continue care in a less intensive level.

Paul’s Reaction to my Response

You helped clarify a misconception I had about the 3.1 level of care and also got me thinking about what patients are appropriate for what residential levels of care and what interventions are appropriate for those patients.

We have really been trying to move to a more patient-driven system of care and have specific language in the contracts stating that patient stays are treatment plan/patient driven. Treatment plans have to be personalized and the levels of care must follow ASAM guidelines. The reality is that these are, and continue to be, program-driven with arbitrary assignments and Evidence-Based Practices (EBPs) implemented with no real evidence that they are clinically appropriate for the particular client.  

In the past year I have really immersed myself in understanding ASAM clinically but also in philosophy. One of the things that I will be working on is development and implementation of a comprehensive plan to help our contracted agencies become patient-driven. Any support along the way we be greatly appreciated. I find it very difficult to articulate how grateful I am for your input.

Thank you

TIP 2

ASAM Criteria Level 3.3 and Dealing with Behavior Problems

Another question from Paul

On another note I would like to pick your brain on Level 3.3, Population Specific High Intensity Residential Level of Care. We have none in our great State of New Hampshire and this seems to be a level of care a lot of folks who “fall through the crack” may benefit from. Patients who are not meeting criteria for psychiatric admission, but cannot function in a typical patient milieu. Patients who have behavioral problems who end up getting discharged for rule infractions (throwing things at staff, cursing at staff, stealing from other patients, stealing medication and hiding it in there room etc). For now, we have been trying to get folks set up with Co-Occurring enhanced 2.1, Intensive Outpatient or 2.5, Partial Hospitalization where there are less restrictions and it is easier for them behaviorally. Obviously problems arise when dangerousness and lethality are high. Wondering if you have any suggestions of other states that are doing this well or what a good 3.3 would look like? Also if the interim solution I mentioned is a good idea for now.

My response:

I know 3.3 is tricky and I don’t have a mecca state for you to go to. But I would make the distinction that 3.3 is for people with cognitive difficulties and Traumatic Brain Injury (TBI) that makes it hard for them to be in a typical milieu. In contrast, patients who have behavioral problems may or may not be having those because of cognitive issues like TBI. Rule infractions can be caused by multiple reasons including, but not limited to:

1. Programs that are more focused on phases in a program-driven system where patients advance by being compliant with rules. “Breaking rules” is seen a behavioral problem requiring behavioral contracts, rather than assessing why the person “broke the rule” and making this part of an individualized treatment plan.   It may help to look at Tips and Topics, Volume 10, No. 11 February 2013

https://www.changecompanies.net/blogs/tipsntopics/2013/02/

2. A patient may be mandated to a program and is not really doing treatment and just “doing time”. If the program is not skilled in Motivational Interviewing and stages of change work, they are going to be more focused on rule breaking and compliance instead of engaging the person in a “discovery” plan rather than a “recovery” plan for which the patient may not be ready. Such a person would be better treated in OP levels unless in imminent danger and then in 3.5 only for the time they are unsafe and unstable. Working with a person who is more interested in getting off probation than in getting into recovery and using residential levels for that work is a setup for rule breaking and the revolving door of discharging people for bad behavior.

3. If there are issues in Dimension 3, Emotional, Behavioral or Cognitive Conditions or Complications, that are causing a person to “break rules”, then the focus should be on assessing what the Dimension 3 problem is and what to do about it, not discharge. If it is an issue in Dimension 5, Relapse, Continued Use or Continued Problem Potential, and the person is willing to change their treatment plan in a positive direction, treatment continues as stealing medication and trying to get and use drugs is normal for people with addiction.

This behavior is not about rule breaking, but about the cravings of addiction. If the person is not interested in treatment, and just thinks they can have fun while “doing time” then discharge or court sanctions are appropriate, not for having used, but because they are not interested in treatment, as evidenced by not participating in a reassessment of what went wrong and changing their plan in a positive direction to get a better outcome next time they get a craving to use. In other words “rule breaking” should be assessed as a bad outcome needing a new treatment plan.

(See Appendix B on Dimension 5 in The ASAM Criteria (2013).

4. It may be that a program has too many rules trying to control behavior rather than assess six dimensional needs and do individualized treatment. Residential levels should focus on preparation of people for OP services not seen as a place for a total life makeover in residential.

Yes, there should be more OP levels that can take people with co-occurring mental disorders and addiction (COD) and for those in early stages of change who need motivational services. We should use residential only for people who need 24-hour services to be imminently safe. So developing levels 1, Outpatient, 2.1 and 2.5 that can be more enhanced and complexity capable is not an interim solution, it is an important solution in an array of approaches.

Paul’s Reaction to my Response

Dr. Mee-Lee,

You helped clarify some misconceptions I had about the 3.3 level of care. During the Quality Assurance (QA) of the treatment plans, these are exactly the types of things I am encountering. On one treatment plan the goal was actually “the client will reduce feelings of shame and improve self-esteem”. I don’t think that goal is Specific, Measurable, Achievable, Realistic, or Time-Limited (SMART)

One of the many obstacles we deal with is clinicians’ knee jerk reaction to treat cases as imminent danger. So many people are dying that folks ignore or misinterpret imminent danger criteria C (“the likelihood that such adverse events will occur in the very near future, within hours and days, not weeks or months.” – The ASAM Criteria 2013, pp 65-68; 420) and are treating their own anxiety. As a result, patients end up in what appears to be an inappropriate level of care. So we have been engaging our providers in a community of practice to help them sharpen their ASAM skills and in a lot of cases teach them a basic understanding.

I have to be honest, prior to the newest edition I was one of those who just did the 1 page checklist! We have done 2 webinars consisting of an overview of the 6 ASAM Criteria dimensions, severity rating, withdrawal management, levels of care, treatment planning and a special Paul Kiernan soap box lecture on what really constitutes imminent danger. 

A point I stressed during these is that just because two patients have a high severity rating in dimension 5 for example, does not mean that they are going to have the same treatment plan. One patient may be using because they do not like dealing with negative emotions and another patient may just really like getting high. Another patient may have absolutely no internal dialogue prior to using (perhaps a red flag to revisit dimension 4, Readiness to Change) where the other person has a real internal struggle. 

These are some of the things that we are working on in hopes of moving providers to a patient-driven model.

Again I am so grateful for your correspondence.

Cheers,

Paul

Reference:

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.

For more information on the new edition: www.ASAMcriteria.org

SOUL

Warning: The following is an unpaid, unsolicited, political opinion. If you are definitely voting for Donald Trump as President of the United States of America, please stop reading. I do not want to argue with or alienate you. I value you as a Tips and Topics reader and more. 

But if you are undecided, you may be interested in my thoughts and concerns. These are not academic political science observations, but just my opinions that you could rightly take with a grain of salt:

1. President of the United States and leader of the free world requires intelligence, integrity, political experience and knowledge of how political systems work. While it is understandable to think career politicians are the problem, I have always favored change from within, rather than blowing things up and radical change from without. It is easy to see solutions when on the campaign trail, but much harder when faced with the real negotiations and issues when in actual office e.g., Barack Obama declared he would close down Guantanamo Bay and meant it. But easier said than done.

2. For any job, especially a highly complex position that requires interfacing with many systems, countries and personalities, I would only consider candidates who have some demonstrated experience in the duties, dilemmas, challenges and complexities of the position. Hilary Clinton apparently delivered on a consensus, collaborative and across-the-aisle style when she was a Senator; and slogan or not, I favor “Stronger Together” than “Build a Wall” type politics.

3. How a candidate has defined their life’s mission and occupied their actual work energies, tells me whether there is a consistency in what they stand for and believe in. Have they demonstrated a commitment to public service or to causes that are consistent with public service? Has their work and systems experience encompassed the kinds of challenges they will face as President? Do the values of their life’s work speak to compassion, integrity, honesty, and fair play; or to materialism, adversarial power plays, bullying and self-centeredness? Is there a value of “it takes a village” or “I alone, can make things great again”?

4. Finally, you have almost certainly heard about the infamous audio and video of Donald Trump bragging about kissing and groping women because as a star, you can do whatever you want. If you don’t know what I’m talking about, see the link:

http://talkingpointsmemo.com/livewire/trump-lewd-comments-women-2005-hot-mic

I give many workshops and keynotes and have often been the featured speaker at a conference. What would you think of my integrity and values; my leadership and presentation content if I were to say that because I’m the keynote speaker I could kiss or grab any woman I wanted at the conference; and then say that if I didn’t do that, it was the woman’s fault that she wasn’t attractive? I am no star and I am not running for President. But I am mystified that millions are not fazed by Donald Trump’s demonstration of distorted values, lack of respect, abuse of power and failure of integrity.

I rarely speak my mind about politics, but in this case, I felt compelled to speak up. I hope you will vote – for whomever your conscience says has the skill; compassion and integrity; and knowledge, character and values to be President of the United States.

Until next time

Thanks for joining us this month . See you in late November with President Clinton or President Trump.                                                                                                                                               

David

Compliance, adherence, Stump the Shrink on treatment courts, Biopsychosocial

Vol. #15, No. 4

Welcome everyone to the July edition of Tips & Topics (TNT).  Glad you could join us.

David Mee-Lee M.D.

SAVVY, SKILLS & STUMP THE SHRINK

You may have heard people described as either “lumpers” or “splitters”. Lumpers look at a certain topic and like to lump information together into as few categories as possible to keep it simple. Splitters like to dive deeply into a topic and tease apart more of the details into a variety of split categories.
Usually in Tips and Topics, I split apart SAVVY, SKILLS and STUMP THE SHRINK to tease apart some knowledge content, assessment, treatment and administrative skills, and challenging questions readers have sent. This month however, I lumped them all together because the comments and questions that drive the content for this edition encompass all three categories.
  • The first two questions/comments are follow-ups from the June edition of Tips & Topics and the article on rethinking discharge categories in substance use disorders treatment. If you missed it, here is the link:  Tips & Topics June 2017
  • The second set of questions/comments arose from the recent Annual Training Conference of the National Association of Drug Court Professionals (NADCP) held in National Harbor, Maryland July 9 -12, 2017.
TIP 1
Distinguish compliance from adherence when considering discharging people from treatment.
Compliance:
  • Merriam-Webster’s dictionary defines ‘comply’ as follows: “to conform, submit, or adapt (as to a regulation or to another’s wishes) as required or requested.”
  • Compliance names and labels participants based on participant behavior.
  • Compliance and following the rules assumes that actual treatment and change is happening. It also assumes that increasing compliance by the person means a good prognosis and successful long-term recovery.
  • However compliance often means “doing time” in a treatment setting rather than “doing change.” It doesn’t necessarily mean treatment has actually been successful.
Adherence:
  • Adherence has quite a different meaning from compliance in various dictionary definitions. According to one dictionary, adherence is to “stick as if glued, maintain loyalty, as to a person; or follow without deviation” (Ogden, 1999, p. 221).
  • Merriam-Webster’s defines “adhere” as “to hold fast or stick by or as if by gluing, suction, grasping, or fusing; to give support or maintain loyalty; to bind oneself to observance.”
  • Treatment adherence allows for treatment plans to be individualized to the specific needs and strengths of the client, not tied to a “one size fits all” program rules and phases.
  • If the treatment plan makes sense to the participant and helps them get what they specifically want, they will more likely stick to it and hold fast.
  • Compliance (versus adherence) with treatment allows a participant to “go through the motions” in a program, not being held accountable for working on whatever is needed to change attitudes, thoughts and behaviors to advance public safety.
 
Question No. 1
David-
I read your TNTs all the time and I definitely agree with you about not discharging patients from treatment. When we have discharged patients, sometimes they die from overdoses.   But what do you do with the person who cannot stop using alcohol, cocaine or illicit benzodiazepines? We offer further treatment but they don’t cooperate. They miss appointments. Do you discharge them then?
 
Judy Dischel, M.D.
Stanley Street Treatment and Recovery
386 Stanley Street
Fall River, Massachusetts
My first response to Judy
Hi Judy:
Thanks for writing and it is a dilemma when patients are hard to engage into treatment. If the person is in imminent danger of overdosing then you have the right and obligation to commit them against their will until stable e.g., someone who has intense cravings, will not agree to treatment . You assess they are very likely to continue to use in a dangerous life-threatening manner over the next few hours and days (not weeks or months, as that is not imminent.)
But if there is not imminent danger, and they are not interested in treatment, then the next intervention to try is to see if there is any leverage from family, significant others or anyone who has power in the person’s life e.g., supports them financially or in their living situation; or an employer; or partner and love relationship.
By working with any significant others, it might be possible to intervene and get a person into treatment to receive motivational enhancement therapy backed up by the leverage of the significant other. If there is no leverage, then basically you have to “Serenity Prayer it” as there is only so much you can do. We are dealing with a deadly disease that sometimes wins, even when we have done all we can.
Hope this helps a bit. No magic answers I’m afraid.
David

 

Judy’s first response
Still, would you kick them out of treatment while you’re saying the Serenity Prayer?
My second response to Judy
Judy, it isn’t a matter of kicking them out of treatment. If the person isn’t changing their treatment plan in a positive direction, even if in tiny steps, then they are not doing treatment, just “doing time” and are choosing not to accept treatment.
Think of it this way: if the patient is not interested in changing their treatment plan in a positive direction when their outcomes and progress are poor (e.g., using substances but not interested in doing something different to learn from that use), then the person is not doing treatment and is “kicking themselves out of treatment”. So you would discharge them (if not in imminent danger) since they are not interested in treatment.
If patients just sit there and don’t do anything different, then you are, in effect, saying to people that it is OK to sit in a program and not do treatment. So I wouldn’t want them to blame you for “kicking them out”, but rather they have decided they are not interested in doing an improved treatment plan. They have a right to be uninterested in treatment and so leave.
It may sound like semantics, but it puts the responsibility on the person to do treatment or choose not to do treatment, which is their right and OK for them to leave.
Hope this helps, but let me know if not.
David
Judy’s final response
Perfect, David, I hate letting people go from treatment, given the dangers, but they do seem to have an adverse affect on others. I really appreciate your time in responding to me.
Judy
Comment from Scott Boyles, LAC, MINT Trainer
Scott Boyles is a long time colleague and friend and is a licensed addiction counselor and the National Training Director for Train for Change Inc. His career has included inpatient and intensive outpatient counselor, clinical director and director for over three decades in the behavioral health field. Scott has passion and expertise in system change approaches to support implementation and use of evidence-based practices. For over two decades, he has been a consultant and trainer, with a focus on the ASAM Criteria, individualized treatment planning, clinical documentation, and motivational interviewing strategies.
His comment relates to the June article on rethinking discharge categories in substance use disorders treatment.
Hi David,
Great article! Raising awareness around Discharge Category (DC) terminology seems like a unique and powerful lever in driving systems change, amongst other things. One of the other classic DC terms, “Received Maximum Benefit,” was the ultimate in implying poor compliance, but not poor enough that we could use “Discharge at Staff Advice”.
 
Or sometimes “Received Maximum Benefit,” actually meant “we kept them for the whole program and they just never changed”, cool part is we got paid anyway…
Thanks,
Scott
My response to Scott
Thanks, Scott. Yes, we thought about putting in Received Maximum Benefit, but wondered if that was still in wide use. Your explanation was quite apt (and funny/cynical) because it captures the all-too-often practice that treatment is all about getting clients to comply with the rules, regulations and phases of the program.
David
Scott’s response
A program reacted to my comment about the Maximum Benefit discharge category when I was training a couple weeks ago in Oregon. The provider explained to me their Criminal Justice contract measured and expected an 80% completion rate based on a fixed length of stay in the program. This is a legitimate and unfortunate truth in their argument for the impossibility of having a variable length of stay (LOS).
 
Contracts and business models are another prong of the system that also drives the “old” measures and discharge categories. Maybe you could do a future piece in TNT on contracting (what’s the product and how is the quality measured?); and business models to support the variable length of stay, person-centered, partnership model.
Take care,
Scott
My Further Comments
Scott is right. Even if counselors and clinicians recognize the need to move to person-centered, collaborative and individualized treatment, the system issues often work against what we know creates lasting, sustainable, positive change.
Here are a few examples:
  • Administrators more focused on filling beds or treatment slots to stay profitable.
  • Contracts and so-called quality measures which require an 80% completion rate.
  • Such expectations perpetuate a program, fixed LOS model rather than expecting measures to track engagement across a flexible continuum of care, with a focus on improvement in function, rather than compliance with program behavioral rules.
TIP 2
Recognize that sanctions and incentives, punishment and reward belong to a narrow behavioral modification approach to addiction treatment.
Here are three questions arising from the NADCP conference earlier this month. They point to Drug and other Treatment Courts’ focus on behavior modification as the primary treatment approach in addiction. The American Society of Addiction Medicine (ASAM) describes addiction as a brain disease that certainly has behavioral manifestations. But behavior modification is just one possible tool in what should be a wide variety of recovery-oriented treatment tools to attract participants into lasting positive change.
Question No. 1
Hi,
I just attended the NADCP Conference with Dr. Mee-Lee and after reviewing my notes I never got a chance to ask him a question – if you could pass along this email to him that would be helpful, thanks.

We talked a lot about sanctions, discharge or suspending – as well as individualized treatment plans and the difference between “doing time” and “doing change.” I think individualized treatment is crucial to the client getting anything out of treatment (I won’t say success because I am aware that treatment doesn’t necessarily correlate with success from this disease)…. But for a while, our court was doing general sanctions (for example: missed therapy = 1 day in jail, missed urine screen = positive test and loss of clean time, missed curfew = 8 hours of community service, etc.).  
 
Then, it started to shift more towards individualized sanctions (for example: person X was late for a urine screen but ended up taking one later so the judge said it was confirmed negative so no loss of clean time, when person Z lost their clean time with the same scenario…. Or person X relapsed for the 4th time but because they are honest and upfront about it they don’t go to jail. But person Z had a positive screen and won’t admit to use so they will go to jail for lying).
Do you think this damaging? We previously tried to remain consistent with sanctions for specific things but then it became more individualized and then the group compares themselves out to one another. Or they say “It’s not fair because I’m telling the truth that I didn’t use, the cup was just positive” and it’s hard to verify this so we have to go by the lab…. Any thoughts?
Also, you mentioned Discovery, Dropout Plans… I am really interested in seeing some examples of these and how they differ from Recovery, Relapse Prevention plans. Since you mentioned that some folks never stopped using long enough for a Recovery, Relapse Prevention plan, I feel like this might be a really great thing to incorporate for folks who are more ambivalent.
 
Thanks for addressing this. I think it’s really important discussion to bring to my team.
Lanier Meeks Yi, MA, NCC
Arlington County Drug Court Therapist
Phone: 703-228-5214
My response to Lanier
Thanks, Lanier for these more in-depth questions. Here are some thoughts and suggestions:
1. When you were doing the “general sanctions” that were more formulaic, standardized and predictable (e.g., missed therapy = 1 day in jail) it can seem to be fair and consistent rules. One problem is that this places all the emphasis on compliance with rules and regulations predicated on a behavior modification approach to “treatment”.
2. If the goal of treatment is to improve attitudes, thinking and behavior and address all of the specific aspects of a participant’s functioning which interferes with public safety and reoffending behavior, then treatment is more complex than reward, punishment and behavior modification.
3. You may remember the importance of assessment of biopsychosocial severity and function using the common language of six ASAM Criteria dimensions to determine needs/strengths in behavioral health (The ASAM Criteria 2013, pp. 43-53).
1. Acute intoxication and/or withdrawal potential
2. Biomedical conditions and complications
3. Emotional/behavioral/cognitive conditions and complications
4. Readiness to Change
5. Relapse/Continued Use/Continued Problem potential
6. Recovery environment
4. When you recognize each person has different strengths and vulnerabilities, then it’s obvious each participant needs an individualized treatment plan to achieve successful outcomes.
E.G. if one person has post-traumatic stress on Dimension 3 and chronic pain on Dimension 2, their treatment needs will be different from another person’s priorities. E.G. Another person may have great difficulty with cravings to use on Dimension 5 and no supportive friends on Dimension 6. Their plan is quite different. A one-size-fits-all behavioral modification sanction plan doesn’t translate into lasting change.
5. Your shift to “individualized sanctions” seems like the right direction, however the “individualization” is based on criteria such as, complying later with a missed drug test, or admitting a mistake and being honest etc. This type of individualization can be too subjective leaving the team vulnerable to sanctioning one participant because they weren’t honest enough or fast enough. This then sets a tone of having all participants focused on who can get around the system more craftily than the next person.
6. Effective individualization is based on the specific unique needs of each participant. Each person is responsible for good faith effort in working on their own treatment plan with adherence, rather than focused on compliance with rules and regulations.
What then is fair for every participant? It is not what sanction they receive for the rule they broke. Rather fairness is that everyone is sanctioned for the same reason. That reason? When a person is not working in good faith on their individualized treatment plan which is designed to improve function and public safety. That is the distinction.
7. If there is a missed therapy day or drug screen, right away you assess what went wrong (e.g, participant overslept or used a substance and was afraid to be tested.) Learning from that poor outcome, the person fashions a new and improved treatment plan to wake up on time, or how to resist cravings to use. If they work to make changes in a positive direction, then no sanction is necessary. Only when someone is not interested in changing their treatment plan in a positive direction, is it then that they receive a graduated sanction.
8. The focus now is not on comparing one individual’s sanction with another, looking for uniformity and “fairness. ” Rather the attention is on what the participant is working on with effort and accountability.
9. Lanier asks if it is “damaging” to have “individualized sanctions” metered out in the the way she described? For example: person X was late for a urine screen but ended up taking one later so the judge said it was confirmed negative so no loss of clean time, when person Z lost their clean time with the same scenario…  I do think both “general sanctions” and your new direction draw attention away from holding participants accountable for adherence to their own treatment plan. It keeps participants’ focus on rules and regulations, compliance and concern with sanctions rather than on demonstrating real change in attitudes, thinking and behavior and pro-social functioning.
10. As regards Discovery, Dropout Plans for a start look at Tips & Topics June 2003:
A “discovery”, dropout prevention plan can use strategies like:
  • “Ask two old timers at an AA meeting why they think you may have an alcohol problem simply because you got two DUIs. Report back to group” or….
  • “Keep a log of all the times you are late with your curfew. See if you parents are on your back more or off your back when you are late”.
Also, see Tips & Topics February 2010:
Tips & Topics February 2010
Question No. 2
Dr. Mee-Lee;
This is a follow-up to our discussions at the “Meet the Expert” ASAM Criteria roundtable last day at the NADCP annual conference.

By way of re-introduction, I am a former prosecutor who is currently working on a project to determine compliance with the requirements of Pennsylvania’s DUI statute. That law requires that each DWI offender undergo a preliminary screening and, if warranted [repeat offender, BAC > .16], a full drug and alcohol assessment prior to disposition of the underlying criminal case. In the course of the review, we reviewed the process of collaboration/consultation between the criminal justice and treatment systems.

During our discussions, I raised concerns expressed by both judges and probation/parole officers present at the table, regarding the quality of status reports provided to them by the treatment providers. Our statute provides that the sentencing order require the defendant to “participate in and cooperate with drug and alcohol addiction treatment”.   The statute also requires the treatment program to report periodically to the assigned parole officer on the offender’s progress in the treatment program. The treatment program shall promptly notify the parole officer if the offender: (1) fails to comply with program rules and treatment expectations, (2) refuses to constructively engage in the treatment process, or (3) without authorization, terminates participation in the treatment program.  

Our state also has confidentiality provisions that provide that information released to the criminal justice system [judges, probation officers] Is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following”: (1) whether the client is or is not in treatment; (2) the prognosis of the client, (3) the nature of the project, (4) a brief description of the progress of the client and (5) a short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
These regulations are given as the reason for the very general descriptions in treatment providers’ status reports such as “client is compliant with the treatment plan.”
You indicated that you may be interested in further discussing the issue in a future edition of your “Tips and Topics”.

If you need any additional information, please don’t hesitate to ask.
All the best,  
Jerry Spangler
Pennsylvania Department of Drug and Alcohol Programs.  
My response to Jerry
Yes, Jerry, I have heard from many judges and probation/parole officers their dissatisfaction with the quality (or lack of quality) of status reports provided to them by the treatment providers.Regarding your confidentiality provisions list and its 1-5 criteria, here is more detail on what treatment providers could provide which would not violate confidentiality, yet provide more meaningful status information:
Our state also has confidentiality provisions that provide that information released to the criminal justice system [judges, probation officers] Is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following”:    
“(1) whether the client is or is not in treatment”
  • This should encompass a report as to whether the client is actively adhering to an individualized treatment plan designed to improve attitudes, thoughts and behaviors that increase public safety and enhance lasting accountable change.
  • Just sitting in groups or handing in an AA attendance log is not being “in treatment”.
  • The status report can indicate if the participant is working in good faith on doing treatment and change or just “doing time” complying with rules, phases and program-driven behavioral expectations.
  • If a treatment provider works with a client to engage them, yet the client continues to passively comply instead of actively work on changing, then a graduated sanction should be discussed with the participant and the treatment court team.
” (2) the prognosis of the client”
  • The status report should indicate if the client is changing in attitude and function, working on that person’s unique mix of strengths and vulnerabilities.
  • If the participant is not working in good faith on actual positive, lasting change, then the prognosis is shaky.
  • This should be discussed with both the participant and court team. This expresses that the client has not yet demonstrated sufficient change in function to decrease public safety risk.
  • If the participant is working hard on improved function, this predicts a better outcome. That information should be shared in a status report also.
“(3) the nature of the project” 
  • Does “nature of the project” refer to the highlights of the treatment plan without the need for intimate confidential details? If so, then the status report should outline those highlights – e.g., the client is working with his ambivalence about the severity of his substance use; or the client is exploring how strong are her parenting skills given she wants to get her children back.
” (4) a brief description of the progress of the client” 
  • Progress is measured not by the client attending all groups and complying with urine drug testing. Progress is measured by whether the client is actually changing in function, attitudes, thinking and behavior towards recovery and public safety.
  • Details on every up and down of a client’s progress is not necessary or useful. But the status report should be clear about whether the client is making progress towards positive change that is sustainable.
“(5) a short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse” 
  • If flare-ups of addiction have occurred (like any poor outcome in any illness) the next step is assessment as well as a change of the treatment plan in a positive direction, learning lessons from the relapse.
  • If the client has learned what went wrong, changed their treatment plan in a positive direction, then that information is what the status report should reflect.
  • If the client is not interested in changing in a positive direction and learning from the flare up, the client is now not doing treatment. This should be in the status report and be discussed for a possible graduated sanction.
I hope it is clear that providers’ status reports such as “client is compliant with the treatment plan” are inadequate, incomplete and need improvement. Concerns about confidentiality does not explain, justify or excuse such flimsy status reports.
Question No. 3
Hello Dr. Mee-Lee,
I was lucky enough to attend two of your wonderful workshops at the National Association of Drug Court Professionals conference and got so much out of each. I’m a therapist in a Drug Court.
I have a few questions for you if you have the time and I certainly understand if you don’t.
My first question is about our policy with high and low creatinines. We changed labs a few years ago and now every random urine drug screen has creatinine levels. We’ve been told the normal range is 20-300 mg/dL. For a level below 20, we give a warning letter for the first time and consider the second and all subsequent lows a positive drug screen test, which can mean jail, returning to a lower phase, change of sober date, 60/60 (60 AA meetings in 60 days), etc. For a high, above 400, we give a warning on the first test result; do daily urine drug screen tests for a week on the second test result above 400; and consider a third and all subsequent highs positives with the typically tough sanctions.

I’ve read and attended workshops and corresponded with Paul Cary, the major proponent of creatinine sanctions. As far as I can tell, he cites only one study for the lows and none for the highs. We certainly have clients who water-load to avoid detection of use and may have clients who supplement with creatine. However, many of our clients with highs and lows have no positive urine screens before or after the highs or lows.
 
Do you have any thoughts on this problem? I have many clients who appear to be really working a recovery program who are terrified about getting highs or lows. I also wondered if you have a toxicologist who you’d recommend my corresponding with on this subject?
My other question is about Vivitrol (trade name for extended release, injectable naltrexone), which we use with many of our alcohol and opioid clients. Sometimes the judge orders the client to take it-for a year-when the client doesn’t want to. What do you think about that?

All my best and thanks again for your extraordinary service on behalf of clients everywhere.
TD
Therapist in a Drug Court
My response to TD
Before I respond to TD’s important questions, here is some information on creatinine levels. Since I am not expert on urine drug screening tests and interpretation, I turned to Dr. Google. If you are an expert and I got it wrong, please let me know.
  • Creatinine is a waste product of creatine, an amino acid contained in muscle tissue and found in urine in relatively constant quantities over a 24-hour period with “normal” liquid intake. It is filtered out of the blood by the kidneys and some amounts are normally secreted into the urine.
  • Therefore, urine creatinine can be used as an indicator of urine water content or as a marker identifying a specimen as urine.
  • A normal result is 20-300 mg/dL in urine.
  • Creatinine level varies based on a person’s size and muscle mass. Below normal creatinine levels indicate that a person has been drinking excess fluids. Such a reading is a red flag in drug tests because it signifies that the person tested has attempted to tamper with the results by disguising other active by-products that would have otherwise been detected.
  • In other words, the creatinine levels determine whether or not a person is trying to cheat on a urine drug test. Most laboratories now perform advanced screening procedures that verify whether there has been adulteration or dilution. In the case of the latter, when the urine sample is too diluted, the results are normally labeled as “inconclusive.”
  • Why Is Creatinine Being Analyzed in Urine Drug Tests? The accuracy and reliability of urine drug test results depend heavily on the validity of the urine specimen.
  • When the specimen is pure and free from adulteration or substitution, those who rely on the results of the analysis can be assured the reported outcome is precise.
  • Adulteration or tampering with the specimen in order to alter the drug test results to produce a false negative is a known practice among drug users. A common way to do is by adding some products such as bleaching agents or detergents to the urine sample.
  • Another method is to conceal the metabolites or by-products of the ingested drugs by consuming excessive amounts of fluids or taking diuretics in an attempt to “flush” out the metabolites and “dilute” the urine.
  • The best way to check for “dilution” is to analyze some urinary characteristics such as creatinine levels.
Another resource:
ASAM has developed the “Appropriate Use of Drug Testing in Clinical Addiction Medicine” document to provide guidance about the effective use of drug testing in the identification, diagnosis, treatment and promotion of recovery for patients with, or at risk for, addiction.
 
TD, here are some thoughts and suggestions:
1. Urine drug screens and creatinine levels are laboratory tests for addiction, like any other lab test in assessing the severity and treatment for any health condition.
2. Lab test results have to be interpreted in the context of the participant’s history, gender, current health conditions and signs and symptoms. Lab test results do not stand alone, and should not be the final answer on a person’s health and well being.
3. Creating sanctions based solely on a lab test result is against good clinical practice in tracking the progress in any disease and health condition.
4. When you say “I have many clients who appear to be really working a recovery program who are terrified about getting highs or lows.” This is a good example of what happens when the focus is on compliance, rule breaking and sanctions rather than on demonstrating positive, sustainable and lasting change (recovery).
5. Even if a client does attempt to tamper with a drug test, the treatment provider should look as much at themselves as the client.
  • What type of culture and treatment atmosphere have we created such that clients feel the need to play games and cheat, rather than be honest about any flare-up or relapse?
  • Do we offer this explanation? While substance use in treatment is never good, if it does happen, it is important to raise that and get help. This is exactly like a depressed person who becomes suicidal. We teach them to reach out rather than hide the depression flare-up.
  • Have we created a ‘gotcha’ attitude to urine drug testing and a ‘police state of affairs’, rather than a treatment healing environment where we expect progress in treatment rather than perfect abstinence?
6. For a toxicologist with expertise about lab tests and addiction recovery, I suggest you contact the American Society of Addiction Medicine and contact any of the members of the Expert Panel who developed the “Appropriate Use of Drug Testing in Clinical Addiction Medicine”.
7. As regards Vivitrol – “Sometimes the judge orders the client to take it-for a year-when the client doesn’t want to.”
  • This is an example of a judge or any court personnel working outside their scope of practice.
  • In addition, the best predictor of good outcomes is the quality of the therapeutic relationship. This means agreement on goals and agreement on strategies and methods, within the context of a safe, trusting working relationship.
  • What if the participant doesn’t agree with the goal of abstinence or the method (medication)? You do not have an alliance. The likelihood of a good outcome is very low.
  • Thus the problem is not only the wrong treatment strategy for the wrong participant, but it is assessed and prescribed by the wrong person working outside their scope of practice. Good intentions don’t produce good outcomes if the alliance and treatment are out of alignment.
References
Adherence. (n. d.). In Merriam-Webster online. Retrieved from https://www.merriam-
American Society of Addiction Medicine (ASAM) “Appropriate Use of Drug Testing in Clinical Addiction Medicine” https://www.asam.org/quality-practice/guidelines-and-consensus-documents/drug-testing
Compliance. (n. d.). In Merriam-Webster online. Retrieved from https://www.merriam-
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.
Ogden, J. (1999). Compliance versus adherence: just a matter of language? The politics and poetics of public health. In J. D. Porter & J. M. Grange (Eds.), Tuberculosis: An interdisciplinary perspective (pp. 213-234). London: Imperial College Press.
Williams IL, Mee-Lee D (2017): “Coparticipative 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

SOUL

Forty years ago this year, psychiatrist George Engel introduced his Biopsychosocial model as a holistic alternative to the prevailing biomedical model that had dominated industrialized societies since the mid-20th century.
Earlier this month, I watched two tennis players in the finals matches of Wimbledon who by tennis standards are “old” – Venus Williams at 37 going for her sixth win and Roger Federer at 35 going for his 8th championship.
I watched Federer win the all time record of 8 Wimbledon tennis tournaments and accomplish his 19th Grand Slam title. I also saw five-time Wimbledon winner, Venus Williams, lose the second set of the finals 6 – 0. Watching them both, “biopsychosocial” crossed my mind.
Although Venus worked hard and was so close to winning the first set and looking like she was headed for victory riding with confidence, she couldn’t win even one game in the second set.
Both players work hard with their physical fitness (Bio). Both have disarmingly calm temperaments and positive outlooks (Psycho). Both have very supportive families and loved ones (Social).
What was the difference between those two champions with such longevity and success in tennis? Who could blame Venus for the impact of two psychological blows?:
  • A month earlier on June 9 an officer at the scene of a fatal car accident was seen telling Venus Williams: ‘You kind of violated his right of way’.
  • The tennis star was at an intersection in Florida when she apparently caused a crash. Jerome Barson, 78, was killed; his wife Linda left with ‘disfiguring injuries’ in the accident.
  • After losing the first set, this same physically fit, socially-nurtured and supported champion could not muster the psychological confidence to win a single game.
The power of the emotions and psychological vulnerability, I suspect, undid Venus that day.
Federer: “Previously I always thought it was just tactical and technique, but every match has become almost mental and physical – I try to push myself to move well. I try to push myself not to get upset and stay positive, and that’s what my biggest improvement is over all these years. Under pressure I can see things very clearly.”
(“Five lessons in success from tennis champion Roger Federer”)
Finding the right balance of bio-psycho-social goes a long way to a happy healthy life – even if you don’t win at tennis.

Until next time

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

January 2018

Vol. 15 No. 10  In this issue India ASAM Criteria Training Transcendental Meditation 5 hearts David Mee-Lee M.D. SAVVY In late November/early December, I made a quick trip to India to do a three day training train on The ASAM (American Society of Addiction Medicine)...

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).

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June 2011 – Tips & Topics – june-2011-tips-topics

TIPS & TOPICS from David Mee-Lee, M.D.
Volume 9, No.3
June 2011

In this issue

— SAVVY   Top 10 reasons to use the ASAM Criteria
— SKILLS  How close your services are to the spirit/use of the ASAM Criteria
— SOUL   R&D – not doing the same old thing
— Until Next Time

Welcome and thank-you for joining us for the June edition.
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December 2005 – Tips & Topics – december-2005

TIPS & TOPICS
Volume 3, No.6
December 2005

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

Happy New Year! By the time you read this, for most it will be 2006. I hope you receive the best gift of all this year – good health. Welcome to all the new subscribers who have joined us since last month. You can browse back issues of TIPS and TOPICS by going to the homepage of www.DMLMD.com . Click on ‘Read Back Issues’. There is also now a printable version of each edition.

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September 2005 – Tips & Topics – september-2005

TIPS & TOPICS
Volume 3, No.5
September 2005

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

A significant number of new readers are joining us this month, so welcome to you. Thanks too, to all of you who have been with TIPS and TOPICS for many months and even years. I appreciate the many comments and messages of appreciation you send me.

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June 2005 – Tips & Topics – june-2005

TIPS & TOPICS
Volume 3, No.3
June 2005

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

Thanks for reading the June edition of TIPS and TOPICS. Welcome to all the new readers who signed up this month.

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January 2005 – Tips & Topics – january-2005

TIPS & TOPICS
Volume 2, No. 9
January 2005

In this issue
– SAVVY
– SKILLS
– SOUL
– SHAMELESS SELLING
– Until Next Time

Welcome readers!

Happy New Year! Actually January is nearly over and it seems 2005 is already in full swing.

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July 2003 – Tips & Topics – july-2003

TIPS and TOPICS
Vol 1, No.3
June 2003

In this issue
– SAVVY
– SKILLS
– SOUL
– SUCCESS STORIES
– Until next time……

WELCOME!

Thank-you for taking the time to read this third edition of TIPS and TOPICS. If you are receiving this for the first time, the April and May editions are on my website. Certainly feel free to forward TIPS and TOPICS to others who may be interested.

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June 2003

Vol 1, No.3 | June, 2003
In this issue


SAVVY | SKILLS | SOUL | SUCCESS STORIES

David Mee-Lee M.D.


SAVVY

There is one assessment dimension of the Revised Second Edition of the Patient Placement Criteria of the American Society of Addiction Medicine (ASAM PPC-2R) that potentially has the greatest impact on how we assess, refer and treat people with substance use and mental health problems. It is Dimension 4 – Readiness to Change. In our field, there is increasing interest in strength-based, client-centered, consumer-driven, customer-focused services that empower clients who come to us to use their own (and community) resources to enhance recovery.

Despite the rhetoric of person-centered services, unfortunately clinicians’ attitudes, knowledge and skills too often create services that are clinician-centered, not client-centered. Many programs and services are designed and dominated by program ideology, referral-source mandates, and funding guidelines. What the client, patient, person, consumer or customer wants- and even needs- are a long second, third or even sixth place concern.

Tips:

  • Many of you are already well versed in Stages of Change models and motivational enhancement strategies. But in case you are not, Procahska and DiClemente’s Transtheoretical Model would be a good place to start.

Here are a few references for that:

Prochaska, JO; Norcross, JC; DiClemente, CC (1994): “Changing For Good” Avon Books, New York.

Prochaska, JO (2003): “Enhancing Motivation to Change”, Chapter 1 in Section 7, Behavioral Interventions in “Principles of Addiction Medicine” Eds Graham AW, Schultz TK, Mayo-Smith MF, Ries RK, Wilford BB, Third Edition. American Society of Addiction Medicine Inc., Chevy Chase, MD.

Prochaska, JO; DiClemente, CC and Norcross, JC (1992): “In Search of How People Change: Applications to Addictive Behaviors” American Psychologist, 47, 1102-1114.

  • People in the Preparation or Action stage are ready to change and are actively doing something about it. They really want to be free of the power of substance and mental health problems over their life. They seek recovery. They also want to prevent relapse into drinking or drugging. They want to stop behaviors like cutting himself/herself, or be free of depression or psychosis. By all means, help them develop a recovery, relapse prevention plan.

However, if the person presents for assessment because they want to stay out of jail, keep their job or their family, treatment is definitely warranted. But, the individual may first need to discover that s/he has a substance use and/or mental health problem before ever being interested in preventing relapse or getting into recovery. In other words, he/she needs a “discovery”, dropout prevention plan; not a recovery, relapse prevention plan! And there is a big difference between the two plans.

  • If you want to educate yourself on the science and skills behind the importance of more person-centered services, check the work of Scott Miller, Ph.D. and his colleagues at The Institute for the Study of Therapeutic Change, www.talkingcure.com. They review decades of outcomes research on how people change. You may be disturbed, yet illuminated on what they find. William Miller, Ph.D. of Motivational Interviewing is the other Miller you will want to read more about.

SKILLS

Every day we face pressures for efficiency, accountability, documentation and performance. It can feel like we do not have the luxury to assess and treat a person’s readiness to change. The courts, child protective services, employers and welfare-to-work can only give so much time for a chance at treatment.

There is a lot of pressure from referral sources to assign a person to a set program that expects quick results in a 30 day, 60 day or 12 month program. Is it really practical to ask a client what they want? Is it feasible to provide services individualized around a participatory treatment plan matched to their particular stage of change? These are dilemmas and hard questions. However the outcomes research data and our clinical “gut” tell us that unless the individual is an active participant in treatment, we are unlikely to really help them to change. We want them to do treatment, not time. We want them to have lasting results in public safety, good parenting, productive employment and social independence.

Tips:

  • If you ask a person “How can I help you? What do you want help with?”- do you really mean it? They may say something like “I want to be clean and sober”, but were just referred by the probation officer or employer. What they really want may be a letter and to stay out of jail or to keep their job; not serenity and sobriety one day at a time. Dig more deeply. Create a therapeutic alliance around what the person really wants, not what they think you want to hear or what you think they should want. Again, they may first need a “discovery”, dropout prevention plan; not a recovery, relapse prevention plan. If you already have a set program and treatment agenda that you are unwilling to adjust, better not to ask them what they want. If you do ask, they might actually want you to listen to what they say!
  • A “discovery”, dropout prevention plan can use strategies like:

>>”Ask two old timers at an AA meeting why they think you may have an alcohol problem simply because you got two DUIs. Report back to group”. or
>> “Keep a log of all the times you are late with your curfew. See if you parents are on your back more or off your back when you are late”.

A recovery, relapse prevention plan may have strategies like:
>>”Go to an AA meeting to get two names and numbers and to find a sponsor”. or
>> “Develop your plan on how not to be late. Ask your group for feedback on how to improve the plan”.

Can you can see the distinction between “discovery” and “recovery” strategies?

  • A treatment plan in which a client participates actively solicits the clients’ ideas on the problem and the solution. People often have strong ideas about what they think will work, or what they will or won’t do.
  • For example: “I don’t want to be in groups, or go to AA, or take medication, or go to residential”.

You can respond several ways.

Response #1: “Do it or else you won’t get your letter”. Or “That’s the program” (and I have a bigger stick than you).
Response #2: You can educate them on the wisdom of your recommendations. If they understand and accept your views, fine. If they remain ambivalent or unconvinced, you may need to start with their plan. If their plan is imminently dangerous, this society allows us to override a person’s opinions and rights.

If dangerousness is not a concern, I’d recommend you start with a treatment plan that only includes strategies the person wholeheartedly agrees to do. This will increase both personal effort and accountability.

A SPECIAL NOTE:

I am pleased to announce the release of a Training Album on this topic I have been discussing.
The training module is titled “Enhancing Motivation: How to Engage People into Addictions Treatment”. This album contains a CD, Videotape and Companion Guide. Read more about it at the link below.

Click here for a time-limited, special introductory offer!

SOUL

Last summer, my family had the privilege of traveling in France, Spain and Italy. Everywhere we went, we continued to be surprised again at how widespread cigarette smoking still is in Europe. As a California resident, (where smoking is not allowed in bars, restaurants and many public places) I was reminded how different cultures and attitudes can be.

A couple of weeks ago, I was in Washington, DC., invited to address a joint European Union/USA meeting on treating the difficult patient at the Office of National Drug Control Policy. The night before, I walked into the hotel sports bar for a light dinner. The place was filled with smoke. I had to quickly move to the less atmospheric, but smoke-free lobby lounge. I was surprised to see how different the culture and attitudes can be – even in the USA.

In the meeting, we compared and contrasted the Europeans’ approach to demand reduction with that of the United States. I was struck again how different we are in culture, attitudes, perspectives and solutions. (Have you ever visited an injection clinic where you can shoot up so long as you bring your own drugs? Clean needles and hygienic clinic supplied!)

It is easy to argue and fight with righteous indignation for the causes and concepts we firmly believe. We should not shrink from standing for what we believe is right. But you don’t even have to travel to Europe, or from California to Washington, DC to face attitude and culture differences. Just notice if the next client or team member agrees with everything you assess or recommend.

What I want and what “the other” wants can often be as different as a smoke-filled room and a crisp, clean morning in Yosemite. Increasingly I want to find effective and efficient ways to achieve results together. Counselor to client. Team member to team member. Care provider to care manager. Administrator to advocate.

It starts with me. Was it Gandhi who said: “Be the change you wish to see in the world”?

SUCCESS STORIES

In the “Skills” section of the first edition of TIPS and TOPICS, I discussed how to organize and present assessment data using the structure of the six ASAM PPC-2R assessment dimensions. One workshop attendee and unofficial supervisee has persevered to discipline himself to stay focused on the client and the assessment.

About his presentations to managed care, he writes this: “My denials from Managed Care Organizations have dropped to almost none. I am able to present myself more cogently, briefly and to properly present the criteria to ensure proper treatment. I have been complimented on my presentation by insurance company reps.” – Paul Herman, M.Ed., Evaluation Therapist, for a large treatment program with multiple levels of care.

Maybe there’s hope we could end the game-playing between providers and managed care companies. Maybe providers can prevent the impulse to exaggerate severity to get authorization of care – e.g., the patient is suicidal. Maybe care managers can resist the reaction to minimize severity; or resort to blanket statements like “it doesn’t meet medical necessity”. I wonder if we could ever start managing care- all of us? It could start with how we organize and present the assessment data.

Until next time

Send us any comments or Success Stories on implementing any of the TIPS and TOPICS. Send any questions to Stump the Shrink. (Tell me how much identifying data you are comfortable with my sharing here.)

All the best…

David

P.S. Time is running out to be part of a select group in a 3 day “Supervisor Intensive”, train-the-trainers workshop in Davis, CA July 30-August 1, 2003.

Learn more about the Supervisor Intensive. Click here.

November 2003 – Tips & Topics – november-2003

TIPS and TOPICS
Volume 1, No. 7
November 2003

In this issue
– SAVVY……..
– SKILLS……..
– SOUL………
– STUMP the SHRINK…
– Until next time……

WELCOME!

Welcome to November’s edition of TIPS and TOPICS. Thanks to all of you who take the time to write to tell me how you are appreciating and using the TIPS and TOPICS with your team and agency. I may not have written you back, but I do read all your messages and am very grateful for your comments and questions.

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May 2004 – Tips & Topics – may-2004

TIPS and TOPICS
Vol 2, No.2
May 2004

In this issue
– SAVVY
– SKILLS
– SOUL
– STUMP THE SHRINK
– Until next time

WELCOME!

Welcome to the May edition of TIPS and TOPICS. Unlike big magazines like TIME where you receive the week’s edition before the date on the cover, this humble effort usually comes late in the month. Finding the “spare time” to get this to you often gets lost in other deadlines. But here it is.

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March 2004 – Tips & Topics – march-2004

TIPS and TOPICS
Vol 1, No.11
March 2004

In this issue
– SAVVY
– SKILLS
– SOUL
– Until next time

WELCOME!

Recently I was training on the ASAM Criteria. I was surprised by some fundamental misunderstandings even from people using the criteria for many years. As you may know, I have been involved with, and chaired the development of the Patient Placement Criteria (PPC) for the Treatment of Substance Related Disorders of the American Society of Addiction Medicine (ASAM) since its beginning in the late 1980’s. For those of you who do not know the ASAM PPC, these are consensus criteria that match people with substance use problems to the appropriate level of care within a broad continuum of services.

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May 2008 – Tips & Topics – may-2008

TIPS & TOPICS
Volume 6, No.2
May 2008

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

Welcome to the many new subscribers to TIPS and TOPICS (TNT). Just a reminder: there are 5 years of Back Issues you can read or download. Simply click on “Read Back Issues” on the homepage of www.DMLMD.com. Coming soon – a revamped website with a Search function to search by topic.

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March 2008 – Tips & Topics – march-2008

TIPS & TOPICS
Volume 5, No.11
March 2008

In this issue
— SAVVY
— SKILLS
— SOUL
— SHAMELESS SELLING
— As a RESULT of your FEEDBACK
— Until Next Time

Welcome to March’s Tips and Topics (TNT), especially to the many new subscribers. As usual we are running late, so this March edition will likely get to you in early April. It is after all, free, so I guess you get what you pay for!

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