May 2003

Vol 1, No.2
In this issue


SAVVY | SKILLS | SOUL | STUMP THE SHRINK

David Mee-Lee


 

WELCOME!

Welcome back to this second edition of TIPS and TOPICS.

The response to the first edition was very positive and satisfying. If you are receiving TIPS and TOPICS for the first time, thanks for signing up along with over a hundred of your colleagues. For a few of you with whom I have had professional contact in the past, I took the liberty of sending this along to you this month. If you would like to keep receiving it, I’ll be happy to send it. But if you are overwhelmed with information already and would rather not receive TIPS and TOPICS free each month, then I totally understand if you unsubscribe (see Unsubscribe link at the very end).

Thanks to all of you who wrote and expressed appreciation and gave feedback. It seems TIPS and TOPICS has already filled a need for many of you. I hope this edition will also be as useful to many.

SAVVY

Over the past month, I was asked to consult about two patients. Between them, both had been hospitalized in acute care medical and psychiatric units five times in the past six months. They were admitted for depression, suicidal feelings and ideation. One had a serious overdose and one even had electroconvulsive therapy (ECT). Alcohol and cocaine were the drugs involved. One of the consultation questions asked of me was this: What should be the focus of treatment given the patient’s poor follow through with treatment, “denial”, and multiple readmissions in a period of months?

In both cases, the substance dependence was correctly recognized as an important element in the patient’s history and treatment needs. However, in both cases, the clinician’s major emphasis was on the mental health problems – partly because those were the most acute presenting symptoms. Very little assessment of the substance use was done to tease apart to what degree the psychiatric symptoms were a result of the addiction problem; or to what degree the symptoms were truly a co-occurring disorder. Both programs were not very savvy about addiction treatment, let alone integrated dual diagnosis treatment.

Tips:

  • If a person is suffering from depression or any other psychiatric presentation, and is actively using alcohol and/or other drugs, specific assessment of both the mental health and substance use is needed. Is there a mental health problem where substance use may be attempts to self medicate the psychiatric disorder? Is this a substance use disorder in which the mental health symptoms are a result of addiction illness? Or is it a true dual diagnosis?
  • It is necessary to understand the difference between Substance Use Disorders and Substance-Induced Disorders. They are both under the category of Substance-Related Disorders (See DSM-IV Text Revision, 2000). This can help tease apart some of these assessment dilemmas.
  • If a person is in an early stage of readiness to change (notice I am downplaying the use of the term “denial”) and demonstrates ambivalence or lack of understanding about addiction, this is an active treatment issue. It is not a reason to exclude a person from treatment, or to provide only passive education about addiction.

SKILLS

Given the prevalence of co-occurring mental and substance-related disorders (dual diagnosis) it is good that both mental health and addiction treatment clinicians are so much more aware about dual diagnosis. However, awareness without clinical savvy can lead to knee-jerk over-reactions. Addiction treatment professionals too quickly can refer a client for a psychiatric evaluation without taking even a little time for more careful assessment and gathering of history data. Mental health professionals similarly can often rush to medicate symptoms before determining if they are looking at a substance-induced disorder or a true dual diagnosis.

Tips:

  • A Substance-Induced Mood Disorder, for example, “is distinguished from a primary Mood Disorder by considering the onset, course, and other factors. Substance-Induced Mood Disorders arise only in association with intoxication or withdrawal states, whereas primary Mood Disorders may precede the onset of substance use or may occur in periods of sustained abstinence.” (Page 405 DSM-IV Text Revision)
  • Take the history and timelines to check the relationship between substance use and addiction problems and the appearance of mental health problems. Not all mood swings are Bipolar Disorder – it could be that the person is using uppers and downers, stimulants and depressant substances. Not all heavy drinking is alcoholic drinking – it may be that the client is drinking at night until he passes out, in an attempt to deal with the severe insomnia of Major Depression.
  • Even after four weeks following detox, people can still have problems with depression, anxiety and mood swings etc. While we want to give people the benefit of medication if necessary, there is also a period of psychosocial adjustment after detox. If an individual has few (if any) positive recovery tools to deal with stress or discomfort- (e.g. dealing with cravings or mood swings) mental health symptoms can still be present after detox. These symptoms may be a part of normal addiction recovery and not positive proof that a co-occurring mental disorder exists.

If you want to learn more about these assessment dilemmas, you can check out the Home Study Course: “Dilemmas in Dual Diagnosis Assessment, Engagement and Treatmentat Professional Psych Seminars, www.psych sem.com.

SOUL

I am writing this section on Mother’s Day at 6:30 AM in a basic, but comfortable tent cabin in Yosemite National Park. What a privilege to be able to drive under four hours to such a place of astounding beauty. But last night, in an incongruous juxtaposition of experiences (sorry for the fancy words) we were in a lodge lounge packed with people cheering on the Sacramento Kings in the NBA Playoffs. If you are not a basketball fan, you would not know that the Sacramento fans are the most loyal and noisy fans in the USA. The Kings lost in double overtime. The prospects look bleak. Chris Webber, the King’s star player, is out for the rest of the playoffs with a torn cartilage in his left knee.

Two games ago, the Kings looked on track to take it all and win the championship this year. Frank Sinatra said it all in his gritty song “That’s Life” – “riding high in April, shot down in May”. In those final minutes of the game, the battle with the Dallas Mavericks seesawed between victory and defeat. Participating in the emotion and passion in the room, you would have thought the most important event in the world was a basketball game. Many of you didn’t even know the game was on, couldn’t care less and won’t ever care.

Outside, the sky is perfectly blue; the air crisp and clear; the sheer granite rocks tower all around us. One can look across the meadow to see Yosemite Falls pounding over the rock face. Half Dome stands huge, tall and impressive. Beside Yosemite’s picture-postcard beauty, we are here to meet up with our college freshman son on a geology class field trip. He gets to hike this grand National Park for two days- and for college credit!

In my view, there’s nothing wrong with the emotion and passion of a tight playoff game. And in the battles over budget cuts, competing theories of treatment, and advocacy for our various rights and noble initiatives, there’s nothing wrong with emotion and passion. But budgets come and go. Theories and rights rise and fall in importance, and basketball games will be forgotten next week. The grandeur of Yosemite, the emotion and passion around our mother and family remain way beyond April and May. I remind myself and perhaps you too, about priorities, perspective and permanence. What really is important? What do you really want for you, your family and the people we serve?

STUMP the SHRINK

Question:

Dr. Mee-Lee:
“I am reviewing a document and they have used the term “substance related” disorder and said they got it from the ASAM material. Is that the official new term? I had just heard two weeks ago that the term was “substance use” disorder. I have been in the field 22 years and have been through a number of these changes and don’t like the former term as it seems to refer to “related” disorders but not necessarily inclusive of substance use directly. Please advise if you have any insight to the “official” terminology. Thanks!”
Jane (real person, but not real name)

Answer:

Dear Jane:
“As regards the term “substance-related disorders”, we are using the language of DSM -IV. Substance-Related Disorders are made up of two categories: Substance Use Disorders (Substance Abuse and Substance Dependence); and Substance-Induced Disorders (Substance Intoxication and Substance Withdrawal and a whole host of other Substance Induced Disorders like Alcohol Induced Depression; or Amphetamine Induced Psychosis etc.) So it depends on the patient and their presentation as to what their diagnosis is. In the ASAM Patient Placement Criteria, we use all of the terms depending on what the history and assessment reveals. In other words, the term “substance-related disorders” is not replacing substance use disorders. ” Substance-Related Disorders” is the overarching DSM-IV chapter for both addiction disorders and for psychiatric disorders induced by substances. These substance-induced disorders are psychiatric disorders that are “related” to the substance, but are not the specific addiction or Substance Use Disorder (Abuse or Dependence). Check out the DSM and it should make sense, but let me know if not.”

Until next time

I would welcome any Success Stories on implementing any of the TIPS and TOPICS, or any questions to Stump the Shrink! Send those along. Just tell me how much identifying data you are comfortable with my sharing in this ezine. All the best until next time.

David.

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.

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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April 2003 – Tips & Topics – april-2003

Why I started this Ezine!
>> Clinicians have ongoing clinical questions that need answers!

I have been training and consulting for over 25 years, but fulltime for nearly the last seven years. I travel the country & get repeated requests for answers to questions on the American Society of Addiction Medicine (ASAM) Patient Placement Criteria and other topics. People ask about books, videos and audio learning materials they can obtain. They want help to implement and apply knowledge and skills presented in one or two-day workshops. An Ezine is one way to answer those common questions and requests more efficiently.

>> To help people apply new-found knowledge!

Budget deficits are hitting almost every state. Attending a workshop can change one’s knowledge and skills immediately. However, fewer can afford to take the time and funds to learn onsite at a workshop. Continual learning is essential, but a challenge to achieve without some ongoing prompting, supervision or assistance. An Ezine is a vehicle to provide supplements and support to previous workshop attendees, or to those who have so far been unable to get to an onsite training.

>>Because I want to make a difference in our field!

Out of sight, out of mind! I want my work to make a real difference in providing, managing and funding person-centered services. An Ezine is a channel available to stay in touch and keep making positive changes in our work. It is a way to feed “Tips and Topics” to healthcare providers sincerely interested in applying concepts and skills to change( for the better) the way we serve people in behavioral health.

What to expect from the Ezine
>> You will receive it once a month.
Please forward it to other interested individuals. Suggest that colleagues sign up on my website.

>> It will be a relatively brief communication.
While, on occasion, I may excerpt or include material from other sources (appropriately referenced of course), most material will be original and be focused on practical tips and topics in the following areas:
— implementation of the ASAM Patient Placement Criteria;
— providing and documenting individualized person- centered services;
— clinical and systems issues to do with co-occurring mental and substance-related disorders (dual diagnosis);
— ways to engage, empower and collaborate with people in getting what they want and changing what they want.

>> There will be 3 Sections: SAVVY, SKILLS, and SOUL
Each section will hopefully imrpove who we are as professionals and as people – it’s not just about “doing”, but also about the “being”!
“Savvy”- to improve our knowledge, wisdom and practical grasp of topics;
“Skills” to focus on tips to improve practical competence;
“Soul” to enrich a person’s total self – both yourself and others;
>>From time to time, I will add in “Successes” & “Stump the Shrink”
In “Successes”, I’ll share what has been working for you and others in the practice of “doing” and “being”.
In “Stump the Shrink”, I will focus on questions and dilemmas you and others face in the “real world. ” I’ll try to answer them; or perhaps I’ll be stumped for a good answer.

>> YOU CAN EXPECT THE NEXT ISSUE TO BE MUCH SHORTER.

So enough introduction. On with it!

August/September 2003 – Tips & Topics – augustseptember-2003

TIPS and TOPICS
Vol 1, No.5
August- September 2003

– SAVVY
– SKILLS
– SOUL
– STUMP the SHRINK
– SUCCESS STORIES
– Until next time

WELCOME!

I have been in summer vacation mode, so this August edition of TIPS & TOPICS is a little later than usual. In fact, since this is already September, I’ve decied to give myself a break and give you less mail to read. So this is now an expanded August-September edition which has the usual sections, with two additional sections that appear periodically – “Stump the Shrink” and “Success Stories”.

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December 2003 – Tips & Topics – december-2003


TIPS and TOPICS
Vol 1, No.8
December 2003

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

WELCOME!

Holiday greetings everyone! Thank you for reading this December edition of TIPS and TOPICS. I enjoy sharing some thoughts with you each month. I am glad that many of you find some tidbit to help you think about the work we do for the people we serve.

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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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October 2003 – Tips & Topics – october-2003

TIPS and TOPICS
Vol 1, No.6
October 2003

In this issue

– SAVVY
– SKILLS
– SOUL
– SHAMELESS SELLING
– STUMP the SHRINK
– Until next time

WELCOME!

A TIPS & TOPICS reader recently asked about information on adolescent treatment. I realized that many of you are working with youth and adolescents, and we have not addressed your needs specifically thus far. So for everyone who works with adolescents, or has ever been an adolescent, this edition is for you.

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