January 2013

Vol. 10, No. 10
In This Issue:


SAVVY
Integrated and Collaborative Care improves care and costs
SKILLS
Why physicians, clinicians and counselors struggle to integrate and collaborate
SOUL
A father’s fears

David Mee-Lee M.D.


 

 

SAVVY

The debate over what to do about guns in the USA has not faded. It so often happens a topic is hot for a few weeks and then disappears as new “breaking news” competes for attention. But I will not saturate your attention this month with some readers’ responses to the December issue on guns – we’ll share those in a future edition.

Instead there’s a couple of healthcare topics that have been close to my heart for many years, and they have been getting more and more attention in the literature. I’ve been writing about them in Tips and Topics for the past decade. I believe these principles are clear and important; nevertheless I am also increasingly aware that many physicians, other healthcare professionals, clinicians and counselors do not share that view. Not only do they not share these values, but some may be outright suspicious and negative about these trends in healthcare.

What I’m talking about is Integrated Care and Collaborative Care.

 

TIP 1

Review your knowledge and values about Integrated and Collaborative Care.

 

The President of the American Medical Association (AMA), Jeremy Lazarus, M.D., who happens to be a psychiatrist, told delegates at the Interim Meeting of the AMA House of Delegates recently:

“It’s a new era in American health care – one that calls for physicians to collaborate with other doctors and health care professionals in a new model of integrated care….Integrated care asks us to cultivate mutual trust, to recognize that each team member offers unique skills and knowledge, and to support this trust with open and timely communication…And we must go all in to improve the quality if health care for our patients and the country.”(Psychiatric News, Volume 47, No. 23, December 7, 2012, pp. 1,9)

–> Years ago Parkside Medical Services had a value: “Everyone has a territory but nobody has a kingdom.” Each discipline and stakeholder has an important contribution to the whole, but nobody knows everything about everything, nor can do it all by themselves.

–> And it isn’t just about physicians collaborating with other health care professionals, it is about addiction counselors and mental health clinicians collaborating with primary care; it is in primary care where most people with addiction and mental health concerns actually show up for health care services.

So what is integrated and collaborative care?

Psychiatrist, Jurgen Unutzer, M.D., M.P.H outlined the following principles of integrated care:

    1. Patient-centered care through close collaboration of mental health and primary care providers. (DML: I would add close collaboration of addiction treatment too)
    2. “Measurement-based treatment to target” – treatments are actively changed until clinical goals are achieved.
    3. Population-based care in which patients are tracked in a registry.
    4. Use of evidence-based treatments.
    5. A system of accountable care in which providers are reimbursed for quality of care and clinical outcomes, not just the volume of care provided.

 

 

(Psychiatric News, Volume 47, No. 21, November 2, 2012, page 5)
http://psychnews.psychiatryonline.org/newsArticle.aspx?articleid=1387816

Does integrated care work?

Dr. Lazarus cited one example of the Southcentral Foundation in Anchorage, Alaska. Patients are assigned to a health care team consisting of a physician, nurse, medical assistants and even traditional healers. Here is how outcomes improved in the last decade:

  • Visits to the emergency department decreased 40%
  • Hospitalizations decreased 75%
  • Routine doctor visits decreased 30%
  • Binge drinking, strokes, heart disease and cancer rates among Alaska Natives are now about the national average whereas before they were much higher.

(Psychiatric News, Volume 47, No. 23, December 7, 2012, page 9)

TIP 2

Collaborative care is also about shared decision-making with patients and clients.

The New England Journal of Medicine (NEJM) published an article “Shared Decision Making to Improve Care and Reduce Costs”. (Emily Oshima Lee and Ezekiel J. Emanuel)
http://www.nejm.org/doi/full/10.1056/NEJMp1209500

  1. “In a 2001 report, Crossing the Quality Chasm, the Institute of Medicine recommended redesigning health care processes according to 10 rules, many of which emphasize shared decision-making. One rule, for instance, underlines the importance of the patient as the source of control, envisioning a health care system that encourages shared decision-making and accommodates patients’ preferences.”
  2. “Randomized trials consistently demonstrate the effectiveness of patient decision aids. A 2011 Cochrane Collaborative review of 86 studies showed that as compared with patients who received usual care, those who used decision aids had increased knowledge, more accurate risk perceptions, reduced internal conflict about decisions, and a greater likelihood of receiving care aligned with their values. Moreover, fewer patients were undecided or passive in the decision-making process – changes essential for patients’ adherence to therapies.”
  3. “Studies also illustrate the potential for wider adoption of shared decision- making to reduce costs. Consistently, as many as 20% of patients who participate in shared decision-making choose less invasive surgical options and more conservative treatment than do patients who do not use decision aids.”
  4. “In 2008, the Lewin Group estimated that implementing shared decision-making for just 11 procedures would yield more than $9 billion in savings nationally over 10 years. In addition, a 2012 study by Group Health in Washington State showed that providing decision aids to patients eligible for hip and knee replacements substantially reduced both surgery rates and costs – with up to 38% fewer surgeries and savings of 12 to 21% over 6 months.”

But what has this got to do with addiction and mental health services?

Longtime readers know how often I have talked about the therapeutic alliance, and how four decades of research indicate that the quality of the therapeutic alliance contributes most to successful outcomes. (Mee-Lee D, McLellan AT, Miller SD (2010): “What Works in Substance Abuse and Dependence Treatment”)

Here is one study’s surprising results:

Patients report benefits from open notes

“Patients involved with the pilot program at Beth Israel Deaconess Medical Center (BIDMC), Geisinger Health System (GHS) and Harborview Medical Center (HMC), who were subjects of an Annals of Internal Medicine study, reported benefits to having access to their physicians’ notes. Very few patients reported confusion or concerns, with the exception of privacy.”

Benefit or risk Portion of BIDMC patients Portion of GHS patients Portion of HMC patients
Felt more in control of their care 84% 77% 87%
Remembers care plan better 84% 76% 83%
Understands health conditions better 84% 77% 85%
Takes better care of self 70% 71% 72%
Takes medications better 60% 78% 73%
Concerned about privacy 36% 32% 26%
Worries more 5% 7% 8%
Found notes more confusing than helpful 2% 3% 8%
Felt offended 2% 2% 1%

Source: “Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead,” Annals of Internal Medicine, Oct. 2 (http://ncbi.nlm.nih.gov/pubmed/23027317/)

Bottom Line
Health care is changing in the USA – both in how it will be delivered and in how we engage patients and clients in shared decision-making. The research evidence is too compelling to keep doing business as usual. One last set of statistics from the Institute of Medicine (IOM) and the National Research Council:

  • The USA health ranks at the bottom among 17 rich countries.
  • Despite spending more per capita on health care than any other country, the United States also ranks at or near the bottom in infant mortality and low birth weight, injuries and homicides, teen pregnancy and sexually transmitted diseases, HIV and AIDS, drug-related deaths, obesity and diabetes, heart disease, chronic lung disease, and disability.
  • Health problems are more common among Americans who are poor or uninsured. But the panel also found that even healthy Americans who are insured, college-educated, or have high incomes seemed to be in worse health than are similar groups in other countries.

http://www.iom.edu/Reports/2013/US-Health-in-International-Perspective-Shorter-Lives-Poorer-Health.aspx

References :
1. Psychiatric News, Volume 47, No. 23, December 7, 2012, pp. 1,9 written by Mark Moran
2. Psychiatric News, Volume 47, No. 21, November 2, 2012, page 5 written by Mark Moran
3. “Shared Decision Making to Improve Care and Reduce Costs” Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D. N Engl J Med 2013; 368:6-8. January 3, 2013
4. Mee-Lee D, McLellan AT, Miller SD (2010): “What Works in Substance Abuse and Dependence Treatment”, Chapter 13 in Section III, Special Populations in “The Heart & Soul of Change” Eds Barry L. Duncan, Scott D.Miller, Bruce E. Wampold, Mark A. Hubble. Second Edition. American Psychological Association, Washington, DC. pp 393-417.
5. “Unveiling the Doctor’s Notes”, Pamela Lewis Dolan. American Medical Association (AMA) News, Volume 56, No.1, January 14, 2013.
6. “U.S. Health in International Perspective: Shorter Lives, Poorer Health” Jan 9, 2013. Institute of Medicine.

SKILLS

So if the research on integrated and collaborative care is compelling, why are some -perhaps many- physicians, clinicians and counselors suspicious and even antagonistic to these changes in health care?

TIP 1

See if you agree with these “people” obstacles to Integrated and Collaborative care.

There are different strokes for different folks and each discipline and health care provider may have different reasons for wanting to maintain the status quo. (In Motivational Interviewing this is called “sustain talk” in contrast to “change talk”.)

Physicians:
Reasons physicians might struggle with the move to integrated and collaborative care:

  • It requires a change in the core values that have motivated physicians – shifting from autonomy to shared decision-making and teamwork (Dr. Lazarus, Psychiatric News, December 7, 2012)
  • For decades, health care was organized and practiced “in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves.” (Dr. Atul Gawande, Psychiatric News, December 7, 2012)
  • Society has rewarded physicians for taking on life and death responsibility with financial and social status. As stressful as great responsibility is, shared power and decision-making requires a major shift and collaborative spirit./li>
  • Physicians have been trained to ask questions, quickly diagnose the disease, prescribe the treatment, often making life and death decisions very quickly. Patients are expected to answer questions, trust the doctor’s judgment and comply with doctor’s orders. And now the doctor is just one of the team and patients get to share decisions!

Addiction counselors:
Reasons counselors might struggle with the move to integrated and collaborative care:

  • Counselors who have come to the profession through their own life experience may have been misdiagnosed by physicians and prescribed psychotropic or addicting medication for years, before finally finding recovery. There is suspicion of physicians, the primary health care and mental health systems that often rejected people with addiction.
  • Addiction treatment has predominantly been abstinence-based with only recent acknowledgement of the possible role of psychotropic medication, opioid treatment services and an array of anti-addiction medications. Many counselors are still very uncomfortable with medication-assisted treatment and recovery.
  • For many addiction program models there has been a strongly held anti-medical, Twelve Step or social model ideology. The Therapeutic Community model, based on social learning theory, holds the power of the community and peers as being much more significant than doctors, nurses and other professionals. The Twelve-Step model has traditionally seen taking medication as “chewing your booze” and invalidating the AA member’s sobriety date. Whole counties and states have in the past prided themselves as being explicitly a social model system antagonistic to the so-called “medical model”. Even if these systems are changing, attitudes persist.
  • Addiction programs see a tiny sliver (1.5%) of the estimated 19.3 million persons aged 12 or older needing, but not receiving treatment for illicit drug or alcohol use. (2011 national Survey on Drug Use and Health, SAMHSA, Sept., 2012)
    http://www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011.htm#1.1With the busyness of waiting lists, limited resources and service demands already, there is little energy or interest to reach out to the millions of people with addiction who are in primary care settings.
  • Federal confidentiality regulations like 42 CFR Part 2 has reinforced separation of addiction and physical health records and flow of information.

Mental Health Clinicians:
Reasons clinicians might struggle with the move to integrated and collaborative care:

  • Insurance payers and managed care organizations have usually “carved out” behavioral health payments and care management from general health insurance. This has kept mental health and addiction fragmented from physical health.
  • The Health Insurance Portability and Accountability Act (HIPAA) and the real or perceived privacy requirements can lead physicians and others to withhold information from those who may have a right to have it. So much for integrated and holistic care!
  • The pecking order of different disciplines, reinforced by differing pay often for similar therapy work maintains boundary, turf and guild battles fighting for a piece of the health care pie.

TIP 2

Check if you can identify with any of these obstacles to Shared Decision Making and Collaborative Care with Clients and Patients.

  • Here’s what one reader asked a while ago:

    “I have been in mental health and drugs and alcohol for over ten years (no not ill or using- helping!) and I am having difficulty understanding why I would allow my client to determine their own treatment, when it is their poor decision-making over the years that have led them to where they are presently: several court cases, social services, probation, children removed from the home, unemployed again etc., so why all of a sudden would they now demonstrate good judgment?…..Would you be so kind as to explain the reasoning again for allowing the client to determine their own treatment?”

    My response:
    Here’s why shared decision-making makes sense especially for someone described as above: All change is self-change and people do what they want to do anyway. If there is to be real change, they have to be the one to choose the healthy choice in the dark of night when nobody is watching. Telling them what to do does not translate into sustainable action, otherwise we could send all our clients memos on how they need to change and to get busy.

  • Some might say:

    “I went to school for all those years, went into debt for the tuition and now have expertise and experience. Are you telling me that my expertise is to take second place to some collaborative care approach with patients and clients who are out of control?”

    My response:
    Shared decision-making with patients and clients isn’t some “touchy feely, politically correct” approach to appease some consumer movement. And it doesn’t mean you abdicate your responsibility and expertise to do a good assessment and share with clients the very best, effective and efficient way to reach their goals. It is a recognition that if accountable, self-propelled change is the outcome you want from your treatment, then the client has to be as engaged and committed to changing as you are. In fact, if you think about your own resolutions to change, it is hard enough to sustain change even if you really want it and know what to do.

    Positive and lasting change has little chance of success if the client doesn’t share the same fervor for the goal as you; nor share the same decisions on how to get there; and doesn’t really trust you anyway.

  • “Righting reflex” – “the desire to fix what seems wrong with people and to set them promptly on a better course, relying in particular on directing” ((Miller, William R; Rollnick, Stephen (2013): “Motivational Interviewing – Helping People Change” Third Edition, New York, NY., Guilford Press. page 6). Clinicians have a hard time resisting the reflexive, clinical response to fix such obvious pathology and poor choices. People who choose the “helping professions” are particularly vulnerable to the “righting reflex”. Motivational Interviewing “guides” not “directs” people to change through collaboration and shared decision making.

SOUL

This morning at 4 AM I was jarred out of sleep with the phone ringing. Being a physician for forty years, it is imprinted to answer the phone and try to think clearly quickly. But I’m not on call anymore and there aren’t any training and consulting emergencies at 4 o’clock in the morning.

So I squinted to see if caller ID would help get me oriented quickly. “Skype caller” it said. Must be my son traveling in Southeast Asia. Fatherly anxiety rising.

“Hello, hello, can you hear me?”

“I’m sick.”

“Tay (Taylor named after James Taylor one of my favorite singer-songwriters just like my son is), Tay what’s wrong and where are you?”

“I’m in Luang Provang, Laos and I’m sick.”

I kicked into doctor mode and took a careful timeline history of symptoms: eating at a supposedly clean tourist-friendly restaurant but still symptoms of diarrhea, lethargy, no appetite; OK the next two days; then some more diarrhea, fever with stomach cramping after taking strong antibiotics.

My initial diagnosis: travelers’ diarrhea related to food contamination complicated by antibiotic side effects. Treatment: water, rest, eat when body says it is ready, avoid risky foods like salad washed in unclean water and uncooked food.

That was 14 hours ago as I write this and no word back, which I hope means “no news is good news”. But I won’t rest well until I know he is really OK. It got me thinking though about all the parents out there with military children and loved ones in harm’s way all over the world.

My son is on a happy adventure. Their children are on a dangerous mission.

I’m worried about food poisoning and diarrhea. They’re worried if their kid will get a limb blown off or suffer from Traumatic Brain Injury, or not even come back home.

A parent’s anxiety for their children’s safety and well-being is powerful, no matter how big or small the danger is. So I count my blessings that, right now, it’s only about diarrhea for this father.

PS. E-mail from Taylor:

“It is 11:41 AM here and just got up and out of the shower. I am significantly better. I woke up around 1 AM and could feel my fever breaking. I have no tummy ache and have an appetite again. I am still very weak and tired though, probably to be expected after 1.5 days of no food and lots of diarrhea. Man, being sick sucks. It really takes it out of you. It is an exciting trip, but you also realize how having your basic health and safety is a must for any type of enjoyment.

We will go out now and get some food and plan our next move. I’ll keep you informed. Thanks for your help and support.
Love you,
Taylor”

Until next time

 

David Mee-Lee M.D.

Vol. 10, No. 12 | March, 2013

In This Issue

SAVVY and SKILLS
Dr. Mee-Lee’s Clichés and what they mean in clinical work and systems change

 

SOUL
First steps – from baby to toddler; and a request reminder for the 10th anniversary edition

 


SAVVY and SKILLS

 

I don’t know about you…. but if you find yourself saving a good article you read, or keeping the notes of a great lecture you heard, it is easy to accumulate boxes and boxes of material over the course of a career.  I wouldn’t classify myself as a hoarder, but you never know when you might want to refer to that article or lecture notes again!Trouble is, you rarely go back through those boxes of pearls of wisdom.  All that valuable material clogs up file cabinets, boxes in the garage or piles on your desk. Or is this just me!?

Anyway, the point is: I am in the process of radical de-cluttering, meaning I am dumping boxes and boxes and boxes- old policy and procedure manuals, yellowed articles pulled from journals and magazines aeons ago, old lecture notes, handouts I knew I would review someday when I had some ‘spare time’….

In the course of that cleansing process trying to achieve good feng shui (look it up on Google), I came across a page of “Dr. Mee-Lee’s Cliches. ” A workshop participant had compiled these as he listened that day thirteen years ago in Phoenix, Arizona. At the end of the day, he handed them to me. I still have his yellow notepad page. I don’t know what the topic was – probably a workshop on the ASAM Patient Placement Criteria, which by the way, we are revising (more on that in another edition of Tips and Topics soon).

So for March, SAVVY and SKILLS is combined.  I am covering some of the phrases on that list compiled by a good listener at my workshop…..or perhaps he was just trying to stay awake by writing stuff down.

TIP 1

Here are some clichés and the meanings and ideas behind them (or at least, my ideas)

Firstly, to say a person is using clichés is not necessarily a complimentary thing to say.

“The term is frequently used in modern culture for an action or idea that is expected or predictable, based on a prior event……A cliché is often a vivid depiction of an abstraction that relies upon analogy or exaggeration for effect, often drawn from everyday experience. Used sparingly, they may succeed, however, the use of a cliché in writing or speech is generally considered a mark of inexperience or a lack of originality.” (Wikipedia).

I don’t see myself as inexperienced or lacking originality. I’ll just ignore that part of the definition of a cliché and focus on the “vivid depiction of an abstraction…drawn from everyday experience.” Here are a few of the clichés that were on the list. I’ll address the meanings and ideas behind the saying as they relate to clinical practice and to systems issues.

1. Turn a blind eye or a deaf ear

Clinical: How often do we see and hear a client saying to us that they are not interested in abstinence, wellness and recovery while we steamroller on with mandates to go to 90 meetings that they don’t like in 90 days? Or comply with medication that gives them more side effects than benefits?

It is as if the focus is on what we think the client should do. It’s like we don’t care what we see in their body language and whether they participate, or not, in treatment. Also it is as though we don’t listen for discord and disagreements they may have with what we are prescribing for them.

Systems: When it comes to systems of care, it sometimes seems they are actually designed to be blind and deaf to the pain of the people we serve.  Do we still provide and fund programs with limited levels of care and inflexible lengths of stay that force us to put people on long waiting lists? Or cause people to call everyday to demonstrate their motivation to access services, even those in severe withdrawal?  Is there no way to see and hear the anguish such waiting lists cause? Can we really not design a better system of care that increases access to care, yet still uses resources efficiently and effectively?

2. Keep their feet to the fire

“Putting someone under pressure. Forcing, or trying to force, someone to do something.”

Clinical: Since all lasting change is self change, forcing change is not likely to last beyond the time you have the “big stick.” But an effective way to reframe this cliché is to hold a person accountable in their mandated treatment experience by focusing on what they really want.

Clinician: “I don’t see, Joe, how you are making a strong case for getting out of 24 hour care when you continue to threaten the staff and get into fights with your roommate. It makes it look like you are too unstable to manage things in the outside community.” This is how to keep clients’ feet to the fire, to stay accountable for their treatment without forcing them to do something.

Systems: The same principle applies if you have staff members more focused on complaining, gossiping, backstabbing or even dragging down morale through negativity and sub-par work. Theoretically you may have the power to write them up and order them to do their work. However if you would rather create a healthy work environment of accountable self-change, there are other ways to keep their feet to the fire.

Do you have a functioning conflict resolution policy, one which empowers people to speak up, advocate for what they believe in, while at the same time requiring respectful communication and resolution? Now there is no tolerance for gossip, negativity or intimidation. It is everyone’s right and obligation to resolve conflicts and keep communication healthy. Do you have effective supervisors who can support supervisees, but also set limits?

3.Keep your eye on the prize

Clinical: Clients and clinicians can easily get distracted into sidetracks that lead nowhere productive. How often do you struggle with clients more focused on telling you how the food or their counselor stinks, how unfair their parents, boss or probation officer are, or how they “don’t even have a problem”? It’s easy for both clients and clinicians to descend into arguments about treatment compliance around medication or rules of the program, and get distracted from “the prize”.

Clinician: “Joe, we can talk all day about how unfair your boss is, or we can put our energy into gathering the data to prove you don’t have an anger or addiction problem. That way we can show her you are a good worker who doesn’t deserve to be fired.”

Systems: Your agency’s mission, I imagine, is to help people achieve their full potential, grow and embrace health and wellness. Yet how focused are you on actually defining and measuring those outcomes for each person? Are you more focused on preserving your particular program model, levels of care, ideology and traditions than on measuring client outcomes to actually demonstrate efficacy and efficiency for the people we serve? Are there struggles between clinical providers and the judge/criminal justice personnel on how to handle positive drug screen results? How can we join together to realize we all want the same outcome: increased health and well-being, decreased crime and recidivism, increased public safety, and safety for children and families?

4.What floats my boat

“An expression which means you can do whatever your preference is.”

Clinical: When working with clients especially severe and chronically mentally ill, it can be challenging to actualize our desire to be strength-based, empowering and recovery-oriented. Our impulse to ‘fix’ what seems so obviously pathological, leads to parent-child type interactions; expert prescriptions on what the client or patient must do; and program and clinician-centered services.

Example: The client who wants people to leave him alone…

Rather than dwelling on his delusions, hallucinations and med. compliance, try conversing and exploring times in his life when he had the freedom and independence to come and go when he wanted, to do whatever he preferred. See if you can reawaken in him what “floats his boat”, turns him onto life. What would inspire him to have hope for joy? Perhaps he wants a job or to return to school for more education. Ask: What worked when you had the job you enjoyed, or attended a school you felt good about?

Systems: It doesn’t matter your role, whether administrator, supervisor or supervisee. Under the cost and time pressures in today’s healthcare system, it is easy to see personal and staff morale plummet. Self-care is not an option. It is an obligation if you are going to be healthily present to serve people – patients and fellow team members. Are you staying in your job out of habit or fear you could fail at something else you might prefer to do? Are you just going through the motions, having lost sight of what attracted you to the job originally? Can those benefits be reawakened? Perhaps the job (or you) has changed so significantly that it no longer matches your needs for fulfillment and meaning?  Self-care may mean re-designing your job or moving on to something that “floats your boat.”

5.A sitting duck

“Something or someone that is easy to attack or criticize.”

Clinical: Have you ever wondered why a client is verbally attacking you for the well-intentioned advice and recommendations you are giving them? As a counselor, isn’t it “my duty” to confront them, point out how their impulse control and anger problems is the cause of their relationship breakdown or legal problems they now face?

Or maybe you don’t wonder why you are a sitting duck. Perhaps you simply tell yourself (and them) that they are “in denial” and need to take suggestions even if they don’t like it. In other words, it is their problem, their resistance, their pathology which explains their anger at you. What’s happening has nothing to do with your approach and interaction with them.

In Motivational Interviewing these “attacks” are evidence of discord (disagreement between two people – you and the client) not resistance (pathology in the client). It is about you and how you engage a person or not, which is as much a part of whether there is discord as it is a problem “in” the client. You’ll be a ‘sitting duck ‘if you always view it as something wrong with the client instead of an interactive process.

Systems: As healthcare reform becomes even more the reality, how you design and deliver services will increasingly be influenced by how you are paid compared to current models. In the current fee-for-service model, you make more money if you provide sick-care rather than health-care. When people are well, don’t need to see you or fill your beds and outpatient slots, you don’t make money. Of course it’s a contradiction: we want people to get well – we don’t purposely try to keep people sick just to fill beds and slots. However, currently, few financial incentives exist to focus more on prevention, or on low-intensity and low-reimbursed outpatient services. The trend to population-based funding and outcomes-driven payment will change that. You and your program will be a sitting duck for loss of business and revenue if you aren’t preparing to move to outcomes-driven services; and ‘health-care’ rather than ‘sick-care.’

–>I hope you discovered some new meaning from old clichés.

SOUL

This month, my granddaughter and only grandchild turned one.  A week later she was taking her first wobbly, yet independent steps.  Soon, no doubt, she’ll be running around.  You would think that with three children of my own, seeing them through all their developmental stages, that this would not be so amazing to witness.  But it is.To see Luna develop from that uncoordinated newborn bundle of love I cuddled just a year ago, to now a walking little person who can wave goodbye, say “ciao,” stand and dance to music with one arm waving high (remember John Travolta, “Saturday Night Fever” style!)- it’s simply amazing.

With the joy of seeing her development, I can’t help but wonder about all the boys and girls her age who don’t have loving supportive parents and grandparents. Who is there for them to hold their hands and comfort them when they cry? Sometimes somebody is there, but sometimes there’s a father or mother passed out in a drug-induced slumber? How can they be emotionally present for this little one, when they are stressed out about how they will get their next meal or are struggling with disabling depression, anxiety or psychosis?

There are an estimated 28 million Americans who are children of alcoholic parents, nearly 11 million under the age of 18. And that is just alcohol-affected children. What about other addictive and mental disorders? Every parent or prospective parent you attract into recovery brings great dividends for the rest of the family.

Have you seen my granddaughter, Luna? (If you want to see more of her dad’s photography, go to http://www.paulodiasphotography.com)

 

P.S. – A request reminder:

Next month is the April Tips and Topics 10th anniversary edition. I’ll publish some of your “appreciation gifts” and celebrate together. So if you are moved to write a brief note of appreciation, or if you remember an edition of a SAVVY, SKILLS, SOUL or STUMP THE SHRINK section that was particularly meaningful or memorable for you, please let me know. Tell me what edition it was in and what was the meaningful part for you.

 

Until next time

Thanks for reading. See you in late April for our 10th anniversary edition.
David

Vol. 11, No. 1

In This Issue
  • SAVVY : Words of appreciation
  • SKILLS : Ten years of anniversary SKILLS Tips
  • SOUL : What a difference in these two 19 year olds
  • SHARING SOLUTIONS : The Anniversary Deal – Tips and Topics book for $10 total

Welcome to the 10th anniversary of Tips and Topics (TNT). Perhaps this is your first edition as a new reader or your 100 edition as a longtime reader. Either way, enjoy this anniversary edition……and my party hat!

David Mee-Lee M.D.

SAVVY

When I turned 30 years old, my wife threw me a surprise birthday party.  It was very thoughtful of her, but I enjoy_ other_ people’s birthday parties. It’s not so comfortable when I’m the center of attention, especially when it’s a surprise.  Now, I’ve gotten a little more comfortable with attention (doing fulltime training and consulting for decades gives you lots of practice.)This month, for our 10-year anniversary of Tips and Topics, I actually _asked_ for readers’ attention!I thought it would be fun (and informative to me) to hear what you appreciate about Tips and Topics.  So here are some of your “appreciation gifts” to me to celebrate 10 years together.  I excerpted from your “gifts” so as not to be too voluminously boring.

Welcome to our Tips and Topics birthday party! (and check out SHARING SOLUTIONS for a special anniversary deal)

TIP 1

See if you resonate with any of the themes of these “anniversary gifts.”

I grouped readers’ comments in like categories….sort of……

Challenging our thinking and sharing TNT with others

What an honor to be asked to share how your efforts with Tips and Topics have impacted us over the years as an anniversary gift to you.

Since first becoming aware of your work and meeting you 6 years ago, I have been a faithful reader of Tips and Topics…….Over the years, I have used Tips and Topics to share with the clinical staff a deeper understanding of how they could assess a caller…  Your ability to bring so many different service delivery providers together and weave the experiences in a meaningful way that makes one stop, think and yes, sometimes even challenge how we think of providing services continued to contribute not only to our development as professionals but also to the benefit of the clients.

I have no doubt that I contributed to adding to your email list because I often encouraged people to make sure they took advantage of having such a powerful resource at their finger tips; especially the interns that I supervised. …I have entered the arena of private practice and the skills I have learned over the years from Tips and Topics come in handy with almost every client.  When I think of the ripple effect of your life works and how many it impacts I stand amazed.

I do have to say one of my favorite aspects is when you share details of your life — from your journeys home to Australia, to your kids and their accomplishments…..And just know that I am looking forward to at least another 10 years of Tips and Topics!

Happy Anniversary!

Theresa Buzek, MS, LPC-S
4009 Banister Lane, Ste 356
Austin, Texas

***

Thank you for the work you do and the newsletter.  I just wanted to let you know I really appreciate it, and pass it along to our staff and my peers in the field

Yvonne Jones, LCSW
Senior Psychiatric Social Worker
CONREP
San Leandro, California

***

Your last e-mail has finally motivated me to write my appreciation to you and your monthly newsletter.  If I receive the e-mail during a particularly busy time at work, I leave it unread until I can make the time to bring my full attention to the tips and topics and have time to contemplate how to apply it to my work and life.  I not only read it myself, but share it with my colleagues and have also forwarded it on to my boss on occasion.  Your thoughts push me to think about how to approach my work differently, to question my current techniques, and how to be an effective clinician (and sometimes parent!).

Thank you very much for all you do.

Stephanie R. Steinman, LPC CSAC
UW Health Gateway Recovery
Madison, WI

***

I am reflecting on your upcoming ten year anniversary, and can hardly believe that you have been publishing this long!!  I recall conversations with you about my interest in searching the archives, long before you had that capability!  Guess that means I am getting old!

I read Tips and Topics fully, and can honestly say that every issue has caused me to pause and think; despite over 30 years in the addictions field, I learn something new each and every time.  I share access with everyone I can, and encourage others to sign up on-line in all of my trainings.    I imagine that this is just one of many competing priorities for you, but know it is thoroughly enjoyed, valued and appreciated!

Dotti Farr   LSW, LADC, CCDP-d
Director of Quality Management
Bucks County Behavioral Health System
Warminster, Pennsylvania

Useful learning and appreciating the TNT edition on Therapeutic Communities

David, we worked together briefly in Delaware and, even in a short time, I learned a great deal from you. I read every edition of your newsletter and wanted to compliment you on the Therapeutic Community article.  You handled the subject productively and ‘gingerly’.  There are probably some who would say you were too gentle but change usually requires persuasion not coercion.

Thanks for your efforts to inform and improve the field.

Colette Croze
Principal, Croze Consulting

Dr. Mee-Lee,

I certainly look forward to Tips and Topics each month, I have yet to read an edition and not get something useful from it. The edition on Therapeutic Community was especially interesting.  When I started working in the field in the late 80s …one of my first experiences was with a seasoned counselor conducting what he called “Gestalt empty chair technique”, but what actually seemed to have as its only goal to have the group make the person cry or storm out of the room…..Things have certainly changed for the better. Thank you for the publication each month.

Dan Adams, MBA, MARS
Assistant Director
Southeast Missouri Behavioral Health
Salem Center

***

Dear David:

My note of appreciation is simple. Somehow, you have a hidden camera in our program, in my office, and in my head. Lest you think that I fit the textbook definition of paranoia, let me say instead that you have, since I started in this position, managed to elegantly publish in your Tips and Topics exactly what I was trying to say just days before in a staff meeting, in a supervision, or in a training. I find myself EVERY month simply forwarding your email to someone else in the program or printing it out for everyone and putting it in mailboxes with a simple….”This is what I was trying to say—he says it so much better”!!!

The best example of this was in Nov 2012 with your response to Ray from Cape Cod.  Being from the “other” large substance abuse agency in Southeastern Mass, I recognized Ray Tomassi of Gosnold and his way of thinking immediately. I immediately copied that article on how we use words and how our words shape our actions and handed it out to everyone in our program—staff and clients alike. It lead to such interesting conversations-not only about those words and actions, but about the role of shame and coercion in treatment. Especially for us as a program that walks that tightrope between voluntary and “court ordered”, we look at issues like relapse and discharge daily—and struggle to be client-focused and evidence-based in our actions and approaches.

The other edition that was so helpful was your Tips and Topics that took on the sacred cow of “Therapeutic Communities”. Technically, we are by our RFR, a “modified therapeutic community”. Given our varied mandates and our population of 100% of our clients with co-occurring other mental health challenges, we find ourselves always searching for the balance between being “client centered and individualized” and “community-based” recovery. As we try to do that while following Motivational Interviewing practices across all levels of the program and integrating as many EBP’s as possible, the core of our model shifts and morphs. For some of us, that is comforting that we are always “making it up as we go along” to be as successful as possible. For others, it creates such panic that “no one is in charge and no one knows what is happening next”. This edition helped calm some of those fears and helped the “old-timers” see that there really is a method in the constantly shifting landscape and that parts of the tried and true will always be a part of what we do.

For the record, we are a pilot program in Mass—the ONE specifically funded year-long program (combination of residential(3 months or so)/community based(9 months)) jail diversion substance abuse treatment program for clients facing incarceration for crimes directly related to substance abuse issues. In year 3 of a 5 year pilot, we have such tremendous support and freedom to try to get it right….and such wise counsel both from our agency leadership and Bureau of Substance Abuse Services to help us be successful and create a program that can be replicated. Please know that I count you as one of our “distance mentors” as well.

Thank you for being part of the knowledge and wisdom that helps shape who we are and what we are doing!

Mary R. Bettley MSW, LICSW
Program Director
Reflections-Court Alternative Program
High Point Treatment Center
New Bedford, Massachusetts

Inspirational, informative and influential

I’ve been a subscriber to your newsletter for a while now….I look forward to its arrival every month. (I confess that I also hoard them.) I’ve been working with individuals who struggle with substance use disorders for over 40 years now and there are a few individuals, including yourself, who I consider to be inspirational. You are those people who I can count on one hand (with fingers left over) who seem to be able to bring “things” into focus for me. I don’t __always__ agree with “you guys” but I love to read everything that you write and I try to hear you speak whenever I can….. I’ve been blessed to consult with other organizations in many states. I try to share your newsletter with as many of these people as I possibly can. You are very inspirational and informative. Sometimes you even manage to interject some humor! Thank you for taking the time to make an investment in my life. I believe that you’re making a difference in our world.

Michael W. Bennett MBA CAP CPP ICADC CCCJS CCFC
8495 Bluestem Court
Jacksonville, Florida

***

Dr. Mee-Lee, I love reading the Tips and Topics even though I don’t counsel in substance abuse treatment. I still have contact with people in recovery as a case manager in a transitional housing program.  Knowledge is always great even if you don’t use it right away.

Michael McMullen

***

Mahalo Dr. Mee-Lee:

For 10 years of sharing your “mana” (interpersonal power, strength, authority, efficacy) with those of us attempting to follow your lead by reading your Tips & Topics newsletter each month.

Your generous offerings and influence have been a guiding light for a me, a substance abuse counselor in a rural, island community.

I’m looking forward to 10 more years of your influence.

In the mean time, I wish you a very fond……..

Aloha,

Lorrain Burgess, CSAC
Makakilo, HI

A couple of suggestions

Dear Dr. Mee-Lee:

I read your TNT with great interest every month. Over the years I have saved the ones that have been particularly helpful to me, as I work in a community mental health center.

I would like to see a new category added to TNT to trumpet new and innovative approaches to Co-Occurring Disorders (COD), or old approaches that are not well known…..

Another thought I have is soliciting a Guest Column each month on something directly related to COD treatment. Along these lines, you could identify a topic such as Guidelines for the First Session, and then invite your readers to solicit brief summaries for review…..

In any case, thank you for being on the cutting edge of treatment!

Harry Ayling, LCSW, ACS
Mental Health Supervisor
Fairfax County, Virginia

Thinking outside the box

***

David I truly appreciate your objectivity, open-mindedness and willingness to think outside the box. In helping addicts help themselves most often the instrument for change is that non-judging compassionate empathic therapeutic alliance that springboards the person to make that most important choice for a path on the road to recovery.

Chris Keeley, LICSW

***

Tips and Topics is always spot on! Thanks for keeping us at the head of the curve. Your ability to eloquently bridge theory with practice has been a real gift to the addictions field!

Bob Lynn Ed.D
Clinical Systems Development
Origins Recovery
C4 Recovery Solutions
Counseling Group and Family Institute

Favorite things

I read TNT pretty voraciously each month.  One of my favorite parts is the SOUL section.  Sometimes it ties into the content from the rest of the month, and sometimes not, but it is a helpful reminder to me of the toll and the wonderfulness of the work we do, and that we face the same challenges of families throughout the lifecycle that our clients do.  I especially like the SOUL about:

Jennifer Harrison, LMSW, CAADC, Western Michigan University, my co-author for the TNT book (see later for a special anniversary offer) wrote the above appreciation note.  When I asked her how she wanted to be identified she added “and awesomest co-author ever would be great.” Jennifer is indeed a great co-author but since I have several co-authors who might read this, I’ll let her say “awesomest co-author ever.”;

Helping clinicians help others

I appreciate that you keep the focus on the idea and reality that the “illness” I see is actually an accommodation my client has made to his or her world and makes sense to the person who holds it.  To assist in the change process, I must show how what I have to offer is a better accommodation to his or her world–otherwise I am not worth my pay.  (No one pays a bully.)  I have just found myself down at the end of that alley with one of my folks–resulting in his leaving the program.  I have to own that, at first, I was relieved.  He’s gone, MY WAY is reaffirmed by events.  Then, I read through this most recent post of yours and felt the underlying guilt based on “How could I have allowed myself to fall into that old trap again!?”

ARTICLE LINK

That was the question I needed to ask weeks back before events worked out the way my ego had ordained that they would.  I can and will look for a way to re-engage with this person so that I can feel better about payday.  Thank you again for holding our feet to principles of good behavior, ethical treatment, and service.  Peace!

Jim Recktenwald

***

While I have read and enjoyed your Tips & Topics, what I have appreciated most was your willingness to help us in our struggles as clinicians. Several years ago, the agency I was working for was moving toward a one-size-fits-all model trying to get everyone to do their Intensive Outpatient Program (IOP)…..I was the Intake Specialist and believed in meeting the client where he/she was and referring them to a level of care that matched their needs at that time.

THANK YOU for your hard work and dedication!

Carol Goulette LCPC, CCS

***

I just want to thank you for this regular piece of sanity in my mailbox. Some days it is hard to put one foot in front of the other in the midst of non-client/programmatic madness.  Seeing your words reminds me that I’m not alone and neither my clients nor I are crazy.

Staci Hirsch, Psy.D. – Program Supervisor
NEIGHBORHOOD SERVICES ORGANIZATION
Supportive Housing/Bridges
Detroit, Michigan

Subject: How Tips and Topics have helped me.


Dr. ML,

My brother, Bill, died on Feb. 4, 2013.  He was diagosed with schizophrenia in his twenties.  He was probably ill since his teens.  He was “hyper-religous”, “hyper-alcoholic”, and smoked as many cigarettes as he could get his hands on.  In retrospect, I think that he sought a community of accepting people (religion), an escape from psychic disturbance (alcohol), and probably an element of the first two conditions in socializing and rewarding himself with what relaxed him (cigarette smoking).  He was a very bright man. People questioned why he didn’t just “take his medications” and “fly right”.  I think, in his own way, that is precisely what he did.  I think of the John Nash story, “A Beautiful Mind”, where, under what might be considered more optimal conditions, people encouraged him to follow his treatment regimen. Why? What is a person giving up to trust another to do what is in their best interest?  I think the Tips and Topics literature has helped me to ask this question.  Why should a person who has many gifts give someone like me an opportunity to assist them in living in a way that others might consider “better”?  What stage of change am I in?  Keep up the good work.

Respectfully,

Peter Fuller, LCSW, LADC

And now for an appreciation note from me

  • Firstly, my heartfelt thanks to you all for signing up for TNT and for the many readers who through the years have taken the time to write notes of appreciation. Your telling me when a certain tip or topic spoke to you and helped you personally/professionally is very gratifying as a writer. Without readers and without knowing if ‘message sent’ is actually ‘message received’, all these words could just be traveling into outer cyberspace. So thank-you.
  • Secondly, if there have been some long and complicated sentences that left you scratching your head, I probably wrote those and they weren’t caught by my life partner and TNT editor, Marcia, my wife without whom none of the 10 years of TNT editions could have been successfully communicated to you in the straight forward and efficient sentences you usually receive and understand when you read TNT each month. (The long sentence is a joke, sort of, but the appreciation is real.)

Each month, I churn out the first draft. Then Marcia and I ‘fight’ over what I meant in some obscure paragraph and how to make it shorter, readable and comprehensible. She keeps me honest and keeps you reading. So thanks to my editor too.

SKILLS

Join me in a retrospective of April’s SKILLS Tips – from year 1 to year 10!TIP 1

See which TIPS take your fancy and click on the link to read more.

April 2003

When assessing the severity or level of function (LOF) for each ASAM dimension, it is useful to consider the three H’s:

History; Here and Now; and How Worried Now.

April 2004

The more the identified client is ambivalent or resistant to recovery, the more you focus on _who has the power_ in the client’s system…

April 2005

Ask “How much?” and “How often?” questions, rather than “Do you?” or “Have you?” questions…

April 2006

Every client who is talking to you in an assessment, treatment session or outreach visit is treatment-ready…

April 2007

Tune into what your clients are feeling on that first visit. Identify what methods you use to effectively engage a reluctant client. Here are what probation officers see and do (in no particular order)…

April 2008

For alcohol, the NIAAA one question is a good start: How many times in the past year have you had 5 or more drinks in a day (men); 4 or more drinks in a day (women)?

April 2009

When clients are ambivalent, don’t always argue for the healthy choice: “You can hangout with those friends if you want to. Why not continue going to parties with them?”

April 2010

Even if there was not the current political focus on healthcare reform, we would need to re-think how we do behavioral health care.

Identify one innovation you are willing to do in at least one of the following three C’s – even if you have to start small.

April 2011

Identify where to start on PEOPLE, PARTNERSHIPS and PERFORMANCE MEASURES

April 2012

Conflict is normal. Not resolving conflict is the problem.  See more SAVVY Tips.

SHARING SOLUTIONS

As a special anniversary celebration, I am offering the Tips and Topics book for a $1 for each year. So for $10 total (shipping and handling free), you can receive the TNT book if you purchase in April and May. 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)

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.

SOUL

SOUL

On Friday, April 12, 2013, on National Pubic Radio’s Science Friday program, I was introduced to Zachary Sawyer (“Zack”) Kopplin.  Zack is 19 years of age and is an American science education activist from Louisiana.

http://www.sciencefriday.com/segment/04/12/2013/the-teenage-troublemaker-fighting-for-science.html

A week later on CNN, I was introduced to Dzhokhar Tsarnaev.  Dzhokhar is also 19 and is an alleged bomber, charged with using a weapon of mass destruction to kill in Boston, Massachusetts.  He was found hiding in a boat about three miles from where we lived for 17 years.

Both 19 year olds have been in the media quite a bit for just being 19.  Zack and his tireless campaign to elevate the importance of science education in the USA has been covered in hundreds of newspapers and radio and television interviews.  He has been interviewed in both national and international media, including Vogue Magazine, MSNBC, and the Washington Post.

Dzhokhar has been interviewed by a special team of federal investigators at Beth Israel Deaconess Hospital in Boston, and his radio and video presence now far outstrips Zack’s for many sad and tragic reasons.

What a contrast in two young men- one with focused energy to do good and the other to destroy.   One who channels his youthful idealistic fervor to build; the other who channels his to tear down and terrorize.  It is easy to deify or demonize and that is not what this is about.

What it is about is the important responsibility we all have to nurture our children and youth: to harness their idealism for good, to protest peacefully, to preserve and uphold life, not destroy and kill; and to speak up for what they believe while respecting the rights of others to differ.

Somehow Zack got that message and Dzhokhar didn’t. One has his life ahead of him to keep being a force for positive change. The other will languish incarcerated forever, or may even be killed as he allegedly did to others.

SHARING SOLUTIONS

As a special anniversary celebration, I am offering the Tips and Topics book for a $1 for each year. So for $10 total (shipping and handling free), you can receive the TNT book if you purchase in April and May. 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)

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.

Until next time

Thanks for joining in the 10th anniversary celebration. I look forward to seeing you in late May.

David

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. 3

In This Issue
  • SAVVY and SKILLS : Getting more culturally sensitive andaware
  • SOUL : Top 10 things you don’t need in Myanmar (Burma)

Welcome to the June edition of Tips and Topics, especially all the new international readers. This edition is influenced by my recent overseas trip.

David Mee-Lee M.D.

SAVVY and SKILLS

Since the May edition, I have visited Singapore, Myanmar (Burma) and Australia. My travels pale in comparison with my friend and colleague, David Powell, Ph.D. with whom I have trained in Singapore and China. So I asked him to share his extensive experience and wisdom aboutSupervising the Culturally Different. I have excerpted from a more comprehensive article he has written and formatted his work in a combined SAVVY and SKILLS for this month. Even if you are not supervising theculturally different, this will help you to increase your cultural awareness and sensitivity. You can see from his biography that he is well qualified to address this topic.

 

 

Bio: 

Dr. David Powell is President of the International Center for Health Concerns, Inc., and the Clinical Supervision Institute, and has trained for the past 36 years on clinical supervision and other topics in 50 states and87 countries. He is also Assistant Clinical Professor of Psychiatry, Yale University School of Medicine and Senior Advisor, Yale Behavioral Health Program, Department of Psychiatry.  In 2012, he assisted the governmentsof Malaysia, Singapore and Vietnam to develop and train clinical supervisors for the respective ministries of health. He oversees a 60-bed adolescent substance abuse treatment center in southern Turkey, on the Syrian and Iraq border,

where he supervises clinical staff via webcam.

 

Dr. Powell has been in the counseling field since 1965 and is a certified clinical supervisor in the alcohol and drug abuse and in sex therapy fields.

 

 

Introduction

 

“Since 1976, I have trained clinical supervisors worldwide, visiting over eighty countries and all fifty U.S. states. As I near the end of this career, there are lessons I have learned about working with the culturally different.

 

How does one provide clinical supervision with staff who is culturally different, or how do you establish a system of supervision in a different cultural context? This seems like a straightforward question. It is not, as I found out.”

 

Common Mistakes and What to Do

Mistake:

  • Americans lecturing or consulting overseas far too often think the people they train will be like us, just using a different language. For example: at international forums, I have shared platforms with numerous presenters who use American colloquialisms, slogans and terminology, leaving the translators uncertain how to interpret what was said.
  • What we miss is they are acting under different cultural rules than we.Unconsciously, we bring our own cultural frame of interpretation when we step on foreign soil. For example: at a conference on addictions at Beijing Medical University in 2002, a prominent U.S. expert (who will remain anonymous) began his talk by speaking of General Douglas McArthur’s parting wordswhen he left Chinese soil after World War II. This was not an image of which the Chinese were particularly fond.

What to Do:

  • The core of intercultural awareness is learning to separate our observations from our interpretations, postponing interpretation until we know enough about another culture.
  • Language is much more than learning new vocabulary. It includes knowing what to say, and when,how, where, and why.
  • Nonverbal communication is critical in working with other cultures: gestures, posture, and other areas that show what we are thinking and feeling.

 

Mistake:

  • Stereotypes area major communication barrier.
  • We tend to evaluate behaviors of the other culture as good and bad, making judgments based on our own cultural bias.

What to Do:

  • We must remember that all foreigners will not one day become like us. This is difficult when one walks into the new airport in Beijing and is immediately confronted by Starbucks and McDonalds. We assume they have become Americanized, untilwe realize while the sign outside might be the same, many things aren’t.
  • We need to distinguish between modernized and westernized. Culture is communicated not through names but through symbols, some as ordinary as the napkins used. (DML: When traveling in Myanmar, on planes and in restaurants, moist, scented individually-wrapped towelettes were often used as napkins.)
  • Even ordinary symbols can have a powerful influence on relationships and the ultimate success or failure of the effort.

 

This article can briefly address key issues a supervisor might consider when implementing supervision for culturally-different personnel. If you supervise staff with different backgrounds, or if you have an opportunity to establish supervision systems in other countries, here are a few tips. The article will highlight principles of cultural variations primarily in four countries where I have recently trained on supervision: Vietnam, China, Singapore and Turkey.

 

 

TIP 1

Remember the powerful role of culture in shaping management/supervision styles.

 

Cultural values are derived from many sources, among them, the relationship to authority, conception of self (the individual vs. the collective), ways of dealing with conflict, certainty and ambiguity and long-term vs. short-term orientation.

  • Norms are standards for behavior that exist within a group or category of people.
  • We cannot change the way people in a country think, feel or act by simply importing our way of management.
  • Globalization meets fierce local resistance because systems are not culture-free.
  • Unawareness of national limits causes supervision ideas to be exported without regard for the values context in which they were developed.
  • Psychology is predominantly a U.S., individualistic discipline. Sociology is predominantly European.

–> This is essential for those who train overseas, thinking far too often that we will simply teach other countries how we do things in the U.S. Then we wonder why they don’t embrace our way of working.

 

 

Example from Vietnam:
With Vietnamese managers, the American way would be to give and receive personal feedback. When tried with Vietnamese managers, this was virtually impossible and resulted in ritualized behavior: the receiver of feedback felt that he must have insulted the sender in some way.

 

Solution: Understand that Vietnamese participants concentrate on tasks, rather than interpersonal process issues.

 

 

TIP 2

Recognize how power differences between management and employees affects conflict resolution and decision making.

 

Power distance indexesaddress how employees respond to disagreements with management, subordinates’ perception of their boss’s actual decision-making styles, and subordinates’ preference for the boss to make the decision.

  • Power distance can be defined as “the extent to which the less powerful members of an organization within a country expect and accept that power is distributed unequally.” (Hofstede, p. 46).
  • America ranks low (59 of 61) in power distance, meaning U.S. employees generally want to be part of the decision-making process, whereas in China (ranked 12th), employees prefer bosses to make decisions for them.

 

Example from work in Turkey

I began overseeing an adolescent treatment program in Turkey (ranked 32nd on the powerdifferential scale). I brought to Turkey a U.S. mentality, which gave preference to the employees to be part of the decision-making process. I’d ask staff for their opinions on what to do. Staff sat there with no response. They are used to being told what to do, not to voice their opinions untilthey know what the boss thinks.

 

 

Example from work in China

In China, employees donot want to lose face by saying something the boss might not agree with. Employees are given a choice so they do not lose face by having to say “yes” or “no” and exploring together what they think the boss thinks.

  • Young psychiatrists in China would express their clinical concerns to me in supervision but, when encouraged to address these issues with their supervisors, said, “No, I cannot do that. It is not my place to do so.”
  • In China, teachers/supervisors are treated with great respect (the older the teacher, the more respect and awe).
  • Classrooms are teacher-centered with strict order, and the teacher initiates communication. People in class speak only when invited to by the teacher.
  • Teachers should never be publically contradicted or disagreed with.Inequalities among people are expected and desired.

 

Example from work in Vietnam

In Vietnam, it is important not to mistake supervisee shyness for apathy or to assume rudeness inthe form of classroom conversations between students.

 

–> In sum, when an American trains in China, Vietnam or Turkey, they must realize how the power differential issue affects their training and their clinical supervision.

  • High power distance between manager and employee or supervisor and supervisee applies to most Asian countries (such as Malaysia, China) and somewhat less for Turkey,France, etc.
  • Low value power distance countries would be the U.S., the U.K., New Zealand, Australia, etc. which value “participative management” where employees are encouraged to take the initiative to have input.
  • Such countries value entrepreneurship and intra-preneurship (encouraging ideas to emerge from within organizations).
  • These principles are unlikely to apply in countries high on the power differential scale where the typical response might be “He is the boss. Why doesn’t he tell me what to do?” In Asia, there is less dialogue and power is based on tradition and charisma.

 

TIP 3

Identify how self-esteem and self-care are affected by Individualistic vs. collectivistic cultures.

 

In individualistic cultures, the individual is expected to look after him/herself vs. collectivistic cultures where the individual is integrated into a strong, cohesive group. Throughout one’s lifetime they continue to protect the group and collective.

  • Collectivistic cultures stress filial piety and patriotism.
  • Individualistic cultures are built around guilt.
  • Shame is social in nature, guilt isindividualistic.
  • Individualistic cultures tend to use the pronoun “I” when referring to themselves.
  • Collectivistic cultures tendto drop the pronoun and rarely capitalize “I”.
  • Individualistic cultures encourage an independent self.
  • Collectivistic cultures stress interdependent self.
  • Not surprisingly, the U.S. is #1 on the individualistic index. We value our independence. Turkey ranks 41, China and Vietnam rank 56-61 respectively.

 

Example from work in China

In China, a shame-based culture, loss of face, saying/doing the wrong thing, is feared. One loseswhen they fail to meet essential requirements placed on them. They “give face” in these cultures by honoring prestige.

 

Supervisors working with Chinese cultures need to understand these factors and never put either themselves or a supervisee in a place where they will lose face or be shamedby the group.

 

Here is an example of this issue. Dr. Hope Lee, a Chinese psychiatrist friend, wrote about an incident in her mental hospital. Another psychiatrist colleague was hit on the head from behind by a patient (not the psychiatrist’s patient). Dr. Lee asked me how to process the incident with staff. I recommended the usual form of critical incident debriefing as we would do in America. When the psychiatrist was asked to engage in a debriefing, she said no because she would lose face in front of her peers. I asked, “Why would you lose face, since this was not your patient?” to which the psychiatrist said she did not want to “stand out from the group, to be different.” Collectivism means being inthe in-group, not standing out.

 

Collectivist-oriented Chinese supervisees tend to perform best when operating with a group goal and in anonymity. Management in individualistic-oriented America is management of individuals vs. management of groups.

 

 

Example from work in Vietnam
In a collectivist society like Vietnam, discussing a person’s performance openly with him is likely to clash head-on with the society’s norm of harmony. The subordinatewill lose face.

Feedback in these cultures is more indirect, either by being withdrawn or verbalized through an intermediary. In the collectivist society, the priority is the personal relationship more than the task to be done and the personal relationship should be established first. In individualistic societies, the task at hand is more a priority than the personal relationship.

 

TIP 4

When students or employees feel threatened by uncertainty and ambiguity, they can expect teachers and managers to make the decisions.

 

“Uncertainty avoidance” is the extent to which members of a culture feel threatened by ambiguity or unknown situations. Turkey ranks 23rd in the world, meaning that people in Turkey are in the top 25 countries where people feel threatened by uncertainty and ambiguity. The U.S. is 62, China and Vietnam are 68-69 respectively and Singapore is last at 74th. Singaporeans are more comfortable with uncertainty and ambiguity.

  • Anxious cultures tend to be expressive cultures: people talk with their hands, where it issocially acceptable to raise one’s voice, to show one’s emotions.
  • People with high uncertainty avoidance want to reduce ambiguity, and stay away from unclear, ambiguous situations.
  • In these cultures, personnel give positive answers to any question, regardless of its content. Students expect their teachers (or supervisors) to be the experts who have allthe answers.
  • Students fromcountries where there is less fear of uncertainty and more comfort with ambiguity accept a teacher who says, “I don’t know.”

 

Example from work in Turkey

I taught addiction counseling in 2008 in Turkey. However I came in with a Chinese mentality, offering the students a range of choices for them to consider, never putting them in a place where they would lose face. In China, ambiguity is tolerated, perhaps even encouraged. In Turkey, employees awaited direction before they would act. “Subtle” didn’t work! Counselors wanted to be told what to do and how to do it. This was a difficult and foreign concept for me.

 

 

TIP 5

Whether a culture takes a short-term or long-term view affects what is valued in personal effort, accomplishments, relationships and counseling.

 

In long-term orientation (LTO) countries (China, Vietnam), virtues are fostered toward future rewards, in particular, perseverance and thrift. (DML: This is the virtue of delayed gratification versus the need for positive feelings and results straight away). In short-term orientation (STO) countries (U.S., U.K., Canada), virtues are related to present and past, in particular, respect fortradition, and fulfilling social obligations.

  • LTO applies to a society in which wide differences in economic and social conditions are considered undesirable.
  • STO applies to meritocracy, differentiation according to abilities – meaning that how you are rewarded and recognized depends on differences in your abilities. (DML: If you are a top athlete or actor, few people in STO cultures resent the celebrities multimillion salary for a game or movie)
  • The Chinese give priority to common sense over rationality, which is seen as abstract, analytical, and idealistic, whereas common sense is seen as more human and in closer contact with reality.

 

When Chinese Premier Chou En-Lai was asked fifty years ago what he thought of the French Revolution he said, “Too early to tell.” China has a very long-term orientation. America measures success by quarterly earnings.

  • Western psychology assumes people seek cognitive consistency, hence the popularity of cognitive approaches to counseling.
  • This is not the case in East and Southeast Asian countries. The Chinese, in comparison with Americans, view disagreement as less harmful to personal relationships than injury or disappointment.
  • The western way of practicing psychology that emphasizes rationality, liberalism, and individualistic ideals does not fit in East Asia where human relations can be characterized as being virtue-based rather than rights-based.

 

Conclusion

This has been a cursory overview of how different it is to work in different cultures and countries. We can apply these same concepts to working with colleagues, born and raised in other countries, who are now working in addiction treatment centers in the USA. Although we might think of the USA as a melting-pot of cultures, we are (and will be) more like a tossed salad, each culture offering its own unique flavors and approaches.

 

When working overseas or with people from other cultures in the USA, we must explore our culturaldifferences, be sensitive to these variables, and not try to export American systems of treatment, training and management without some adaptation tocultural norms.

 

For further information, contact David J. Powell, Ph.D., at the International Center for Health Concerns, Inc., djpowell2@yahoo.com

 

 

In the May edition, I asked for feedback on what’s on your Top 10 list of waysto improve patient safety and behavioral health care NOW!? – especially ifyou have any supporting evidence or data. Thanks to readers for their suggestions that I will share next month.  I will add yours too if you send them to me.  Tell me if and how you would like to be identified whenI include your feedback.

SOUL

Obviously I have been impressed with my trip to Myanmar – why else would I have two SOUL sectionsabout this back to back?! It was fascinating to see what a country is really like before we Americans dot the country with McDonalds, Subway, Kentucky Fried Chicken, Starbucks and 7-Elevens.

 

It reminded me a lot of what it was like going into China in the late 1970s soon after that country opened up to tourists. Now China feels like New York, Tokyo or London.

 

So I thought it would be fun to share about “Things you don’t need in Myanmar“. We thoughtof maybe 30, but here’s the top 10 list:

 

No. 1: 401 K Retirement accounts

Our English-speaking guide made less than $2,000 US dollars a year.

 

No.2: Dog groomers

Skinny dogs abound roaming the streets scrounging for food, but no one is worrying about making them look like cute dolls.

 

No. 3: Weight LossClinics

There are lots of places to eat, but no fast food restaurants. Portion sizes are adequate and appropriate, so no obesity.

 

No.4: Parenting classes

“It takes a village” to raise the children and that’s what they have: lots of relatives and extended family/villagers to help.

 

No. 5: Fancy toys for children, Toys R Us mega stores

Children know how to play with simple toys – a stone, a rock, a stick or whatever. They don’t need iPads and ‘Angry birds.’

 

No. 6: Televangelists

It seems that there isa pagoda or temple on every corner. No need to tune into TV to practice your spirituality.

 

No. 7: Yoga classes

Children and adults seem like they can squat for hours at a time with great flexibility and natural stretching. No Downward Dog moves needed.

 

No.8: Health club memberships

Between walking, biking and carrying heavy loads on your head, every muscle gets exercised every day.

 

No. 9: Shoeshinersand shoe racks in your closet

Flip flops are sufficient and easy to slip off, especially when needing to be bare-footed in temples and pagodas.

 

No.10: Conveniencestores

Everything you need for day-to-day living is on the street near you already: food markets, gasoline in small bottles if you are wealthy enough to own a motorbike or scooter(that carries you, your wife, your toddler and your packages).

 

But savor the moment, because when we return in the future, likely this will all be changed.

Until next time

Thanks for reading. See you in late July.

David

Vol. 11, No. 4

In This Issue
  • SAVVY : Readers’ suggestions on how to prevent harm andimprove safety
  • SKILLS : How to guide and help people in motivational work
  • SOUL : Finding the perfect guide

Thank-you for joining us for the July edition of Tips and Topics.

David Mee-Lee M.D.

SAVVY

In the May 2013 edition, I discussed ways to prevent harm and improve patient safety in addiction and mental health treatment.
I asked for feedback:  What’s on your Top 10 list of ways to improve patient safety and behavioral health care NOW!? – especially if you have any supporting evidence or data.

I promised to share readers’ suggestions.

Here are three and some editorial comments:

 

Reader #1
Hi Dr. Mee-Lee:

I read your latest Tips & Topics (May 2013) with great interest. As you know, approximately 90% of clients seeking treatment in community mental health centers have been exposed to trauma. Safety is absolutely enhanced by resisting the urge (from oneself but also the patient) to engage in premature trauma retrieval work. This advice has been repeated over and over by such luminaries in the field as Bessel van der Kolk, Judith Herman, Joan Turkus and Lisa Najavits.

 

Regards,

Harry Ayling, LCSW, diehard devotee to Tips & Topics  (Harry’s words, not mine).

 

–> Comment from David Mee-Lee

There has been a lot of attention over the past 15 years on co-occurring mental and substance-related disorders.  The more recent refinement of that attention is to be trauma-informed: to be aware of how many addiction and mental health clients present  with past histories of trauma.  When people with addiction sober up, intense feelings can rise to the surface.  It is always a fine balance to know how to address intense feelings which can’t be ignored.  Yet, at the same time it is important, as Harry says, to make sure that our clients are safe to deal with trauma; and not cope by returning to substance use or other self-destructive behaviors like cutting.

Of course, trauma-informed work is even more in our consciousness as we face the thousands of veterans returning home.
Take a look at a brand new journal from The Change Companies: “ComingHome: A Warrior’s Guide”
Reader #2
Dear David:
Thank you for your excellent comments on our health care costs and the Affordable Care Act (ACA).  I am personally offended by the sizeof the executive compensation packages, and the large bureaucracies funded to try to get paid (medical facilities) and to avoid paying (insurers).  A Google search of executive compensation packages in the insurance and medical care industries show many senior execs make over $1million per year, with some getting more than $40 million per year.  Soon the taxpayers will be contributing even more to their life styles.  Steven Brill documented many key issues in his fine article Bitter Pill: Why Our Health Care Costs So Much (Newsweek, Feb 20, 2013).  A big part of what impedes our ability to solve problems in this and other arenas (guns, food habits, worker safety) is the commandment “Thou shalt not interfere with profit.”  I think all of the measures designed to bring down costs will also produce a lot of howling and attempts to sabotage full implementation of the ACA.  The more people can be made aware of what goes on in other countries, the better.  It does not have to be this way.

 

Joan Zweben, Ph.D.

Berkeley, CA

 

–> Comment from David Mee-Lee

In Overview of the Uninsured in the United States: A Summary of the 2012 Current Population Survey Report, the “Census Bureau released data on health insurance coverage and the uninsured for 2011 on September 12, 2012.  Although there are four major government surveys that produce estimates of health insurance coverage, the Current Population Survey (CPS) is the most widely cited and receives national media attention. …. During 2011,an estimated 48.61 million people were without insurance, a statistically significant decrease of 1.34 million from the estimated 49.95 million uninsured in 2010.”http://aspe.hhs.gov/health/reports/2012/uninsuredintheus/ib.shtml

 

Regardless of your political leanings (right or left); or where you stand on the continuum of individual rights (right to buy health insurance or not) to collective action for the greater good (requiring health insurance of all so as to pool resources to allow universal coverage), the fact remains:  There are 40 to 50 million people who do not have health insurance in the USA.  This creates huge human costs, as well as significant healthcare costs, as scarce resources are used inefficiently and ineffectively.

 

As Joan says on this and other related issues, “It does not have to be this way.”

Reader #3
Dr. Mee-Lee:
Number One Way to improve patient safety and behavioral healthcare now:

Address the stigma in the 12-step based treatment community against methadone and Suboxone (buprenorphine and naloxone) maintenance for the treatment of opioid dependence (now opioid use disorder in DSM-5).  About 95% of treatment programs in the public sector are based on the 12-step philosophy, and are staffed by people who are undereducated about medications, and either covertly or openly biased against medication-assisted treatment.

There is NO scientific controversy that for established opioid dependence, medication- assisted treatment is the treatment of choice.  Clients must receive informed consent regarding this treatment option, but in my 25 years of experience in publicly funded treatment in California, this rarely happens.  This MUST change, as we are in the midst of the largest epidemic of opioid dependence since heroin use rose in the 60’s.

Please, devote not just one, but several issues of your newsletter to educating your readership on improving delivery of evidence-based treatment of opioid dependence.  You are a thought leader whose opinion is respected in the field; you are well positioned to lead the efforts to improve the treatment of opioid dependence. Young people are dying from overdoses after completing abstinence-based treatment programs; this needs to stop.

 

Sincerely,
Nancy Friel MFT
Senior Mental Health Counselor
County of Sacramento DHHS, DBH, Alcohol and Drug Services
 –> Comment from David Mee-Lee
There has been lively discussion on methadone and Medication Assisted Treatment (MAT) in previous editions of Tips and Topics.  Take a look at Jerry Shulman’s piece on MAT in the October 2008 guest tips edition.
In the May 2007 edition, we discussed harm reduction and methadone treatment followed by some readers’ comments in the June 2007 edition.

In the new edition of The ASAM Criteria, there is an expanded section on Opioid Treatment Services (OTS) to include opioid agonist medication like methadone and buprenorphine in Opioid Treatment Programs (OTP) and Office Based Opioid Treatment (OBOT); and opioid antagonist medication like naltrexone. Take a look at the updated website all about the new edition at www.ASAMcriteria.org

SKILLS

One of the skills I address very often in Tips and Topics is how to do truly individualized, person-centered work.  The recent third edition of Motivational Interviewing (MI) explains a  continuum of communication styles.  This distinction has really helped me understand MI.

 

Here’s the reference:Miller, William R; Rollnick, Stephen (2013): “Motivational Interviewing – Helping People Change” Third Edition, New York, NY., Guilford Press. Pages 4-5 and some resources on the third edition:

http://www.changecompanies.net/motivational_interviewing.php

 

 

TIP 1

Identify where you are on the continuum of communication styles from Directing to Guiding to Following

 

Directing <————-> Guiding <————–> Following

 

  • Here is an example of a Directing style for working with a client who says they want help to stop drinking:

 

It’s good that you want to stop drinking because you’re an alcoholic and you need to really accept that you suffer from addiction and develop a supportive recovery network. Here’s what I want you to do: go to an AA meeting every night this week and get some names and numbers so you can start calling people and developing that network. It is also important for you to stay away from those three friends of yours you usually drink with and start hanging around recovering people. Any questions?”

 

  • Here is an example of a Following style for working with a client who says they are depressed:

 

Clinician: So I understand you have been feeling down and blue lately.

 

Client: Yes, I’ve been really feeling depressed and don’t know what to do.

 

Clinician: So you feel lost and not sure how to handle your depression.

 

Client: Yes, I have no energy and can’t concentrate at work. Is there medication that can help me?

 

Clinician: So you having trouble with work in your concentration and energy level and wonder if medication would help.

 

Client: That’s right. What medication should I take because my primary care doctor’s medication didn’t seem to work well?

 

Clinician: You’d like me to tell you what medication would help.

 

Client: Yes, should I see a psychiatrist or is my family practitioner OK to prescribe?

 

Clinician: You’re wondering whether to see a psychiatrist or a family practitioner?

 

Client: Yes, I’m really depressed and don’t know what to do.

 

Clinician: You really feel lost and not sure how to handle your depression.

 

Client: Yes, what should I do – see a psychiatrist or is my family practitioner OK to prescribe?

 

Clinician: You’d really like to know whether to see a psychiatrist or a family practitioner.

 

At this point the client is really depressed and hopeless.  You’ve done nothing except follow the client around their presenting concerns, reflecting back what you hear.

There is some following that is important and necessary to do at first with a client so you know what they want and what to focus on.  But if that is all you do, they understandably get frustrated as you act like a therapy robot.

 

  • Here is an example of a Guiding style for working with both these clients. Guiding is a combination of Following and Directing in what Motivational Interviewing calls a “conversation about change”.

 

Clinician:  So I understand you want help to stop drinking. (Following)

 

Client: Yes, I’ve been trying to do that on my own for six months and am not getting anywhere.

 

Clinician: What have you tried that hasn’t been working? (Following)

 

Client: Well I went to some of those AA meetings, but I’m not as bad as those people.

 

Clinician: How many meetings did you go to? (Following)

 

Client: Two or three, but I didn’t get anything out of it except for one person I spoke to who seemed to really understand me.

 

Clinician: Did you get that person’s name and number? (Following)

 

Client: Yes, but I haven’t had any more contact.

 

Clinician:  Would it be OK with you if I gave a suggestion? (Seeking permission to be Directive)

 

Client: Sure, go ahead.

 

Clinician: How would you feel about calling that person and seeing if they would go to a different meeting, because sometimes certain meetings fit certain people better? (Directing)

 

Client: I guess I could do that.

 

Clinician: You sound a bit unsure if you want to do that (Following).  Do you need to think about it a bit more; or would you like to give it a try, at least one or two times? (Guiding).

 

 

And for the depressed client:

 

Clinician: So I understand you have been feeling down and blue lately (Following).

 

Client: Yes, I’ve been really feeling depressed and don’t know what to do.

 

Clinician: What has been most troubling about your depression? (Following)

 

Client: I have no energy and can’t concentrate at work. Is there medication that can help me?

 

Clinician: Have you taken medication before? (Following)

 

Client: My primary care doctor’s medication didn’t seem to work well.

 

Clinician: There are other methods besides medication that we could try if you were interested. (Directing)

 

Client: What do you mean?

 

Clinician: We could try cognitive behavioral therapy and exercise? (Directing)

 

Client: I’d rather take medication.

 

Clinician: So you feel more confident that medication would help the best. (Following)

 

Client: Yes, I’d like to see a psychiatrist to get my medication changed.

 

Clinician: So let’s arrange for a psychiatric consultation and track how you are doing. If medications don’t seem to be the full answer, maybe we could try some of these other approaches I mentioned. (Guiding)

 

 

Directing is easy to do, as it involves just telling people what to do to change regardless of whether they are ready to do that.  You have taken little time to listen to what goals and methods are important to them.

 

Following is also easy to do, as it involves just reflecting back what you hear they are saying.  This can be frustrating to the client if every interaction is a question and summarizing without moving forward to get some sense of direction of what to do next.

 

Guiding is the art of using both Directing and Following to ask enough questions to clarify what goals and methods are important to the client, but then building on that knowledge to collaborate and Guide the person in a facilitated self-change process.

SOUL

If you’ve ever done touristing in a foreign country, it’s a relief to have an informative guide,especially an English-speaking one.  Actually, only an English-speaking guide for me.  A good guide is one who knows how to balance “directing” and “following”; to get you where you want to go in the most efficient, effective and enjoyable way.

(That sounds a lot like good person-centered treatment – no wonder Motivational Interviewing is founded on good guiding.)

 

In May, we were in Yangon (Rangoon) for just a day!  There is no way anyone could see all the major temples, pagodas and top tourist spots.   So it’s really important to have a guide who can “follow” your lead about the sights you are most interested in seeing, in the limited time available.  At the same time, what we needed from Nandar, our female guide, was also to “direct” us- by listing the top recommendations for what could be done realistically in six hours.  Then collaborate with us on:

 

  • what sightseeing goals were important for us (which temples, markets and local crafts caught our fancy)
  • what methods would best achieve those goals (taxi, walking, timing at each spot)
  • what was the plan for the day – Now that sounds like a therapeutic alliance and a great service plan.

 

Imagine if Nandar had told us we had to go to the top five tourist spots whether we wanted to or not; stay there for a fixed amount of time, whether we had seen what we wanted or not; and then kicked us off the tour if we weren’t able to be the perfect tourist. (I know, it’s not the perfect analogy, but sounds a bit like some addiction treatment programs).  Nandar, I thought you were our guide, not a director/dictator!

 

What if we had a guide who followed us around all the time, passively walking in our footsteps?

We ask: “Where should we go next?”

Well where would you like to go?”

“I can’t decide which would be better – another temple or the silversmith crafts.”

“Well they are both interesting.”

“So what would you recommend?”

“You want me to decide for you?”

 

At this point, I would fire the guide who is not a guide.  She must have missed the Guide School training class on how to balance directing with following.

 

There are no perfect guides, perfect tourists, perfect counselors and clinicians plus no perfect patients and clients.  However if you can join up with someone who has a good sense of balance between directing and following, you can enjoy both the journey and the destination.

 

Whether you tour Yangon or Yakima, the museums of Florence, Italy or New York, New York,  or the temples of Thailand or Salt Lake City, may you find a good guide.

Until next time

Thanks for reading. See you in late August.

David

Vol. 11, No. 5

Welcome to the August edition of Tips and Topics.

David Mee-Lee M.D.

SAVVY

I am not a golfer. Mini golf is fun – it fits my level of expertise. Ping-pong (table tennis) is even more fun. This month’s SAVVY is about golf, a bit strange since I am not all that into it. As usual, I listen to National Public Radio’s Science Friday. You can hear the July 26, 2013 program yourself. http://www.sciencefriday.com/segment/07/26/2013/phil-mickelson-takes-a-swing-at-science.html

Before you do listen, let me tell you some points that struck me.

 

TIP 1

Structured, focused deliberate practice is more important and effective than many hours of general, non-specific activity.

Interviewed was Mark F. Smith, a sports scientist and Phil Mickelson,recent winner of the British Open golf tournament and also the Scottish Open – some say one of the best golfers of all time. Dr. Smith discussed the neuroscience: the brain functional differences between the amateur golfer and the professional. At the end of the segment he mentioned “deliberate practice”.

 

Phil Mickelson beautifully described examples of deliberate practice that has made him such a winner. In SKILLS, I’ll tie this together – to make sense of this for our work in addiction and mental health.

 

A few of Dr. Smith’s points:

  • Deliberate practice is structured practice with a specific focus on objectives and outcomes.
  • Before hitting a ball, the part of the brain that activates in amateurs is the limbic area, which is associated with emotions. However for the professional, the part of the brain which “lights up” is the pre-supplementary motor cortex; this is “associated with the generation of movements; and the sequence and planning of movements.”
  • In other words, an amateur’s emotions of any uncertainty, anxiety and worry- even before taking the shot- will affect the effectiveness and outcome of the shot. By contrast, the more effective golfer’s brain is activated around the actual motor activity of how to hit the ball, where it will land and how to apply the exact force needed to get as close to the flag and the hole as possible.

 

Now for how Phil Mickelson explained what he does, which fits right into deliberate practice:

  • Phil explained he uses science as well. He knows: If I am within 3 feet of the hole, I have a 100% chance of sinking the putt (putting the golf ball in the hole). Four feet out, that drops to 88%; 5 feet drops further to 75% ; and 6 feet, he has a 67% chance of success.
  • Therefore, Phil practices to land the ball within that 3 feet circle. Then he knows he’ll sink the putt.
  • Similarly, he practices to know what a 145 yard drive feels like -what kind of force, angle, stance etc.he needs to apply to make the ball go 145 yards…or go 115 yards. So when he is in a tournament and knows he has to make 118 yards, he knows exactly what 115 yards feels like. He can then add a touch more to reach 118 yards and put the ball in that 3 feet circle.
  • What is he talking about? Focused practice and practice with a purpose…and it doesn’t have to be for hours on end. 45 to 50 minutes of focused practice or even 15 or 20 minutes is more effective than hours of random hitting of golfballs on the practice range.
  • So Phil’s practice involves: getting the ball to that 145 yard mark or within the 3 feet circle of the hole – focused practice with a purpose, not random, unplanned general activity.

 

TIP 2

Practice without real-time feedback is like hitting golf balls and not tracking where they land.

 

A related lesson from a golfer a bit closer to the behavioral health field…..
This comes from a keynote presentation at the 2013 Annual Conference of the California Association of Marriage and Family Therapists (CAMFT). Jim Walt is a licensed Marriage and Family Therapist and an ICCE Associate (International Center for Clinical Excellence, http://www.centerforclinicalexcellence.com). Scott D. Miller, Ph.D., my colleague and friend, has influenced my thinking about treatment outcomes, real-time feedback, the therapeutic alliance and more recently, deliberate practice.

 

In the Top PerformanceBlog section on his website, www.scottdmiller.com, you can watch Jim Walt talk about golf and what it has to do with Feedback-Informed Treatment (FIT). Just like Phil Mickelson was saying: If your practice is not focused with purpose, you may feel like you are doing good work, but without feedback, you don’t really know if you are being effective.

        • When you drive the golf ball, you need immediate feedback on how close you came to the 3 feet circle of the hole; or how far away you were from the 145 yard mark.
        • Based on that real-time feedback, you can know whether you have to apply more force, a better angle or adjust your grip on the golf club to hit your mark.
        • Hitting golf balls with no feedback is meaningless practice if the goal is to be effective and purposeful.
        • Jim Walt talks about how we should relish getting feedback from the client on whether the just-completed session with him hit the mark – or not. Even better,candid feedback on how the session was not helpful provides the information the therapist needs to know how to adjust things for the next session.

 

Take a look at Jim’s golf lesson:

http://scottdmiller.com/uncategorized/what-does-golf-have-to-do-with-feedback-informed-treatment-watch-the-video/

 

Now let’s try to pull this together for your daily work.

SKILLS

Deliberate practice has been around for a while, but relatively new to me and maybe you too. You can see a nice summary at http://expertenough.com/1423/deliberate-practice

 

TIP 1

Find the edges of your comfort zone and practice those specific skills.

Just as Phil Mickelson knows what specific target he needs to reach (a 145 yard drive; or to putt from within a 3 feet circle of hole), find the edge in a clinical skill you have to practice to reach. That is your target for practicing.

 

Take the task of engaging a client quickly and completing an assessment in one hour.

What are the edges of your comfort zone?

  • Finding a quick way to make your client comfortable?
  • Asking questions quickly and comprehensively?
  • Doing this all under time pressure, but in a friendly manner?

 

When practicing for the oral part of my Psychiatry Board-Certification examination, I knew I would only have 30 minutes to interview a patient, formulate my provisional diagnosis and be ready to discuss the case with two examiners. For weeks before, I practiced how to ask assessment questions in ways that didn’t take a lot of words, but was still comprehensive enough to obtain the needed information.

 

Example:
Instead of asking: “Now tell me about your sleep pattern. Do you have trouble falling asleep or do you get to sleep and then find yourself waking up in the middle of the night?” That may seem reasonably efficient, but not as streamlined as: “Do you have troublegetting to sleep or staying asleep or both?”

 

Dr. Smith, the sports scientist, found that amateur golfers’ limbic system (associated with emotions) lit up with performance anxiety and uncertainty. This negatively affected the accuracy of their golf shot. On the other hand, the professionals had a focused, purposeful practice. This allowed their limbic systems to stay quiet, and let their skills shine forth, free of any emotional baggage.

 

Back to the task of engaging and assessing quickly:

If you’ve practiced and built your confidence and competence, now you can channel your energy into the task at hand, instead of wasting it on performance anxiety.

 

 

TIP 2

Help clients practice to know what it feels like to be relaxed or serene.

Not only does Phil Mickelson know his specific target, he understands what it feels like to hit that target. By deliberate practice to reliably and repeatedly hit his target, his body, posture, muscle exertion and force of the stroke all feel a certain way that he can reliably replicate- over and over again.

 

Take the client who is struggling with anxiety. Because anxious feelings are mutually exclusive of feelings of relaxation, the goal is to have them know what it feels like to be relaxed, as much as they know what it feels like to be anxious.

 

If you simply tell your client to “just relax”, they do not know what relaxation feels like- UNLESS they practice! This is where the technique of progressive relaxation comes in.

 

When anxiety next arises, the client can call up feelings of relaxation to replace the anxiety.

 

Not all sensations need to be practiced to know what they feel like.

  • If I cut a very sour lemon in half, and squeeze the juicy lemon into your mouth, can you immediately call up what that feels like? Maybe your salivary glands are already working just by imagining the lemon in your mouth?
  • Or -imagine my fingernail poised on the chalkboard. I am about to run my fingernail squeaking over the surface. Can you already feel your skin crawl and your ears twinge, anticipating that awful scratching, scraping sound! No need to practice what that feels like, it is almost in your DNA.

In the midst of an anxiety attack, a client who has practiced relaxation a hundred times before can quickly evoke a relaxed state. They know what it feels like now.

 

 

TIP 3

Be excited when clients tell you if the session didn’t help.

If a client has a safe and trusting enough relationship with you, and you’ve created a culture of feedback, they can authentically tell you that you didn’t help them at the end of the session. Or if you invite their comment about what works for them, and the model/methods you’re using, they may tell you “It’s not working.” This is great news!   It gets you closer to your mark of a successful outcome. It helps when clients can tell you you messed up, or didn’t listen to them, or you’re on the wrong track.

 

Better to know you’re missing the mark (than to think you’re putt-ing within the 3 feet circle of the hole, when you are actually 4 feet away.) Or to know you are nowhere close to 115 yards. This way you can adjust your methods to hone your skill and reach the desired goal.

 

So real-time client feedback provides the information you need to improve your craft, practice better engagement, to listen better, to facilitate client change and improve outcomes.

SOUL

This month I had a birthday. No need to send wishes or gifts……I’m not fishing for those. It is interesting how many companies remember my birthday almost better than I, or my loved ones, do.

 

Companies send you all kinds of wishes and even real loot. Starbucks gives you a birthday drink – any size or price you want. If I want, I could have the big Trente (31 oz size) not simply the economical 8 oz size. It’s my birthday and the store is mine!

 

Here’s what CVS Pharmacy sent me. AND check the fine print*:

 

Happy Birthday – Save $3 on any purchase*

Just for you for your birthday!

One time only

Coupon redeemable in store only.

 

*Maximum $3 value. Valid in-store only. ExtraCare card must be presented to receive the offers. Excludes alcohol, gift cards, lottery, money orders, prescriptions, postage stamps, pre-paid cards, and tobacco products. Not valid at MinuteClinic®. Tax charges on pre-coupon price where required. Limit one coupon per customer. No cash back.

 

CVS/pharmacy will not accept offers printed from unauthorized internet postings or reproductions, copies, or facsimiles of this offer. This coupon is the copyrighted property of CVS/pharmacy; it is intended for use by ExtraCare cardholders who subscribe to the CVS/pharmacy email program and have received this message directly from CVS/pharmacy. CVS/pharmacy reserves the right to reject any coupon presented by parties outside of the original distribution list. Original coupon must be relinquished at the time of purchase. Coupon is void if copied, transferred and where prohibited by law.

 

Please note: All images may not print in your internet browser. Just print the coupon in black and white or color, and bring it to the store as-is.

 

That fine print is like those TV adds for the miracle depression pill; it takes 10 seconds to describe the medication and 30 seconds to warn you of precautions and side effects. The gift sounds like a gift -until you read the fine print.

 

Now here’s my point. My birthday will forever have mixed feelings, like these gifts with the fine print. Because my father died at age 72 in 1976 ….on my birthday! And just last year, my mother at 97 years of age died….on my birthday too!

 

So this is a one-year anniversary and birthday – with very mixed feelings. I have made meaning and comfort of this however, by seeing their death as the birth of carrying forward their legacy of service to others, which they exemplified in their lives.

 

My birthday will always have the fine print.

 

Until next time

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

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. 11, No. 9

Welcome and Season’s Greetings to everyone around the world. I wish you a healthy, meaningful and serene 2014.

David Mee-Lee M.D.

SAVVY

On December 10, 2013,the National Institutes of Health released a press statement with the headline: “Stimulant-addicted patients can quit smoking without hindering treatment.” The sub-headline said: “New NIH study dispels concerns about addressing tobacco addiction among substance abuse patients. ” http://www.nih.gov/news/health/dec2013/nida-10.htm

 

With the new year just around the corner, this is a good time for healthcare providers and addiction treatment professionals in particular, to resolve that 2014 will be the year we start taking nicotine addiction seriously. If you are still a tobacco user, could this not be a New Year’s resolution and gift to yourself which keeps giving every day and will pay dividends many times over?

 

Easy enough for me to say, as I have never been a tobacco user.

 

TIP 1

It is time to face the facts that nicotine addiction or tobacco use disorder is as deadly as other addiction illness.

 

According to the Substance Abuse and Mental Health Services Administration in 2008:

  • 63 percent of people who had a substance use disorder in the past year also reported current tobacco use, compared to 28 percent of the general population.
  • “Smoking tobacco causes more deaths among patients in substance abuse treatment than the substance which brought them to treatment. “
  • Check again that second bullet point: Patients may have gone into addiction treatment for cocaine, alcohol, heroin or some other drug, but smoking tobacco is what causes more deaths than the very drug that caused them to seek treatment in the first place! (Nicotine addiction is not the ‘kinder, gentler’ drug addiction, it is the killer for many.)
  • Despite this, most addiction treatment programs do not address smoking cessation.

National Institute onDrug Abuse (NIDA) Director Dr. Nora D. Volkow said: “However, treating their tobacco addiction may not only reduce the negative health consequences associated with smoking, but could also potentially improve substance use disorder treatment outcomes.”

 

–> Here are the CONCLUSIONS in the Abstract of the study this press release was trumpeting:

“These results suggest that providing smoking-cessation treatment to illicit stimulant-dependent patients in outpatient substance use disorder treatment will not worsen, and may enhance, abstinence from non-nicotine substance use.”

 

Dr. Theresa Winhusen,from the University of Cincinnati College of Medicine and first author on the study said: “These findings, coupled with past research, should reassure clinicians that providing smoking-cessation treatment in conjunction with treatment for other substance use disorders will be beneficial to their patients.”

 

TIP 2

Review the DSM-5 criteria for Tobacco Use Disorder.

You’ll notice that tobacco (or more accurately, nicotine) causes the same kind of addiction disorder as other drugs. How is it then, that many still consider it different from other drug addiction?

 

Tobacco Use Disorder is defined by the following criteria in DSM-5:

 

A problematic pattern of tobacco use leading to clinically significant impairment or distress as manifested by at least two of the following, occurring in a 12-month period:
1.  Tobacco is often taken in larger amounts or over a longer period than was intended.

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

3.   A great deal of time is spent in activities necessary to obtain or use tobacco.

4.   Craving, or a strong desire or urge to use tobacco.

5. Recurrent tobacco use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., interference with work).

6.  Continued tobacco use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of tobacco (e.g., arguments with others about tobacco use).

7. Important social, occupational, or recreational activities are given up or reduced because of tobacco use.

8.   Recurrent substance use in situations in which it is physically hazardous (e.g., smoking in bed).

9.   Tobacco use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by tobacco.

10.   Tolerance, as defined by either of the following:

a.  A need for markedly increased amounts of tobacco to achieve the desired effect.

b.  A markedly diminished effect with continued use of the same amount of tobacco.

11. Withdrawal, as manifested by either of the following:

a. The characteristic withdrawal syndrome for tobacco (refer to Criteria A and B of the criteria set for Tobacco Withdrawal)

b. Tobacco (or a closely related substance, such as nicotine) is taken to relieve or avoid withdrawal symptoms.

(DSM-5, page 571 in hard covered edition)

 

References:

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

 

Winhusen TM, et al: “A randomized trial of concurrent smoking-cessation and substance use disorder treatment in stimulant-dependent smokers.” J Clin Psychiatry. 2013 Dec 10.

SKILLS

When a clinician or program decides that tobacco use disorder and nicotine addiction are the same addiction illness as alcohol, heroin, cocaine or any other substance use disorder, the first impact is on the counseling staff.

 

The new edition of The ASAM Criteria (2013) has a special section on Tobacco Use Disorder pp. 367-392.  To read an article from the co-authors of this section, Drs. Blank and Karan, go to the “WHAT’S NEW” tab at www.ASAMcriteria.org, and then click on Read full article: NewSection in The ASAM Criteria: Tobacco Use Disorder.

 

TIP 1

Examine this case example from The ASAM Criteria chapter on Tobacco Use Disorder

 

Case 6 (page 391) 

TH is a 50-year-old addiction counselor who works at a residential addiction treatment center. The center has decided that they are going to begin treating tobacco addiction along with all other addictions. The staff is not going to be able to smoke at all at work, and will not be allowed to come to work smelling of tobacco smoke.   TH is in recovery from addiction to alcohol and pain medications. He has been sober for 23 years and always felt that tobacco was not part of his disease. He feels that he has extra rapport with patients since he goes out smoking with them on breaks.   TH has often advised patients who wanted to stop smoking that they should wait at least a year before they even consider stopping, because “it is too hard to quit more than one thing at a time.”   TH has been told by his doctor that his frequent bouts of bronchitis are directly related to his smoking, and that he needs to stop before he does permanent damage to his lungs. TH is about 40 pounds overweight and fears that if he stops smoking, he will gain even more weight. He has never tried to quit, and is angry about his workplace forcing him to stop.

 

This is one of seven case studies that illustrate treatment and placement principles. What is interesting in Case 6 is that counselor TH “feels that he has extra rapport with patients since he goes out smoking with them on breaks.It is true that many programs have stopped smoking inside the treatment program building, but will have a smoking gazebo on the grounds where counselors like TH can “bond” with clients while joining them smoking.

 

My mischievous poke at such programs is to ask where is the alcohol gazebo where counselors can share a beer; or the heroin gazebo to shoot up together? And what about a benzodiazepine gazebo where patients can bring their favorite tranquilizer to share with each other?

 

 

TIP 2

Note this rhetorical question: Would it be OK for a counselor whohad a beer or glass of wine at lunch to lead a group session with alcohol on his or her breath?

 

I can think of no program or team that would be OK with this. Yet the same program would think nothing of letting a counselor smoke together with clients and then lead group treatment reeking of tobacco smoke.

 

So as more and more programs start to take nicotine addiction seriously, the same expectations for tobacco users will apply to alcohol using staff: if you use your drug in breaks at work, you cannot do individual or group counseling with either alcohol or tobacco odor on your breath or clothing. This means:

  • Either don’t drink or smoke in breaks while on the job
  • Or if you do, there has to be a long period of time for all evidence of use to dissipate before counseling. For smokers, that means a change of clean clothes as tobacco smoke does not quickly dissipate.

For counselors like TH in the case study, the inconvenience of having to change clothes after every smoke break may ultimately just get too much to handle.  Programs in transition are providing smoking cessation programs for staff first, before moving the whole program to tobacco-free for patients.

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-OccurringConditions. Third Edition. Carson City, NV: The Change Companies.

SOUL

A few weeks ago in Australia, I visited my childhood neighbor who has known me since I was three years old. I’ll call her Mrs. Martin – not her real name. She was telling me how hard it has been to talk with her oncologist and be heard. Joan has ovarian cancer which went into remission but recently metastasized to her bowel and is now inoperable.

 

The chemotherapy left her weak, emotionally and physically drained, and using a walking stick. Until now, she has never had to use a stick even though approaching 90 years of age. Joan’s physician wanted her to undergo more chemotherapy despite the patient’s wishes to have a break from the awful treatment. Joan was ready to take whatever path her cancer would lead her, but she wanted some quality of life and not treatment that was worse than the disease.

 

Somehow she could not be heard. It needed her son to be intensely assertive for the oncologist to hear Joan’s wishes.

 

When I visited Mrs. Martin, she had just returned from ten days at an alternative holistic health retreat where they use a combination of massage, diet, colonics and who knows what else. Before I arrived she had already gone for a morning walk without any sight of a walking stick. She greeted me with: “I’m a new woman.”She was optimistic, beaming, feisty and totally different from her son’s report a few weeks earlier, which sounded as if she was on her deathbed.

 

The cancer isn’t cured and she will have darker days. But I was first inspired by the faith and positive attitude Joan beamed; and then sobered by how hard it is for patients to be heard by well-intentioned, but “deaf” physicians and healthcare providers who do not engage and listen to their clients and patients.

 

Joan was scheduled to see her oncologist two days after our visit. This time, she will present in a totally improved condition to her physician who will perhaps wonder what worked. Joan stated she would not be telling the physician where she has been and what she’d been doing that brought her back to such a state of well-being.

 

He wouldn’t understand, she mused. And I tend to agree with her.

SHARING SOLUTIONS

I often receive emails and questions from providers and clinicians on what to do when a payer or managed care company is not using The ASAM Criteria correctly. I also receive questions in reverse about providers or programs not using The ASAM Criteria correctly.

 

1. “Using” the ASAM Criteria means different things to different organizations and providers. So take a look at the article I wrote for Counselor Magazine: “How to Really Use the New Edition of The ASAM Criteria: What to Do and What Not to Do”.  You can access it at www.ASAMcriteria.org .Click on “WHAT’S NEW.”  Scroll down to the article/link for the November-December 2013 edition of Counselor Magazine.  Article is entitled:”How to Really Use the New Edition of the ASAM Criteria: What to Do and What Not to Do.”  (There are other articles there as well.)

 

2. Perhaps you are a provider or payer having concerns about how The ASAM Criteria are being used. Feel free to complete an Incident Report. There’s one for patients, providers and programs and a different one for payers and managed care organizations. Go to www.ASAMcriteria.org. Click on FAQ tab.  Search for: How do I report incidents of misuse of The ASAM Criteria?

 

3. There are opportunities for training on The ASAM Criteria. This happens via eTraining modules or via onsite workshops and conferences nationally.  Learn about eTraining at the RESOURCES & TRAINING tab.  For workshops and conferences near you, click on the EVENTS tab at www.ASAMcriteria.org

 

4. There also exists an enhanced web version of the ASAM book.  Click on the BOOK & WEB tab.  Take a test drive with the informative video.

Until next time

Happy New Year and see you again in late January.

 

David

Vol. 10, No. 10

In This Issue
  • SAVVY : Integrated and Collaborative Care improves care and costs
  • SKILLS : Why physicians, clinicians and counselors struggle to integrate and collaborate
  • SOUL : A father’s fears

David Mee-Lee M.D.

SAVVY

The debate over what to do about guns in the USA has not faded. It so often happens a topic is hot for a few weeks and then disappears as new “breaking news” competes for attention. But I will not saturate your attention this month with some readers’ responses to the December issue on guns – we’ll share those in a future edition.

Instead there’s a couple of healthcare topics that have been close to my heart for many years, and they have been getting more and more attention in the literature. I’ve been writing about them in Tips and Topics for the past decade. I believe these principles are clear and important; nevertheless I am also increasingly aware that many physicians, other healthcare professionals, clinicians and counselors do not share that view. Not only do they not share these values, but some may be outright suspicious and negative about these trends in healthcare.

What I’m talking about is Integrated Care and Collaborative Care.

 

TIP 1

Review your knowledge and values about Integrated and Collaborative Care.

 

The President of the American Medical Association (AMA), Jeremy Lazarus, M.D., who happens to be a psychiatrist, told delegates at the Interim Meeting of the AMA House of Delegates recently:

“It’s a new era in American health care – one that calls for physicians to collaborate with other doctors and health care professionals in a new model of integrated care….Integrated care asks us to cultivate mutual trust, to recognize that each team member offers unique skills and knowledge, and to support this trust with open and timely communication…And we must go all in to improve the quality if health care for our patients and the country.”(Psychiatric News, Volume 47, No. 23, December 7, 2012, pp. 1,9)

–> Years ago Parkside Medical Services had a value: “Everyone has a territory but nobody has a kingdom.” Each discipline and stakeholder has an important contribution to the whole, but nobody knows everything about everything, nor can do it all by themselves.

–> And it isn’t just about physicians collaborating with other health care professionals, it is about addiction counselors and mental health clinicians collaborating with primary care; it is in primary care where most people with addiction and mental health concerns actually show up for health care services.

So what is integrated and collaborative care?

Psychiatrist, Jurgen Unutzer, M.D., M.P.H outlined the following principles of integrated care:

    1. Patient-centered care through close collaboration of mental health and primary care providers. (DML: I would add close collaboration of addiction treatment too)
    2. “Measurement-based treatment to target” – treatments are actively changed until clinical goals are achieved.
    3. Population-based care in which patients are tracked in a registry.
    4. Use of evidence-based treatments.
    5. A system of accountable care in which providers are reimbursed for quality of care and clinical outcomes, not just the volume of care provided.

 

 

(Psychiatric News, Volume 47, No. 21, November 2, 2012, page 5)
http://psychnews.psychiatryonline.org/newsArticle.aspx?articleid=1387816

Does integrated care work?

Dr. Lazarus cited one example of the Southcentral Foundation in Anchorage, Alaska. Patients are assigned to a health care team consisting of a physician, nurse, medical assistants and even traditional healers. Here is how outcomes improved in the last decade:

  • Visits to the emergency department decreased 40%
  • Hospitalizations decreased 75%
  • Routine doctor visits decreased 30%
  • Binge drinking, strokes, heart disease and cancer rates among Alaska Natives are now about the national average whereas before they were much higher.

(Psychiatric News, Volume 47, No. 23, December 7, 2012, page 9)

TIP 2

Collaborative care is also about shared decision-making with patients and clients.

The New England Journal of Medicine (NEJM) published an article “Shared Decision Making to Improve Care and Reduce Costs”. (Emily Oshima Lee and Ezekiel J. Emanuel)
http://www.nejm.org/doi/full/10.1056/NEJMp1209500

  1. “In a 2001 report, Crossing the Quality Chasm, the Institute of Medicine recommended redesigning health care processes according to 10 rules, many of which emphasize shared decision-making. One rule, for instance, underlines the importance of the patient as the source of control, envisioning a health care system that encourages shared decision-making and accommodates patients’ preferences.”
  2. “Randomized trials consistently demonstrate the effectiveness of patient decision aids. A 2011 Cochrane Collaborative review of 86 studies showed that as compared with patients who received usual care, those who used decision aids had increased knowledge, more accurate risk perceptions, reduced internal conflict about decisions, and a greater likelihood of receiving care aligned with their values. Moreover, fewer patients were undecided or passive in the decision-making process – changes essential for patients’ adherence to therapies.”
  3. “Studies also illustrate the potential for wider adoption of shared decision- making to reduce costs. Consistently, as many as 20% of patients who participate in shared decision-making choose less invasive surgical options and more conservative treatment than do patients who do not use decision aids.”
  4. “In 2008, the Lewin Group estimated that implementing shared decision-making for just 11 procedures would yield more than $9 billion in savings nationally over 10 years. In addition, a 2012 study by Group Health in Washington State showed that providing decision aids to patients eligible for hip and knee replacements substantially reduced both surgery rates and costs – with up to 38% fewer surgeries and savings of 12 to 21% over 6 months.”

But what has this got to do with addiction and mental health services?

Longtime readers know how often I have talked about the therapeutic alliance, and how four decades of research indicate that the quality of the therapeutic alliance contributes most to successful outcomes. (Mee-Lee D, McLellan AT, Miller SD (2010): “What Works in Substance Abuse and Dependence Treatment”)

Here is one study’s surprising results:

Patients report benefits from open notes

“Patients involved with the pilot program at Beth Israel Deaconess Medical Center (BIDMC), Geisinger Health System (GHS) and Harborview Medical Center (HMC), who were subjects of an Annals of Internal Medicine study, reported benefits to having access to their physicians’ notes. Very few patients reported confusion or concerns, with the exception of privacy.”

Benefit or risk Portion of BIDMC patients Portion of GHS patients Portion of HMC patients
Felt more in control of their care 84% 77% 87%
Remembers care plan better 84% 76% 83%
Understands health conditions better 84% 77% 85%
Takes better care of self 70% 71% 72%
Takes medications better 60% 78% 73%
Concerned about privacy 36% 32% 26%
Worries more 5% 7% 8%
Found notes more confusing than helpful 2% 3% 8%
Felt offended 2% 2% 1%

Source: “Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead,” Annals of Internal Medicine, Oct. 2 (http://ncbi.nlm.nih.gov/pubmed/23027317/)

Bottom Line
Health care is changing in the USA – both in how it will be delivered and in how we engage patients and clients in shared decision-making. The research evidence is too compelling to keep doing business as usual. One last set of statistics from the Institute of Medicine (IOM) and the National Research Council:

  • The USA health ranks at the bottom among 17 rich countries.
  • Despite spending more per capita on health care than any other country, the United States also ranks at or near the bottom in infant mortality and low birth weight, injuries and homicides, teen pregnancy and sexually transmitted diseases, HIV and AIDS, drug-related deaths, obesity and diabetes, heart disease, chronic lung disease, and disability.
  • Health problems are more common among Americans who are poor or uninsured. But the panel also found that even healthy Americans who are insured, college-educated, or have high incomes seemed to be in worse health than are similar groups in other countries.

http://www.iom.edu/Reports/2013/US-Health-in-International-Perspective-Shorter-Lives-Poorer-Health.aspx

References :
1. Psychiatric News, Volume 47, No. 23, December 7, 2012, pp. 1,9 written by Mark Moran
2. Psychiatric News, Volume 47, No. 21, November 2, 2012, page 5 written by Mark Moran
3. “Shared Decision Making to Improve Care and Reduce Costs” Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D. N Engl J Med 2013; 368:6-8. January 3, 2013
4. Mee-Lee D, McLellan AT, Miller SD (2010): “What Works in Substance Abuse and Dependence Treatment”, Chapter 13 in Section III, Special Populations in “The Heart & Soul of Change” Eds Barry L. Duncan, Scott D.Miller, Bruce E. Wampold, Mark A. Hubble. Second Edition. American Psychological Association, Washington, DC. pp 393-417.
5. “Unveiling the Doctor’s Notes”, Pamela Lewis Dolan. American Medical Association (AMA) News, Volume 56, No.1, January 14, 2013.
6. “U.S. Health in International Perspective: Shorter Lives, Poorer Health” Jan 9, 2013. Institute of Medicine.

SKILLS

So if the research on integrated and collaborative care is compelling, why are some -perhaps many- physicians, clinicians and counselors suspicious and even antagonistic to these changes in health care?

TIP 1

See if you agree with these “people” obstacles to Integrated and Collaborative care.

There are different strokes for different folks and each discipline and health care provider may have different reasons for wanting to maintain the status quo. (In Motivational Interviewing this is called “sustain talk” in contrast to “change talk”.)

Physicians:
Reasons physicians might struggle with the move to integrated and collaborative care:

  • It requires a change in the core values that have motivated physicians – shifting from autonomy to shared decision-making and teamwork (Dr. Lazarus, Psychiatric News, December 7, 2012)
  • For decades, health care was organized and practiced “in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves.” (Dr. Atul Gawande, Psychiatric News, December 7, 2012)
  • Society has rewarded physicians for taking on life and death responsibility with financial and social status. As stressful as great responsibility is, shared power and decision-making requires a major shift and collaborative spirit./li>
  • Physicians have been trained to ask questions, quickly diagnose the disease, prescribe the treatment, often making life and death decisions very quickly. Patients are expected to answer questions, trust the doctor’s judgment and comply with doctor’s orders. And now the doctor is just one of the team and patients get to share decisions!

Addiction counselors:
Reasons counselors might struggle with the move to integrated and collaborative care:

  • Counselors who have come to the profession through their own life experience may have been misdiagnosed by physicians and prescribed psychotropic or addicting medication for years, before finally finding recovery. There is suspicion of physicians, the primary health care and mental health systems that often rejected people with addiction.
  • Addiction treatment has predominantly been abstinence-based with only recent acknowledgement of the possible role of psychotropic medication, opioid treatment services and an array of anti-addiction medications. Many counselors are still very uncomfortable with medication-assisted treatment and recovery.
  • For many addiction program models there has been a strongly held anti-medical, Twelve Step or social model ideology. The Therapeutic Community model, based on social learning theory, holds the power of the community and peers as being much more significant than doctors, nurses and other professionals. The Twelve-Step model has traditionally seen taking medication as “chewing your booze” and invalidating the AA member’s sobriety date. Whole counties and states have in the past prided themselves as being explicitly a social model system antagonistic to the so-called “medical model”. Even if these systems are changing, attitudes persist.
  • Addiction programs see a tiny sliver (1.5%) of the estimated 19.3 million persons aged 12 or older needing, but not receiving treatment for illicit drug or alcohol use. (2011 national Survey on Drug Use and Health, SAMHSA, Sept., 2012)
    http://www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011.htm#1.1With the busyness of waiting lists, limited resources and service demands already, there is little energy or interest to reach out to the millions of people with addiction who are in primary care settings.
  • Federal confidentiality regulations like 42 CFR Part 2 has reinforced separation of addiction and physical health records and flow of information.

Mental Health Clinicians:
Reasons clinicians might struggle with the move to integrated and collaborative care:

  • Insurance payers and managed care organizations have usually “carved out” behavioral health payments and care management from general health insurance. This has kept mental health and addiction fragmented from physical health.
  • The Health Insurance Portability and Accountability Act (HIPAA) and the real or perceived privacy requirements can lead physicians and others to withhold information from those who may have a right to have it. So much for integrated and holistic care!
  • The pecking order of different disciplines, reinforced by differing pay often for similar therapy work maintains boundary, turf and guild battles fighting for a piece of the health care pie.

TIP 2

Check if you can identify with any of these obstacles to Shared Decision Making and Collaborative Care with Clients and Patients.

  • Here’s what one reader asked a while ago:

    “I have been in mental health and drugs and alcohol for over ten years (no not ill or using- helping!) and I am having difficulty understanding why I would allow my client to determine their own treatment, when it is their poor decision-making over the years that have led them to where they are presently: several court cases, social services, probation, children removed from the home, unemployed again etc., so why all of a sudden would they now demonstrate good judgment?…..Would you be so kind as to explain the reasoning again for allowing the client to determine their own treatment?”

    My response:
    Here’s why shared decision-making makes sense especially for someone described as above: All change is self-change and people do what they want to do anyway. If there is to be real change, they have to be the one to choose the healthy choice in the dark of night when nobody is watching. Telling them what to do does not translate into sustainable action, otherwise we could send all our clients memos on how they need to change and to get busy.

  • Some might say:

    “I went to school for all those years, went into debt for the tuition and now have expertise and experience. Are you telling me that my expertise is to take second place to some collaborative care approach with patients and clients who are out of control?”

    My response:
    Shared decision-making with patients and clients isn’t some “touchy feely, politically correct” approach to appease some consumer movement. And it doesn’t mean you abdicate your responsibility and expertise to do a good assessment and share with clients the very best, effective and efficient way to reach their goals. It is a recognition that if accountable, self-propelled change is the outcome you want from your treatment, then the client has to be as engaged and committed to changing as you are. In fact, if you think about your own resolutions to change, it is hard enough to sustain change even if you really want it and know what to do.

    Positive and lasting change has little chance of success if the client doesn’t share the same fervor for the goal as you; nor share the same decisions on how to get there; and doesn’t really trust you anyway.

  • “Righting reflex” – “the desire to fix what seems wrong with people and to set them promptly on a better course, relying in particular on directing” ((Miller, William R; Rollnick, Stephen (2013): “Motivational Interviewing – Helping People Change” Third Edition, New York, NY., Guilford Press. page 6). Clinicians have a hard time resisting the reflexive, clinical response to fix such obvious pathology and poor choices. People who choose the “helping professions” are particularly vulnerable to the “righting reflex”. Motivational Interviewing “guides” not “directs” people to change through collaboration and shared decision making.

SOUL

This morning at 4 AM I was jarred out of sleep with the phone ringing. Being a physician for forty years, it is imprinted to answer the phone and try to think clearly quickly. But I’m not on call anymore and there aren’t any training and consulting emergencies at 4 o’clock in the morning.

So I squinted to see if caller ID would help get me oriented quickly. “Skype caller” it said. Must be my son traveling in Southeast Asia. Fatherly anxiety rising.

“Hello, hello, can you hear me?”

“I’m sick.”

“Tay (Taylor named after James Taylor one of my favorite singer-songwriters just like my son is), Tay what’s wrong and where are you?”

“I’m in Luang Provang, Laos and I’m sick.”

I kicked into doctor mode and took a careful timeline history of symptoms: eating at a supposedly clean tourist-friendly restaurant but still symptoms of diarrhea, lethargy, no appetite; OK the next two days; then some more diarrhea, fever with stomach cramping after taking strong antibiotics.

My initial diagnosis: travelers’ diarrhea related to food contamination complicated by antibiotic side effects. Treatment: water, rest, eat when body says it is ready, avoid risky foods like salad washed in unclean water and uncooked food.

That was 14 hours ago as I write this and no word back, which I hope means “no news is good news”. But I won’t rest well until I know he is really OK. It got me thinking though about all the parents out there with military children and loved ones in harm’s way all over the world.

My son is on a happy adventure. Their children are on a dangerous mission.

I’m worried about food poisoning and diarrhea. They’re worried if their kid will get a limb blown off or suffer from Traumatic Brain Injury, or not even come back home.

A parent’s anxiety for their children’s safety and well-being is powerful, no matter how big or small the danger is. So I count my blessings that, right now, it’s only about diarrhea for this father.

PS. E-mail from Taylor:

“It is 11:41 AM here and just got up and out of the shower. I am significantly better. I woke up around 1 AM and could feel my fever breaking. I have no tummy ache and have an appetite again. I am still very weak and tired though, probably to be expected after 1.5 days of no food and lots of diarrhea. Man, being sick sucks. It really takes it out of you. It is an exciting trip, but you also realize how having your basic health and safety is a must for any type of enjoyment.

We will go out now and get some food and plan our next move. I’ll keep you informed. Thanks for your help and support.
Love you,
Taylor”

Until next time

Thanks for joining us for the start of 2013. See you again in late February.

David