January 2015

David Mee-Lee M.D.


SAVVY

As I prepare for this month’s edition, it is Martin Luther King Jr. Day. So it is fitting that I continue last month’s topic and share with you some lively responses from readers….along with my comments on their comments. It is always stimulating and informative to hear passionate responses on a hot topic that is still boiling in the pot of public opinion.

Here are some comments with the reader’s identification (or non-identification as they requested.) Where I used only their credentials, I did not yet hear back from the reader on how they wished to be identified or not. So I have edited out any identifying information.

 

Reader Comment #1

So, Blacks are equally responsible for however it is that they’re treated? Hmmm, interesting. Isn’t that equivalent to “What did she wear?” “Why doesn’t she leave?” “Why was he there?” “Was that real rape?” How were the Chinese equally to blame for the Chinese exclusion laws? How were Black and Brown people equally to blame for ‘The War On Drugs’? And severely mentally ill people are at least partially to blame for their mistreatment and incarceration. Well, this notion of contributory culpability certainly helps some people feel better. Is that what this is about? Is this an idea of being fair? I’m not buying it, sorry.

 

Reader #1, MSW, Ph.D., LCSW

 

My Comments on Reader Comment #1

 

As I said in last month’s edition, http://www.tipsntopics.com/2014/12/race-relations-dont-be-a-rat-violence/ I don’t have any pat answers and am more intent on listening, as race relations is a complex issue with no simple answers. So I was grateful for the readers’ comments to fill me in on their varying perspectives. Here are a few bullet point comments:

  • I am not sure where this reader perceived that I said: “Blacks are equally responsible for however it is that they’re treated”.
  • Perhaps the reader thought that SKILLS last month was blaming the victim for their treatment by police; and I can see how someone might interpret that section this way.
  • What I was passing along in SKILLS from people more experienced in these issues, was that parents owe it to their children, to teach them how to survive being arrested by police.
  • Actually, whatever the color of a person’s skin, but even more so if part of a race or subculture that is often profiled (African Americans, Hispanics, Latinos, Moslems, Asians, LGBT,mentally ill, homeless people, sex workers etc.,) SKILLS addresses some good tips for all of us. Perhaps I should have clarified that.

The main point I heard from this reader was that African Americans, rape victims, Chinese and others discriminated against are not responsible for injustices perpetrated against them. The reader challenges the notion of “contributory culpability”.

  • I don’t know. But it is hard for me to say that Michael Brown in Ferguson, MO and Eric Garner on Staten Island, NY contributed nothing to the way they were treated. I don’t mean the color of their skin. I mean what were they doing and how were they acting that caught the attention of the police in the first place? How did they respond when confronted by the police? If they had the SKILLS of last month’s edition, could they have prevented such a tragic end?

 

Reader Comment #2

Lisa raises good points about how alcohol and other drugs is a common and even determining theme in all three cases. “Drugs NOT Race!!” is what she declares.

Just a brief comment to your response in Tips and Topics. Succinctly said!! I just changed jobs and was a therapist in the mental health department of Louisville Metro Corrections, the downtown jail in Louisville, Kentucky for a total of 12 years. I was born and raised in Cincinnati, Ohio and my father was a police officer for 30 years. This month’s newsletter is an excellent message for parents but is the correct audience “listening”? If you study statistics of people on some substance who are booked into a jail, the stats do not hold up. What I mean by that is there are many other reasons they come in. For example if a probation officer drops (requires a urine drug screen) someone and they are positive, they arrest them and bring them in under the heading of PROBATION VIOLATION (but the offender was actually high on drugs). Same thing with domestic violence. There are always drugs and/or alcohol involved in an arrest but they come in with the charge of Assault IV usually, or higher with Assault 3, etc. I could go on and on.

As Lisa said: ‘People behave in irrational ways when they are in midst of very real biological “urges.” (Everyone can relate to speeding when in need of a toilet.) MB didn’t want to go jail; he wanted to go get high, and no one was going to stop him. THAT explains his bizarre response to being detained by Officer Wilson. It’s called “dope” for a reason – it turns off the “thinking” part of the brain!’”

Thanks again for bringing attention to the real reason powering these feuds.”
Sheila Redella, MS., CADC

Addiction Services Therapist

The Brook Hospital, KMI

Louisville, Kentucky 40242

Sheila.Redella@uhsinc.com
My Comments on Reader Comment #2

Sheila sees real value in Lisa’s explanation for each victim’s contribution to their treatment by police. That contribution was not the fact of their skin color, but their drug-induced behavior. If drugs were actually involved, that would seem to help explain their inability, even if they had been taught, to employ the SKILLS in last month’s edition.

 

The next reader was not so impressed with Lisa’s perspective.

 

Reader Comment #3

I am a Substance Abuse counselor. I am also black, a career Navy veteran and service connected disabled veteran. I am in total agreement with having a dialogue on race/race relations.

 

Not knowing all the circumstances surrounding Michael Brown (MB), I won’t bother to comment on the incident, per se. However, I will give response to Lisa’s comment. In the years of my experience as a Substance Abuse Counselor, I have never seen nor heard of someone with high THC levels CRAVING to the point she mentions. Had she used her scenario to describe someone on LSD, Peyote or some other hallucinogenic, her assertion would be more acceptable and understandable. However, like so many other ‘arm-chair’ quarterbacks mentioning this atrocity, one would think she were a Forensic Therapist on the scene.

 

What I believe is Lisa’s not realizing what seems to be a biased perspective on race.

Lisa’s comment in my opinion would be right-on, had she had known or was a sighted witness as to what happened! Thus my bias! She believes and justifies what occurred to this young man as fact, based on what she read in the media. Mind you, I have not assumed Lisa’s race or ethnicity in my response. It merely gives reference to how some people believe all that is written in the media to be fact, when the situation/crime gives reference to race; black or brown people.

 

I remember years ago as a young Navy seaman stationed in Maryland, myself and a Caucasian friend and shipmate went to spend a weekend in Baltimore, Maryland. We were in full dress Navy Blues when we entered and sat for service at a White Front restaurant, service similar to White Castle restaurants. My friend and I each ordered four of the small hamburgers; his were placed on a plate, and mine in a bag. I was asked to pay and leave, or frequent one of the restaurants on the Eastside of town, a predominantly black community.

 

Some years later, I was appalled by the racism experienced when our ship made a Port visit in Hawaii, on the way to Vietnam. There too, racism was obvious when black and/or shipmates of color weren’t as welcome on beaches, clubs or restaurants as our Caucasian shipmates. We were obvious to being welcomed on Hotel Street, then a red light district of drug addicts and prostitutes.

 

Although some changes have been made since the Civil Rights movement, little in my lifetime of race relations has. Racism has become clothed with subtleties. Until there is some bond of honesty and trust on both sides of the equation, open discussion on racism will be minimal to say the least

 

Respectfully,

Wendel

 

My Comments on Reader Comment #3

Wendell has experienced racism first hand and recounts for us these unjust and painful experiences. I agree that in most places, racism is not as blatant as in the days ofMartin Luther King Jr. As Wendel says “Racism has become clothed with subtleties”. What I don’t agree with or get from Lisa’s comments last month was that there was a “biased perspective on race”. If the media did report on drug use by Michael Brown and if Lisa accepts that as fact, I don’t see that as racism. Her point was to highlight the power of substance-induced behavior and focus on that, not race.

 

 

Reader Comment #4

“Thank you so much for addressing this issue this month. I come from a long line of former and current law enforcement officers and at times it is a fine line for me as a substance abuse professional to distinguish between behavior that I assume is substance induced and the behavior of cops that may not be as trained in Substance Abuse and Mental Health disorders that they should be. With regard to race relations, there are people of all races that do things wrong. It is the person and their actions that needs to be looked at, not the color of their skin.   I wholeheartedly agree with the “RAT” concept and I believe in the mutual respect that needs to take place between detainee and police officer. At the end of the day, my family members need to come home, and I trust that they will use their best judgment if push comes to shove.”

 

Best,

Jody Polidoro

New Jersey

jpolidoro@ncaddnj.org

 

My Comments on Reader Comment #4

Sheila and Jody remind us about what it is like for the family members of police officers who everyday risk their lives to maintain the peace and preserve public safety.

  • Jody, like Lisa, emphasizes “It is the person and their actions that needs to be looked at, not the color of their skin”.
  • That is a message good for all involved: those arrested, those doing the arresting and those watching all this. Reader #7 (below) speaks again to this point.
  • I like what President Obama said in his January 20, State of the Union Address:

“We may have different takes on the events of Ferguson and New York. But surely we can understand a father who fears his son can’t walk home without being harassed. And surely we can understand the wife who won’t rest until the police officer she married walks through the front door at the end of his shift.”

 

 

Reader Comment #5

Thank you so much for addressing this very difficult topic. You are right there are no simple, easy solutions, but the more we can talk and listen with compassion and respect perhaps the closer we can get to some solution. How sad it is that we have to teach our children (and adults) how not to be harmed by the police. I am trying to live and embrace the sadness without being lost in the anger and outrage. I too try to remember the Non Violent Communication (NVC)approach.”
Peace to us all.

Lori Rugle, Ph.D., NCGC-II

Program Director

Maryland Center of Excellence on Problem Gambling

University of Maryland, School of Medicine

Lrugle@psych.umaryland.edu
My Comments on Reader Comment #5

I agree with Lori about the importance of talking and listening with compassion and respect.

  • When African Americans and other minorities have suffered generations of discrimination and injustice, anger and suspicion is understandable. What will it take for the oppressed to feel safe enough to talk and listen with compassion and respect rather than with hate and defiance?
  • For generations, the police and law enforcement have dominated and placed themselves in harms way to protect law and order and the community. Such absolute power can breed insensitivity to the needs of others. What will it take for law enforcement to feel safe and talk and listen with compassion and respect rather than wield force to subdue and subjugate?

 

Reader Comment #6

This Tips & Topics was (as they all are) right on about the current violence.”

 

Thanks

Phil Cerrato, LCSW,

Substance Recovery Therapist

Manassas, Virginia.

 

 

Reader Comment #7

I am a black man who works in Maryland. I read this article and I felt both your urgency to resolve this issue as well as your discomfort with the topic. It is understandable that most people struggle and are uncomfortable with this issue and then again, when you stop and think about it, we really shouldn’t be. After all, we’re only talking about skin color here. Yes, there are cultural differences, but to tell the truth, most people only react to a person’s color.

 

I too have been guilty but more and more, I am able to at least speak to someone before I judge them just because of their skin color. I have been pleasantly surprised when I speak to someone who I have had preconceived ideas about (even people of my own race!) to find out that they are nothing like what I thought they were.

 

Regarding the police shootings, each one of them involved different circumstances but yet they are all lumped together simply because of skin color. There is no doubt that the police have, for years, prejudged people based on skin color. Yet, they are no different than any of us. This does not excuse their behavior when they do that (as many do not always do that) just as it does not excuse our behavior when we do it.

 

I do not think it is complicated. I think that people just have to acknowledge that when they see someone with a different skin color, they are prone to prejudge. We just need to acknowledge it and consciously work on seeing beyond a person’s color. We are able to do it when it comes to money…We value it, no matter what it might look like!

 

George Phillips

Maryland

 

My Comments on Reader Comment #7

George is right about what he sensed: “felt both your urgency to resolve this issue as well as your discomfort with the topic”. I hesitated to raise race relations last month because there are such strong feelings being expressed about this issue and not a lot of listening. But George raises some important points thatI highlight again:

  • Discussing race relations doesn’t need to be complicated and uncomfortable if we realize we all easily fall into the mistake of seeing only a person’s skin color.
  • It would be worth remembering that “There but for the grace of God, go I”. As George says, including himself: “most people only react to a person’s color.”
  • Speak to a person before judging them on preconceived ideas because of skin color. That applies in all directions: blacks talking to whites; whites talking to blacks; blacks talking to browns; browns talking to whites etc.
  • Police do and have prejudged people on the basis of skin color. But haven’t we all?
  • Acknowledge that when you see someone of a different skin color, you are prone to prejudge. Work on seeing beyond a person’s color.

SKILLS

There is a lot of attention, and rightly so, on trauma and the importance of being trauma-informed. This is raised in the context of working with people with addiction and/or mental disorders; returning veterans and Posttraumatic Stress Disorder (PTSD); intimate partner abuse and domestic violence; and young people in violent and gang-infested neighborhoods.

 

I was recently listening to a radio piece on “Up2Us: Trauma-Sensitive Coaching Transforms Urban Youth Sports by Karen Given (September 20, 2014). You can hear the whole story at: http://onlyagame.wbur.org/2014/09/20/up2us-trauma-sensitive-youth-sports

 

In the training of trauma-sensitive, youth sports coaches, Lou Bergholz explained really well an approach that could help police officers and others avoid escalation of traumatized youth. He was explaining the central role the amygdala plays in how some youth react and what to do about that.

 

But first, here is a brief overview of the Amygdala quoted from information at http://biology.about.com/od/anatomy/p/Amygdala.htm

  • “The amygdala is an almond shaped mass of nuclei (mass of cells) located deep within the temporal lobe of the brain.
  • It is a limbic system structurethat is involved in many of our emotions and motivations, particularly those that are related to survival.
  • The amygdala is involved in the processing of emotions such as fear, anger, and pleasure.
  • The amygdala is also responsible for determining what memories are stored and where the memories are stored in the brain. It is thought that this determination is based on how huge an emotional response an event invokes.”

 

Coach Bergholz explains further and quoting from Karen Given’s news story:

“So the amygdala has one job, and its only job is to look around all day and wonder, ‘Can I eat it or does it eat me?’” he said.

 

“When there’s danger,the amygdala kicks into gear. Muscles get tense, the heartbeat quickens and blood leaves the brain. Higher-level problem solving is out. If the brainis kept in this hyper-alert state for too long or is pushed there too often, scientists say the brain loses its pathways to critical thinking.

 

Why is this important for a group of young sports coaches to understand?  Studies have shown that as many as one-third of children living in America’s most violent neighborhoods have post-traumatic stress disorder. That’s nearly twice the percentage of PTSD-affected soldiers returning from Iraq or Afghanistan.”

 

These children have been exposed to ongoing physical and sexual abuse, violence in the home and streets, substance-induced yelling and arguments at home. This keeps their brains (amygdala) in a constant state of alertness and their bodies tense and ready to fight. Critical thinking goes out the window when faced with danger and survival.

 

TIP 1

How to talk to a person whose amygdala is activated

 

These tips are relevant in a clinical situation with clients with PTSD, but also on the street when police officers are involved with traumatized youth and others.

 

Writer Karen Given again:

“Bergholz says coaches already know what to do when a kid shows up to basketball practice and has no idea how to dribble the ball.

  • “But you have a kid come and you say, ‘stand here,’ and they stand there, and you say ‘listen here,’ and they are talking,” he said.
  • “We think of that as a will issue, that somehow they’re doing it on purpose. They’re misbehaving. But what if it’s also a skill issue?”

Here’s the tip that applies not just to trauma-sensitive coaches, but also to trauma-sensitive clinicians:

  • Thetrauma-sensitive coach’s job isn’t just to teach basketball players to dribble. It also includes training kids’ brains to redevelop those pathways tocritical thinking.

 

Role Play at the Up2Us training session:

Player: “Oh my god, coach, did you see that? She’s all over me.”

Coach: “Calm down.”

Player: “Calm down? You calm down! What do you mean, calm down?”

 

Trauma-sensitive coaches know:

  • Asking a traumatized youth whose amygdala is in overdrive to “calm down” doesn’t help.
  • Asking “what’s wrong?” isn’t any more successful. That only works to escalate the player’s emotions.

 

Instead, Coach Bergholz suggests the following dialogue:

Coach: “Do you know what eight-seven-eight means?”

Player: “Eight-seven-eight, no. Eight-seven-eight, I don’t know.”

Coach: “You got eightrebounds so far, seven assists, and eight points. Do you know what a triple double is?”

Player: “Yeah.”

 

“The idea is to get the player thinking, which helps to shut down the amygdala.”

These are good tips for clinicians and police officers who may inadvertently escalate an interaction with a traumatized person whose amygdala is over-activated.

 

Reference:

Up2Us: Trauma-Sensitive Coaching Transforms Urban Youth Sports

By Karen Given September 20, 2014

http://onlyagame.wbur.org/2014/09/20/up2us-trauma-sensitive-youth-sports

SOUL

Earlier this month, I was in the Emergency Room of my local hospital. I wasn’t there to do a consultation evaluation for a psychiatric or addiction patient. I was the patient. If you happen to be a woman who has given birth and knows intimately what labor pains are like, you know what I was going through.

 

I’m told that renal colic – the pain of your kidney’s plumbing trying to pass a kidney stone – is in the same ballpark as childbirth. My hat is off to the women of the world who graciously navigate that baby through their birth canal and even come back for more!

 

The older you get, the more precious the gift of good health becomes. I have been blessed with basically very good health and energy. It is easy to get smug and complacent. I’ve known for years that I should drink more water. Water is not just good for helping prevent kidney stones, but it can help prevent heart attacks from dehydrated sludgy blood that can cause clots.

 

But some days I can go the whole day with barely a glass or two. You can bet this was a wake-up call. Now I’m running to the bathroom all the time to keep up with my increased intake.

 

It was like some years ago when I used to pride myself as having normal blood pressure with little exercise. Then one day, my dentist screened for hypertension and I was in the marginal range. Knowing I wanted to avoid antihypertensive medication, that was a wake up call to get moving and start the exercise I should have been doing ages ago.

 

So how come I need all these wake up calls? Unfortunately I don’t think I’m the only one. There is an old Chinese proverb that goes something like:

 

The foolish personlearns from their own mistakes.

The wise person learns from the mistakes of others.

 

I invite you to be wise and learn from my mistakes.

Until next time

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

David

SAVVY & STUMP THE SHRINK

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

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

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

 

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

 

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

 

TIP 1

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

 

Case #1

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

 

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

 

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

 

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

 

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

 

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

 

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

 

 

TIP 2

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

Diagnostic Criteria Sets 

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

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

References:

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

 

Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies.

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

SKILLS

Case #2

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

 

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

 

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

 

Here is the documentation on Dimension 4 assessment:

Dimension 4: Readiness to Change:

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

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

 

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

 

TIP 1

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

 

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

 

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

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

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

 

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

SOUL

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

 

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

 

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

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

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

 

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

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

 

This is where Feng shui “eyes” come in.

 

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

 

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

Belated Happy Chinese New Year!

SHARING SOLUTIONS & STORIES

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

 

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

 

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

Until next time

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

David

Vol.12, No.12

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

David Mee-Lee M.D.

SAVVY

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

 

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

 

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

 

TIP 1

Distinguish between gender dysphoria and gender identity issues

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

 

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

 

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

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

 

TIP 2

Become familiar with current Transgender Terminology

 

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

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

 

Here are a few highlights to note:

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

References:

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

 

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

 

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

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

 

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

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

SKILLS

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

 

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

 

TIP 1

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

 

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

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

 

Here are some of the points his article raises:

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

 

TIP 2

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

 

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

 

Dimension 1: Acute intoxication and/or withdrawal potential    

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

Dimension 2: Biomedical conditions and complications

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

Dimension 3: Emotional/behavioral/cognitive conditions and complications

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

Dimension 4: Readiness to Change

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

Dimension 5: Relapse/Continued Use/Continued Problem potential

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

Dimension 6: Recovery Environment

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

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

 

References:

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

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

 

Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies.

SOUL

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Enjoy.

Until next time

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

David

SAVVY

In the February 2015 edition of Tips and Topics, I outlined a case presentation of a client who had already been in Level 3.5 Residential addiction treatment service for over four months when she was discharged to outpatient services. The client used alcohol within a day of discharge. The treatment program readmitted her for more weeks in their residential program. It was as if the treatment agency felt several more weeks of the same level of care would produce a better outcome.

https://www.changecompanies.net/blogs/tipsntopics/2015/02/

Joe Gerstein, MD, FACP, is the Founding President of SMART Recovery Self-Help Network is an internist and pain management consultant. He wrote and shared perspectives and information worth passing onto you this month.

 

Here’s some of what he said:

“In the 2nd case presented, the woman who had been over 4 months in residential care and relapsed immediately on discharge, there seems to be more than just a failure to observe a rational and patient-centered interpretation of criteria. There seems to be total obliviousness to the likelihood that the therapeutic approach being used may be entirely incorrect for this patient’s temperament and worldview and that “more of the same” will be unlikely to achieve any benefit.”

 

Dr. Gerstein went on to correctly suggest that there be a re-assessment of the type and style of therapy rather than the “assumption that the fault always lies with the patient’s obstinacy and lack of cooperation and denial.” He then shared the following link as an example of how a change in treatment approach can yield dramatic results.

See https://www.youtube.com/watch?v=o4S70dPBSIM by Leigh who is now Regional Coordinator for Wales, UK SMART Recovery Trust.

 

Many are familiar with Alcoholics Anonymous, Narcotics Anonymous and other 12-Step recovery groups; and I always try to mainstream people into AA or NA since these groups are so readily available. But too few fully understand SMART Recovery as an adjunct or alternative to AA and NA for those who may need a different approach to improve outcomes. Since Joe has facilitated over 3,000 SMART Recovery meetings in communities and prisons around the world; and has written about and lectured at a number of symposia on alternatives to the 12-Step approach, I asked him to explain more about SMART Recovery.

 

TIP 1

Take a look at what you know or do not know about SMART Recovery

 

Here’s what Dr. Gerstein explained about SMART.  His comments are indicated with quotation marks:

 

Some history:

“I certainly would like to clarify things about the origin of SMART Recovery. This was definitely a group endeavor. SMART started out as the non-profit arm of Rational Recovery. As I recall, there were 8 professionals [all except myself from the mental health profession] and 2 lay people who had used the program to achieve sobriety at the first organizational meeting of the Rational Recovery Self-Help Network. The detailed history is capsulized in several sources, which I will note below.

 

It became clear in the next few years that there were irresolvable differences between the non-profit and the for-profit elements, so the non-profit broke away and renamed itself SMART Recovery (Self-Management And Recovery Training) in 1994. Originally only a 2-Point program, Coping With Urges and Dealing More Rationally With Problems, it rapidly evolved into a 4 Point Program by adding Motivational Enhancement and Lifestyle Balance components. By now there are 13 Tools. Our Correctional Version of SMART Recovery, InsideOut, funded by the National Institute on Drug Abuse (NIDA), contains an additional module, Criminal Thinking Errors.”

 

SMART in the Prisons and Criminal Justice:

Dr. Gerstein again: “My own particular areas of involvement in the program have been here in Massachusetts where we have had over 25,000 meetings, prison applications of SMART [I have facilitated almost 800 prison meetings and introduced the program into Australian and UK prisons, where it has flourished] and the formation of SMART Australia, SMART UK and SMART South Africa. The Kingdom of Denmark has provided almost $2,000,000 to translate SMART materials and support startup of 24 SMART groups. A recent study from New South Wales (Australia) prisons involved 3,000 inmates exposed to SMART and 3,000 controls matched in 7 parameters. Those inmates attending at least 9 SMART sessions had a 53% reduction in reconviction rate for violent crimes.”

 

SMART and Science:

  • “The scientific underpinnings of the program are Rational Emotive Behavioral Therapy (REBT)/Cognitive Behavior Therapy (CBT), Motivational Interviewing, Solution-Focused Therapy, Stages of Change and Motivational Enhancement Theory.”
  • “Incidentally, a number of surveys have demonstrated that about 30% of participants who attend SMART meetings fairly regularly and consider SMART their primary recovery modality also attend AA/NA meetings at least occasionally. We have absolutely no problem with this approach. SMART has no objection to use of appropriately-prescribed medication for either the addiction or underlying mental health problems, or both.”
  • “A study by the Walsh Group several years ago demonstrated that progress in recovery via SMART was about the same for people with varying degrees of religiosity or the non-religious.”
  • “A study by Reid Hester funded by NIDA was a randomized control trial (RCT) with 183 new SMART attendees. They were divided into 3 cohorts receiving different types of access to the SMART program and/or to Hester’s interactive online program, “Overcoming Addictions: Introduction to SMART Recovery. All had alcohol as their addictive substance. All had a corroborative person available. We have the 3- month results (6-month results due soon). There was about a 70% reduction in all groups in drinking days, drinks per drinking day and negative social/legal/medical events.”

SMART online and internationally:

“The online experience has been quite a phenomenon. Except for a webmaster (in Uruguay!) and an intermittent web designer, virtually the entire enterprise is run by volunteers. Thousands have had their entire recovery on the website and develop incredible bonds amongst themselves.

 

SMART Recovery now has 1500 meetings in 17 countries and is in use in a number of treatment facilities. About 150 trainees per month take the interactive online training program, about 2/3 professionals or students training to become professionals. At our 20th Anniversary Conference in Washington last Fall, we were gratified to have Michael Botticelli, Director of National Drug Control Policy, give the welcoming address and bring along a Presidential Proclamation honoring SMART’s contribution to the recovery community.”

 

Joe Gerstein. MD, FACP

508 733 6469

jgerstein@hotmail.com

 

 

References:

Atkins, Randolph G., Hawdon James E (2007): “Religiosity and Participation in Mutual-Aid Support Groups for Addiction” J Subst Abuse Treat. 2007 Oct; 33(3): 321-331.

The Walsh Group Study: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2095128/

 

Blatch, C., et al. Efficacy of SMART Recovery Program in New South Wales Prisons. Submitted for publication.

 

A Chronology of SMART Recovery®

Compiled by Shari Allwood and William White

 http://www.williamwhitepapers.com/pr/Chronology%20of%20SMART%20Recovery.pdf 

 

Hester, Reid K, Lenberg, Kathryn L, Campbell, William, Delaney, Harold D. (2013): “Overcoming Addictions, a Web-Based Application, and SMART Recovery, an Online and In-Person Mutual Help Group for Problem Drinkers, Part 1: Three-Month Outcomes of a Randomized Controlled Trial” Journal of Medical Internet Research. Vol 15, No 7 (2013): July. The Hester Study: http://www.jmir.org/2013/7/e134/

SKILLS

Last month I introduced some information on Transgender individuals and an article by Beck Gee.

 

Beck wrote to me and I’ll share some of the dialogue we exchanged as I learned something new. This led to this month’s SKILLS section:

 

Dear Dr. Mee-Lee,

“I wanted to thank you for your Tips & Topics discussion this month. One of my friends forwarded it to me as he noticed I was referenced. This topic is very dear to my heart and it is my passion and calling to work with trans-individuals and substance use….. I just wanted to make a small remark. You referenced me with male pronouns. I identify on the spectrum of trans, as gender nonconforming and use them/they/their pronouns. I was assigned female at birth. It’s totally okay that you identified me as male, probably due to my name… these are the things that I continue to work on and help treatment centers and addiction professionals be more aware of. It’s an amazing opportunity, and relevant, and timely. I think if I would have started talking about this 2 years ago, it would not be having the same effect as it is now.”

 

All the best,

 

Beck Gee MA LADC ADCR-MN

Assistant Director of Clinical Services

Pride Institute

2101 Hennepin Ave #202

Minneapolis, MN 55405

612-825-8714 (main)

rebecca.gee@uhsinc.com

  

My response:

Thank-you, Beck, for writing and for your original article which was informative for me. I am relatively new to the whole subject of transgender people and appreciate your pointing out who I assumed you were -male- and referred to you that way. Yes, your name did lead me to make that assumption, although, as I think about it now, I’m not sure if Beck is a male or female name and so is perfect for gender nonconforming people. This goes to show how I still have more to learn.

 

So if I had referred to you correctly, how should I have said that: “In their article, Beck Gee emphasizes…..” Would readers understand that “their” was used instead of “his” or “her” because you are a gender nonconforming person? Is this an issue you teach clinicians about – how to refer to each person by asking them do you want to be referred to as “he”, “she” or “they”?

 

Thanks for writing and helping raise my consciousness about trans people.

David

 

TIP 1

Raise your consciousness about gender nonconforming individuals who identify on the spectrum of transgender. Note terminology on how to address them.

 

Here’s what Beck taught me:

  • You would be correct in using “In their
    article…” When I train clinicians we can sometimes battle on the grammar piece, when someone comes in who is gender non conforming and uses the pronouns them/they/theirs. In lectures/sessions, I’ve experienced battles with clinicians on grammar. It would be easier if we lived in Sweden, where they use a third gender pronoun

http://www.washingtonpost.com/blogs/worldviews/wp/2015/04/01/sweden-is-about-to-add-a-gender-neutral-pronoun-to-its-official-dictionary/

  • Beck pointed to the following article:

http://feministing.com/2015/02/03/how-using-they-as-a-singular-pronoun-can-change-the-world/

  • “I also tell them that in clinical notes, I make a note at the beginning that states “The client uses them/they/their pronouns, therefore all clinical notes will refer to the client with those pronouns”.   I also make note that therapeutic alliance relies heavily on affirmation and respect. If we are not affirming of a client’s identity then we are doing a disservice. And respect must come from the institution as a whole, if someone is misgendering a client, we must correct them. Even where I work, when a client comes in, and someone may misgender them in staffing or report, I instantly correct them. Because even behind closed doors we must be respectful and aware.
  • We also have done away with “What pronouns do you prefer?” question. We ask “What are your pronouns, or what pronouns do you use?” Because it’s not a preference, it just is.”

So was your consciousness raised? Or did you already know all about this and it was just me who was oblivious to these issues?

 

SOUL

I don’t know what your high school teachers were like and whether they were as confrontive as some of mine. (Of course this was last century). But I remember one teacher almost yelling at a fellow student who was an unmotivated learner and kind of pouty and negative: “Change your attitude!”

   

“Change your attitude” indeed.  Not so easy to do.  But then, maybe it is easier than I would have thought.  Society in the USA – even more so in some other countries-  is changing attitudes and cultural norms at a more rapid pace than you would have thought possible even a decade ago:

  • Same-sex marriage is legal in 37 states and the District of Columbia.  I’m no math wiz, but that seems like a pretty substantial majority.
  • Medical marijuana is legal in 23 states and the District of Columbia with nine more states pending.
  • Four states have already legalized recreational use of marijuana and the District of Columbia has legalized possession of small amounts of marijuana. Seven more states are getting ready to legalize it too.
  • Transgender individuals are increasingly being recognized and accepted and will likely get a boost with Bruce Jenner’s recent interview on his transition seen by 17 million people and counting. (Bruce asked to be referred to with male pronouns for the time being.)

When it comes to addiction treatment providers though, it is interesting to see how slowly attitudes are changing in regards to one of the most difficult forms of addiction – nicotine addiction or tobacco use disorder. Ever since the new edition of The ASAM Criteria (2013) published a new chapter on Tobacco Use Disorder, I’ve been quoting a statistic that surprises people:

 

  • More people die in the USA every year from smoking tobacco and nicotine addiction than from alcohol, heroin and cocaine combined.

Recently, I thought I better check this statistic to make sure this is accurate. I found out I was wrong – or at least only partially correct. Actually…..

 

  • More people die in the USA every year from smoking tobacco and nicotine addiction than from alcohol, heroin and cocaine; AND from AIDS, car accidents, murders and suicides; AND in World War II… all combined.

http://www.politifact.com/truth-o-meter/statements/2009/jun/29/george-will/claims-smoking-kills-more-people-annually-other-da/ 

 

Now that is some statistic that you think would change the attitude of addiction treatment providers to make treatment programs smoke and tobacco-free. And in fact, more and more treatment providers are taking nicotine addiction seriously.  But there are still many programs that don’t allow smoking in treatment groups or in the building, but have a smoking gazebo on the grounds where clients and staff can have a cigarette before group treatment.

 

Well, I’m looking for the beer and wine gazebo where clients and staff can bond and have a beer or glass of wine before group.  What’s the difference?

 

“Change your attitude” indeed.  It’s harder than you think……or is it?

SHARING SOLUTIONS

The ASAM Criteria Software was released on April 25, 2015 at the Annual ASAM Meeting in Austin, Texas. Now branded as Continuum ™, The ASAM Criteria Decision Engine.

 

Continuum ™ provides counselors, clinicians and other treatment team members with a computer-guided, structured interview for assessing and caring for patients with addictive, substance-related and co-occurring conditions. By branding the software as “Continuum” it means The ASAM Criteria isn’t just about assessment at the front intake part of treatment in order to make a placement decision. It means that The ASAM Criteria is about ongoing chronic disease management across a whole continuum of care.

 

The book and Continuum ™ are companion text and application. The text delineates the dimensions, levels of care, and decision rules that comprise The ASAM Criteria. The software provides an approved structured interview to guide adult assessment and calculate the complex decision tree to yield suggested levels of care, which are verified through the text.

For more information, go to the website www.asamcontinuum.org 

Until next time

For the May edition, I have asked a special guest-writer to share his experience.  My son,

Taylor, will share with you his observations on what it is like to set aside alcohol for Quarter 1 of the year.  I know you’ll enjoy hearing about his experience.    

David

Vol.13 , No. 2

Welcome to the May edition of Tips and Topics with special guest writer, my son, Taylor. I hope you enjoy his blogging debut.

David Mee-Lee M.D.

SAVVY

I don’t have the family construction business or ice cream store where I can hand over the reins of management to my children. I’m not in a business where my son can become the CEO while I hold onto Chairman of the Board. But I can provide an opportunity for my children (and in this case, my son) to try their hand at leadership and personal and professional growth through writing and speaking, just like dear ole dad.

 

So please enjoy Taylor’s first Tips and Topics piece. Here it is – from the life and pen of Taylor Mee-Lee:

 

A couple of years ago, a friend introduced me to the idea of “Sober Q1”, abstaining from alcohol and any other intoxicants for the first 3 months of the year. At the time, it had about as much appeal as carrying a backpack full of rocks around all day. However, like most good ideas, a seed was planted that waited for the right conditions to germinate and grow. Those conditions arose in late fall of last year, as I emerged from a relatively intense period of anxiety. Some people struggle with anger, others with boredom and apathy; for me, worrying and the tendency to ruminate about all that could go wrong has caused a lot of pain over the years. Whether it was the natural questions arising from turning 30 last year – What am I doing with myself? Why do I keep doing this (insert any unhelpful behavior)? Why don’t I have what I want yet? – or just bad timing, I found myself feeling scared, shaken, and resolved to get stronger so I didn’t have to go through that kind of suffering again.

 

They say it’s always darkest before the dawn; there’s always breakdowns before breakthroughs; or you must hit rock bottom to really get motivated to make a change. (I’ve been hearing about the Stages of Change since I was a teenager!). Whatever it was, I was ready to take something on, to feed that part of me that goes on a mission for something. It dawned on me that Sober Q1 could be it.

 

TIP 1

Find your “why”, and keep reminding yourself, again, and again

 

Picture this:
You go out one night and have a few too many drinks. You wake up the next morning, head pounding, and say to yourself “I’m gonna be healthier”, “I’m cutting back”, or if you feel really dramatic, “I’m never drinking again!” The thing is, in that moment, you really mean it. But a few days or weeks later, when you’re feeling rested, well and that hangover is a distant memory, chances are you’re going to have a beer or that glass of wine.

 

What’s the point? It is that running away from something is rarely enough to keep you committed to a goal. I learned the only thing that helped me honor my word throughout Sober Q1 was realizing why I was doing this, and then reminding myself over and over again. I knew giving up drinking for three months would have a lot of benefits, but as I approached January 1st, it dawned on me why I was doing this: I wanted a clear mind more than anything else. I wanted to face the insecurities, the fear, the uncomfortable thoughts and feelings that would come up…and move through them. What I really wanted was to discover who I could be without alcohol.

 

I won’t lie, it was hard at first. In mid-January, when I was standing in a bar watching the New England Patriots go down by 14 points twice in the same game against the Baltimore Ravens in the National Football League (NFL) playoffs (Go Pats!), every fiber of my being wanted to order a drink. I was sucking back soda waters with lime like a camel about to enter the desert! In that moment though, I reminded myself of why I was doing this, and I held firm. I can promise you that in that moment, nothing less than my deepest commitment, my real “why” would do.

 

TIP 2

Tell Everyone!

 

Whether it’s Sober Q1, cutting out sugar, going to the gym 3x/week, or giving up criticizing yourself, I learned that the most important thing to be nurtured is the commitment to your goal. We often think of commitment as something which lives only inside of us personally. When we’re feeling good, it’s easy to say no to the drink or the piece of cake. However when we’re tired, frustrated or things become stressful, that commitment is gone and we usually end up slipping. If you’re like me, what follows shortly thereafter is withering self-criticism about how I’m lazy, can never stick to anything, and will never get what I want!!

 

There is a way around this. It involves tapping into a whole other realm of where your commitment can live: with other people. I learned that people get inspired by your goals and want to help. First, you must tell them what you’re doing and why you’re doing it. If you do that, your commitment now lives not only inside of you, but in the minds and hearts of everyone you speak to. When I would go out with friends, they would always make sure my soda water glass was full, or asked the bartender to concoct some exciting virgin cocktail.

 

I think the best thing about telling all of my friends, co-workers, housemates, and even random strangers about Sober Q1 is that it firmly slammed shut the back door I could have kept open. When thoughts crept into my mind of “Screw this. I don’t care anymore. I’m just gonna drink,” I knew that there was a boatload of people I would have to answer to. In essence, my commitment didn’t live only inside of me, subject to my moods, levels of energy or inspiration. It lived outside of me as well, and that made all the difference.

SKILLS

Taylor continues:

 

As I write this, it’s late April and I made it!

 

TIP 1

Take a look at the lessons learned from Sober Q1.

 

LESSON: All that you’re ever dealing with is an uncomfortable thought or emotion, and they will pass. What’s on the other side is bliss.

 

Before I took on Sober Q1, I had a number of fears: “What if I don’t enjoy going out to bars anymore? What will I do on a Friday night? Where do I take a girl on a first date? What if I get awkward?” Underneath it all though, was really this: “What if I’m unhappy?”

 

Throughout these 3 months, there were a number of times, while at parties, concerts, or happy hours, when I would think: “What if I don’t have fun?” Almost simultaneously, an emotion would come over me – a mix of fear, worry, and general discomfort. And then…it would be gone, just like that. Sometimes it would take 10 seconds, other times it would hang around for hours, but it always went away eventually- always. What would be left after the fear or discomfort dissipated is hard to put into words. But here are some adjectives which seem to fit: rooted, centered, rock-solid, unshakeable, deeply peaceful, excited.

 

LESSON: It’s easy when you’re all in.

 

Jack Canfield, the author of the “Chicken Soup for the Soul” series, has a saying: “99% is a bitch. 100% is a breeze.” This goes back to the idea of keeping a back door open for yourself. If you’re always negotiating with yourself about whether or not you will stick to something, the most tiring and cumbersome part is trying to figure out, in each moment, whether or not you should do this or that. In the past, I’ve said to myself, “I’m only gonna drink when it’s really worth it, when the mood is right, or I’m with great people.” What inevitably happened was an opportunity to drink would come up. I would debate back and forth in my mind as to whether it was “worth it” or not. Whether I did or didn’t drink was unimportant. There was a cost! It was in the mental bandwidth taken up by constantly debating between my commitment and my desire in the moment.

 

In my Sober Q1, I realized just how much energy that debate of “should I or shouldn’t I” takes up, and because I was all in, I realized how free it feels to be 100% committed. The energy that would have otherwise been consumed by the internal dialogue was free to go to other things, or nothing at all. Either way, there was no struggle.

 

LESSON: I can do whatever I want.

 

On one level, Sober Q1 was about a rather narrow slice of my life: whether or not I would drink a certain type of beverage. However, what it took to stay true to my commitment and what got strengthened and uncovered in the process, is something affecting every area of my life.

 

I think there is a part of us that lives beneath all the ups and downs of life, and knows we are good and everything is going to be OK, no matter what happens. I like to refer to that part of me as “Big Me”. “Little Me” can be freaking out about how I’ll never get what I want because I’m too lazy, don’t work hard enough, or will end up alone and unhappy. But Big Me just sits in the background like a happy rock – peaceful, at ease, and free. I imagine this is what many religious traditions refer to as the laughing Buddha, or Spirit, or the Peace of God.

 

What I do know is that Big Me was strengthened by taking on Sober Q1. I faced the fear and discomfort of unknown territory. I became more acquainted with what has always been there underneath. Now the question can be, “What do I want to do next?”

SOUL

From the Soul of Taylor: 

df97e068-9deb-49af-9a40-e1ca134e498e     d0ac8882-07c3-4ce0-9359-72875dc8263a

 

I imagine some of you have known my father or been reading Tips and Topics for years. For others, this may be your first edition, in which case I give you my apologies and promise the expert will be back next month! In any case, I thought it would be nice to use this section to tell you what I really love and admire about my father.

 

 

1: He’s always there. Always.

 

When I was in junior high, class got out at 3:15 pm every day. I would wait on the corner for one of my parents to pick me up. I soon learned if it was my mom’s turn, it was best to tell her school got out at 2:45 that day, so with the customary 30-minute lag, she would be right on time!  My mother is a wonderful woman, but punctuality was never a strength in those days. On the other hand, there would be Dad sitting in his car right as the bell rung. This is just a fun memory now, but I have learned so much from him about the power of showing up, especially for those you love. Emails always get answered, phone calls are always picked up.  What that has given me is an unshakeable foundation I have relied upon again and again for comfort and strength, as I’ve grown up and ventured out on my own.

 

2: He lets go of the past and listens with an open mind.

 

No one is perfect.  I’m sure my mother might have a thing or two to say about this after 42 years of marriage, however my father is one of the most present and generous people I know.  My sisters and I have come to our parents with all sorts of grand plans (or expensive ideas!) over the years, whether to lend us money to travel or send us to study abroad. My Dad’s reaction has never been to criticize, bring up prior failings, or otherwise allow things that have happened in the past to cloud his judgment of the situation at hand.  We have always known if you just explain to Dad why you want to do something and your thought process behind the decision, he’ll support you.

 

As we’ve gotten older, decisions are less about his giving us money and more about sharing with him our goals and dreams. I can’t overstate how lucky I feel to have the space and encouragement to explore different career paths, lifestyles, and creative endeavors.  I know it takes a lot of work to stay open and loving, especially with people you have known for a long time. I admire him for staying so committed to that, and I’m inspired to do the same.

 

3. He is committed to something bigger than himself.

 

There is a wonderful quote by the author James A. Michener which reads:

 

The master in the art of living makes little distinction between his work and his play, his labor and his leisure, his mind and his body, his information and his recreation, his love and his religion. He hardly knows which is which. He simply pursues his vision of excellence at whatever he does, leaving others to decide whether he is working or playing. To him he’s always doing both.”

 

I have always laughed at the idea of my father retiring.  I simply can’t imagine him sitting on the deck sipping iced tea or playing golf.  When my Dad isn’t eating, exercising or traveling, he is working.  While this has been labeled by society as workaholism in a derogatory sense, I am inspired by it because I know what drives him.  He is committed to empowering systems and people to be well, to be effective, and to thrive.  I have seen the joy and satisfaction his mission has brought him over the years, and the energy and purpose it has brought to his life.  It makes me want to look beyond simply getting my own needs met, and daring to consider what my gift to the world will be. What will it take to give fully?

SHARING SOLUTIONS

Here are a couple of readers’ comments on last month’s edition of Tips and Topics:

 

The first:

Hi David:

I as always enjoy reading your “Tips and Topics” and I would like to add a comment to the discussion of SMART Recovery. (The April 2015 edition included information about SMART Recovery: https://www.changecompanies.net/blogs/tipsntopics/2015/04/)

 

As a clinician with over 50 years of experience in addiction, I prefer 12 Step group involvement for continuing care both because of its documented success and its availability, but this is “when I have my druthers.” The problem is that I sometimes don’t have “my druthers.” Regardless of how helpful 12 Step Recovery Support groups can be, it won’t help if patients refuse to attend or be involved in them. Their reasons are many but chief among them seems to the “God thing.”

 

There is now some early research* that indicates that people with an external locus of control (outer-directed) seem more attracted to, and do better with 12 Step Recovery groups while people with an internal locus of control (inner-directed) seem to do better with SMART Recovery (and possibly other cognitive behavior therapy – CBT-based approaches) that rely more on self than on a Higher Power. I believe that more research needs to be done in this area but even prior to that, when a patient objects to going to Alcoholics Anonymous, other options, particularly SMART Recovery, should be offered.

 

*Personal Responsibility and Locus of Control

A. Tom Horvath, Ph.D., ABPP, Kaushik Misra, Ph.D., Amy K. Epner, Ph.D., and Galen Morgan Cooper, Ph.D., edited by C. E. Zupanick, Psy.D. CenterSite.net.

 

Jerry Shulman

Shulman Training & Consulting in Behavioral Health

2780 Kelsey Place, Jacksonville, FL 32257

(904) 363-0667 – GDShulman@icloud.comwww.ShulmanSolutions.com

 

 

The second:

Dr. Mee-Lee:

Thank you for your Tips and Topics email. It broadens my life and work. Three great topics in one in this last edition.

 

I appreciated your mention of how some counselors ignore the smoking addiction of their clients, but I wish you had taken it one step farther. While smoking is the number one cause of death of our clients, overall health care, including obesity, is also a major factor in the wellness of our clients. I work in a community Mental Health (MH) and Substance Use Disorder (SUD) system.

 

It bothers me when we work to make a client a bit less anxious, depressed, confused, or substance using only to see them become disabled and die many years early from ignored medical problems. My organization is working in several ways to integrate physical care with MH/SUD treatment.  All of us can ask about, discuss, refer, and be in touch with the clients’ primary care providers (with releases, of course).

 

I encourage you to use your pulpit to mention this.

 

The Substance Abuse and Mental Health Services Administration (SAMHSA) has an effort to increase awareness of wellness and their 10 by 10 initiative at this link, with a goal to increase the life span of our clients by 10 years in the next 10 years.

http://www.promoteacceptance.samhsa.gov/10by10/sitemap.aspx 

 

But above all, thank you for the work that you do.

 

Gary McNeill APRN, LADC, CCS

Quality/Compliance Coordinator

Maine Behavioral Healthcare

2 Springbrook Drive

Biddeford, ME 04005

W:207-294-7111

E-mail: gmcneill@MaineBehavioralHealthcare.org

Until next time

Vol.13, No. 3

Welcome to the many new readers of Tips and Topics. Thanks for joining the long time readers for the June edition.

David Mee-Lee M.D.

SAVVY

Remember the 1970’s and 1980’s TV series MASH. I’ve always appreciated Alan Alda for making me laugh. However I have come to appreciate Alda even more but for the different contribution he has made today – with the Alan Alda Center for Communicating Science at Stony Brook University, New York. When he started the Flame Challenge, the goal was for scientists to communicate, succinctly and effectively, to explain science to an 11-year-old.

 

The 2015 challenge focused on something we all do everyday, for every day of our life. You might think that would mean we’d be both familiar and knowledgeable about something we do everyday. But for most of us, that’s not true. I’m talking about sleep.

 

It was illuminating to read the top-ranked written answer by Brandon Aldinger, Ph.D and watch the top-ranked video explanation by Eric C. Galicia. These were the winning entries in the 2015 Flame Challenge question: “What is Sleep?”

 

You can listen to their interviews in the June 5, 2015 edition of Science Friday

http://www.sciencefriday.com/segment/06/05/2015/what-is-sleep-a-superpower-a-power-cleanse.html 

 

TIP 1

Note these tidbits about sleep and dreams written for 11 year olds and the 11 year old in all of us.

 

Here are excerpts from the winners’ succinct, creative and informative explanations about sleep. Entries were judged by more than 20,000 11 year-olds in schools around the world. Firstly from Brandon Aldinger’s written entry:

  • “If you don’t sleep, you’ll die! Like us, almost all animals need to sleep-everything from fish, to horses, to birds. Even butterflies and worms sleep!”

First Function of Sleep

  • “Our body takes care of two big things while we’re sleeping. First, our brain organizes what it learned while we were awake. Your brain is made up of billions of cells called neurons. These neurons are connected in a huge network.”
  • “While we sleep, our brain strengthens and rearranges these connections to help us remember things more quickly and easily when we are awake.

Second Function of Sleep

  • “The second thing that happens during sleep is our body heals itself. Sleep is a little bit like a superpower.” 
  • “If you want to get over a cold quickly, make sure you sleep a lot. You might also have noticed that adults in your home don’t sleep as much as you do. That’s because your body needs more sleep to manage the stuff that happens while your body and brain are still growing.” 

Dreams

  • “But what about dreams? Well, as your brain is calming down from being awake, parts of it shoot out random signals, like a TV station with too much static.”
  • “Another part of your brain does its best to make sense of these signals, but the story it puts together can be pretty weird!”

http://www.centerforcommunicatingscience.org/the-flame-challenge-2/flame-challenge-2015-finalists/ 

 

 

TIP 2

Enjoy the video winner’s short film about sleep and dreams. But here are some excerpts before you see the video.

 

Eric C. Galicia is a candidate in the Master of Health Physics program at Illinois Institute of Technology. He produced the top-ranked video explanation about sleep, and he did that in just under five minutes. To watch it, click on this link and scroll down the page a bit:

http://www.centerforcommunicatingscience.org/the-flame-challenge-2/flame-challenge-2015-finalists/ 

  • “Your brain categorizes things that you learn during the day and generates a lot of cellular waste while doing it. One kind of waste is Amyloid beta, a gummy plaque of brain.”
  • “Cerebral spinal fluid cleans the brain. This fluid is essential and helps the brain re-learn the lessons it learned during the day.”
  • “When you sleep, your body and mind are hard at work replenishing crucial brain functions.”
  • We spend 36% of our life sleeping.

Good sleep

  • With good sleep, we remember lessons from the day before.
  • Good sleep is when the brain cleans itself – get increased concentration, creativity, decreased stress and moodiness.

Bad sleep

  • “When you don’t get enough sleep, it’s hard to remember things; or you can become moody.” Risks for Alzheimer’s disease, depression, anxiety and other emotional disorders.
  • Poor memory, judgment, increased stress and impulsivity with not good sleep.

Dreams

We still don’t understand a lot about dreaming:

  • Dreams are important and contribute to creativity and learning.
  • A part of the brain is dedicated to incapacitating the body while dreaming. It releases serotonin, which inhibits your muscles from moving when intensely dreaming. This disarms movement when dreaming and stops physical movement.
    (My comment: This explains to me how I can never run fast enough or fight back and defend myself when having that bad dream.)

SKILLS

Sleep hygiene has been defined in different ways. Here are elements of those definitions along with points about the importance of sleep hygiene:

  • “habits and practices that are conducive to sleeping well on a regular basis.” “sleep hygiene is the key to sweet dreams(Google sleep hygiene)
  • “a variety of different practices that are necessary to have normal, quality nighttime sleep and full daytime alertness.”  http://sleepfoundation.org/ask-the-expert/sleep-hygiene
  • “The promotion of regular sleep” (Centers for Disease Control and Prevention, CDC.  http://www.cdc.gov/sleep/about_sleep/sleep_hygiene.htm 
  • Sleep hygiene is important for everyone, from childhood through adulthood. A good sleep hygiene routine promotes healthy sleep and daytime alertness.
  • Good sleep hygiene practices can prevent the development of sleep problems and disorders.
  • Sleep disturbances and daytime sleepiness are the most telling signs of poor sleep hygiene.
  • If one is experiencing a sleep problem, he or she should evaluate their sleep routine. It may take some time for the changes to have a positive effect. (Michael Thorpy, MD.)  http://sleepfoundation.org/ask-the-expert/sleep-hygiene

 

TIP 1

How do you measure up with these good sleep hygiene tips?

 

I merged and rearranged into categories the following tips which are excerpts from The National Sleep Foundation  http://sleepfoundation.org/ask-the-expert/sleep-hygiene

Centers for Disease Control and Prevention (CDC) http://www.cdc.gov/sleep/about_sleep/sleep_hygiene.htm, and

American Sleep Association (ASA)

https://www.sleepassociation.org/patients-general-public/insomnia/sleep-hygiene-tips/ 

 

A. Regular wake and sleep pattern

  • Maintain a regular wake and sleep pattern; go to bed at the same time each night and rise at the same time each morning. Ideally, your schedule will remain the same (+/- 20 minutes) every night of the week.
  • Establish a regular relaxing bedtime routine. Have a comfortable pre-bedtime routine: a warm bath, shower, meditation, or quiet time.
  • Spend an appropriate amount of time in bed, not too little, or too excessive. This may vary by individual; for example, if someone has a problem with daytime sleepiness, they should spend a minimum of eight hours in bed. If they have difficulty sleeping at night, they should limit themselves to 7 hours in bed in order to keep the sleep pattern consolidated.
  • Avoid napping during the day. It can disturb the normal pattern of sleep and wakefulness and naps decrease the ‘Sleep Debt’ so necessary for easy sleep onset. Each of us needs a certain amount of sleep per 24-hour period. We need that amount, and we don’t need more than that. When we take naps, it decreases the amount of sleep we need the next night – which may cause sleep fragmentation and difficulty initiating sleep, and may lead to insomnia.
  • Try to avoid emotionally upsetting conversations and activities before trying to go to sleep. Don’t dwell on, or bring your problems to bed.
  • Don’t stay in bed awake for more than 5-10 minutes. If you find your mind racing, or worrying about not being able to sleep during the middle of the night, get out of bed, and sit in a chair in the dark. Do your mind-racing in the chair until you are sleepy, then return to bed. No TV or internet during these periods! That will just stimulate you more than desired.
  • If this happens several times during the night, that is OK. Just maintain your regular wake time, and try to avoid naps.
  • If you’re taking too long to fall asleep, or awakening during the night, you should consider revising your bedtime habits. Most important for everyone is to maintain a regular sleep-wake schedule throughout the week and consider how much time you spend in bed, which could be too much or too little.

B. Food, caffeine, nicotine and alcohol

  • Avoid stimulants such as caffeine, nicotine, and alcohol too close to bedtime. The effects of caffeine may last for several hours after ingestion. Caffeine can fragment sleep, and cause difficulty initiating sleep. If you drink caffeine, use it only before noon. Remember soda and tea contain caffeine as well.
  • While alcohol is well known to speed the onset of sleep, it disrupts sleep in the second half as the body begins to metabolize the alcohol, causing arousal.
  • Food can be disruptive right before sleep. Stay away from large meals close to bedtime.
  • Dietary changes can cause sleep problems. If struggling with a sleep problem, it’s not a good time to start experimenting with spicy dishes. And, remember, chocolate has caffeine. 

C. Exercise

  • Exercise can promote good sleep. Vigorous exercise should be done in the morning or late afternoon.
  • A relaxing exercise, like yoga, can be done before bed to help initiate a restful night’s sleep.
  • Exercise regularly as exercise promotes continuous sleep. Avoid rigorous exercise before bedtime. Rigorous exercise circulates endorphins into the body, which may make initiating sleep difficult. 

D. Sleeping and Bedroom Environment

  • Ensure adequate exposure to natural light. This is particularly important for older people who may not venture outside as frequently as children and adults. Light exposure helps maintain a healthy sleep-wake cycle.
  • Make sure your bed is comfortable and associate your bed with sleep. It’s not a good idea to use your bed to watch TV, listen to the radio or music, or read. Remove all TVs, computers, and other “gadgets” from the bedroom. When you watch TV or read in bed, you associate the bed with wakefulness. The bed is reserved for two things – sleep and hanky panky.
  • Have a quiet, comfortable bedroom with a sleep environment which is pleasant and relaxing. The room should not be too hot or cold, or too bright. Set your bedroom thermostat at a comfortable temperature. Generally, a little cooler is better than a little warmer.
  • Turn off the TV and other extraneous noise that may disrupt sleep. Background ‘white noise’ like a fan is OK.
  • If your pets awaken you, keep them outside the bedroom.
  • If you are a ‘clock watcher’ at night, hide the clock.

 

TIP 2

Consider your digital devices and their effect on your sleep

 

In its “Sleepless in America” special series, NBC Nightly News of June 24 reported, “The CDC has called lack of sleep a public health epidemic, and most sleep experts say all our digital devices we’re taking into the bedroom are taking a toll on getting a good night’s rest.”

  • NBC News correspondent Hallie Jackson explained: “Experts say it’s no coincidence 95 percent of us look at some kind of screen within an hour of bedtime and 85 percent have trouble falling asleep.”
  • Blue light emitted from “screens send[s] a signal it’s still daylight, triggering a surge of energy and blocking the melatonin that makes us sleepy.” Therefore, it’s “no wonder then that with the device on nearly every nightstand, one in three people sleeps less than six hours a day, raising the risk for diabetes, heart disease, obesity and depression.” (American Psychiatric Association Headlines, June 25, 2015)

 

TIP 3

What you can do to boost your chances of getting a good night’s rest

http://www.nbcnews.com/nightly-news/sleepless-america-how-digital-devices-keep-us-all-night-n381251 

  • “Create a charging station in another room to power your devices overnight. Don’t keep them on the bedside table.”
  • “Buy a real alarm clock – don’t use your phone. “It’s better to have an alarm clock that is not interrupting your sleep in the middle of the night,” said Czeisler, “than to have a [phone-based] alarm clock that is waking you up at all hours.”
  • “Turn off all your screens – televisions, phones, computers – an hour before bed. Read from a printed book instead of a tablet, for example.”
  • “If that’s not realistic for you, try an app that flips your screen’s background. Instead of black letters on a white background (like you’re reading right now), it will show white letters on a black background, helping to cut down on how much light is emitted.”

For your children:

“Start good habits early, especially with your kids. A startling 75 percent of children have at least one electronic device in the bedroom when they sleep, according to the National Sleep Foundation. Create a bedtime routine for that does not involve electronics.”

SOUL

One of the most gratifying joys of working to attract people into recovery is when they come back and thank you for helping them change their lives. That’s what happened this week as I had lunch with Todd (not his real name). Todd had come back to thank his counselor and care coordinator and tell his story.

 

Todd is 25. About 14 months ago he was doing $1,500 worth of drugs a day supported by drug dealing and “selling my girlfriend for sex”. When he presented for treatment, he was homeless, penniless and was done with drugs. It was addiction treatment, supportive living in a halfway house and Todd’s daily commitment and active participation in Narcotics and Alcoholics Anonymous (NA & AA) meetings which brought him a new start to life. With over a year of recovery, he is now:

  • Working full time, supporting himself in legal work and paying off all his court debts and obligations.
  • Living in a stable environment; and trusted to baby-sit an 8 and 11 year old while their mother works the night shift.
  • Taking addiction seriously. He has quit not only alcohol and heroin, but also nicotine and caffeine (two drugs many addiction programs are still very ambivalent about).

If you’ve ever been to an AA or NA meeting, you’ll notice it can be a great training environment – for public speaking, humorous and pithy nuggets of wisdom, and inspiring, motivational encouragement for newcomers and long time attendees alike.

 

Todd, at such a young age and relatively early in his recovery, demonstrated the impact of that “training,” projecting his passion for recovery, which is what AA and NA is all about. As he told his story, Todd shared some nuggets of wisdom I’ll share with you:

  • You can’t be No. 1 unless you are odd,” he said. I was impressed with how ready he was to break away from negative peer influences, quit nicotine and caffeine – “odd” for someone so young in age and recovery.
  • Go early and you’ll never be late” was something his Dad taught him. This spoke to Todd’s level of responsibility and accountability.
  • We live in a world where we’re always noticing the bad things. Keep looking at the peaks instead of dwelling on the valleys.” He joked about whether you ever hear the police thanking you for going nicely through a green light. They only notice when you go through a red light. We all do the same thing and dwell on the bad things in the valleys of life.
  • You need to struggle to succeed.” It was reassuring to me that Todd was not “pink-clouding” thinking recovery was easy, even though he was so positive and made it look easy.
  • Using drugs is not a family event.” When Todd said this, he was not saying addiction doesn’t affect families. In fact, he now has a growing positive relationship with his mother and brother. He is also resolving the death of his father from addiction. The idea he was expressing is that drugs isolate you and he is recovering from the alienation his addiction caused.

What an inspiration Todd was to us! He reinvigorated and re-motivated us to keep attracting people into recovery. Nobody fell asleep listening to this young and grateful man.

Until next time

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

David

Vol. 13 , No. 4

Welcome to the July edition of Tips and Topics. I hope your summer is going well for our northern hemisphere readers. Stay warm Down Under.

David Mee-Lee M.D.

SAVVY & STUMP THE SHRINK

Earlier this month, I received a question prompting this combined SAVVY and STUMP THE SHRINK.  This is especially relevant if you work in a program that focuses on rules and regulations, consequences for breaking the rules, and behavior contracts.

 

Even if it is the treatment plan that focuses your work with the client, it is easy to become distracted by behavior which disrupts the group and treatment milieu. Here is what Bob Fox of St. Paul, Minnesota wrote:

 

Question

Dr. Mee-Lee:

“I work in Level 2.1 Intensive Outpatient, mixed gender group. What is your view on policies about treatment peers forming exclusive, romantic relationships, or plain old sexual intimacy (hooking up) in treatment?”

 

Bob gave me three multiple choice options, but as you can see further below, I waxed eloquent and expanded way beyond the offered choices:

 

“a.   Should the relationship be prohibited and one or both clients be discharged (referred to another program?)

b.   Should the relationship be allowed, but the involved clients be separated into different groups? And then a focus of treatment is learning about healthy relationships, boundaries, etc.?

c.   Or some other option?”

 

TIP 1

Think about how you deal with emotional, behavioral and cognitive issues that are potentially disruptive to the group and treatment milieu.

 

My response

In general, my view is to see all emotional, behavioral and cognitive problems as treatment issues needing to be dealt with in the context of an individualized treatment plan.  That plan should be frequently and collaboratively changed depending on what is working well (or not working well) in the client’s progress in treatment.  

 

So in this case…. if peers are forming relationships and hooking up, that is behavior which is going to happen while a person is in treatment and certainly occurs when people are not in treatment.  I suspect that for many clients in treatment the relationships and sexual behavior they engage in has created problems in their lives previously – both substance-related and non-substance-related.

 

In outpatient and residential treatment, we have an opportunity to create:

  • A safe, therapeutic environment.
  • A therapeutic milieu which seeks to engage and attract people into an exploration of what has worked well for them before and what has not worked well.
  • An opportunity allowing clients to develop and practice new and healthier ways to deal with their behavioral health problems.  

In addiction treatment and sometimes in mental health as well, we have had a tradition of creating a safe environment by having rules, policies and consequences if clients break the rules: like behavioral contracts; set back a level or phase in residential settings; loss of privileges; writing tasks; separating people into different groups; discharge etc.

 

We need to rethink our attitudes about what treatment is meant to do:

  • Meet people at the stage of change they are at. (What is the person at Action for? Identify their issues. Are they possibly still in a Precontemplation, Contemplation or Preparation stage of change?).
  • Help them self-identify and own the issues that keep “shooting themselves in the foot.” What behaviors are counterproductive to recovery and getting them what they want? Is it health and wellness? Maybe getting their children back? Getting off probation? Keeping a job? Retaining a relationship? Keeping their housing? Being sober and embracing recovery? Whatever it is that brought them to treatment- find it out.
  • Work compassionately with them to facilitate a self-change process using a collaborative, accountable treatment plan.
  • Fashion with them an updated treatment plan whenever progress stalls or new issues arise e.g., exclusive relationships and sexual behavior. The new strategies should move in a positive direction.

TIP 2

Help clients assess and evaluate the “differential diagnosis” of their emotional, behavioral and cognitive issues and the effect on their lives.

 

The answer to the STUMP THE SHRINK question centers around having a talk with the clients in the exclusive relationship. In addition, talk with all their peers in group regarding the dangers of becoming distracted by exclusive relationships and sexual behavior. Explore with all the clients about how this type of situation has distracted them in the past, how it distracts now in the present setting. Converse about how it can ‘de-focus’ people from recovery, from attending to their “work” of embracing new ways of being and doing.  

 

1. Engage the group in talking. Where has this been an issue in other peers’ lives? What have they learnt from those experiences?

2. You can also discuss the dangers of forming intense new relationships early in recovery, especially if the new “love of my life” is also new in recovery and may even be less interested in recovery than I am.  

3. How easy it is to turn to relationships and sex as a way to deal with pain e.g., regrets of past mistakes, lost relationships and jobs, mental health issues? Discuss this angle.

4. Pose this question for discussion: How can sex or a new relationship avoid the hard work of recovery? Can people avoid taking “a searching and fearless moral inventory of ourselves” (Alcoholics Anonymous 4th Step)? Looking at your life, whether in addiction or mental health treatment, can be a very hard thing to do.

5. Identify if certain mental health issues are contributing to such behavior e.g., unresolved issues with parents; or trauma or sexual abuse.

 

In other words, there is a whole “differential diagnosis” of what forming relationships and sexual behavior can mean.  These are assessment and treatment issues to be opened up for the clients involved.  There is also a rich opportunity for the other peers in the group to explore these issues for themselves for “there but for the grace of God go I.”  

 

TIP 3

Consider what happens to treatment if the focus is on rules, consequences and discharge.

 

You can “prohibit” the exclusive relationship and sex, but are you also going to “prohibit”:

  • Substance use and relapses (we still do this often and I have written before about discharging people for having the symptoms and signs of their addiction illness).
  • Angry outbursts.
  • Cravings to use with irritability and isolating behavior.
  • Disrespectful talking and interactions with peers and staff.
  • Hanging out with drug-using friends.
  • Telling war stories about drugs etc. etc.

Treatment is not about us making people behave. It is about helping them make the right decisions in the dark of night when nobody is watching.  If people do the right thing only when in our program, have we helped them to help themselves when we are not around?  Have we facilitated a self-change process which enhances sustainable recovery? Or have we externally imposed compliant behavior that too easily falls away after “graduating” from treatment?

 

TIP 4

When is it appropriate to discharge people for their behavior?

 

A. There may be mandated clients who say they want treatment, but end up just “doing time”.  They occupy and distract themselves by forming relationships and hooking up. They are not, in good faith, looking at the meaning of their behavior, the negative effects on their life and on others.   Just sitting in a chair is not doing treatment. They are not choosing the work of treatment. At that point, you can talk about discharge.  

  • So you would be discharging them not because of bad behavior or breaking rules, but because they are not being open and willing to change their treatment plan in a positive direction. They have a right not to do treatment. As the clinician, you have a right to keep the treatment milieu therapeutic and “discovery” and “recovery”-focused.

B. If you ascertain someone is a sexual predator focused on disrupting treatment for themselves and others through forming relationships and hooking up, then discharge is appropriate. Why? Because you run a treatment place, not a dating place.  

  • Let’s say you determine a client’s behavior is part of their biopsychosocial-spiritual illness with implications for addiction, mental health and physical well-being. Then these are important treatment issues to pursue with further assessment and treatment. Do not discharge and hope you can just prohibit human behavior. If the person is willing to deal head on with this behavior and attitudes, then treatment is what they need. To discharge them for having problems to work on doesn’t fit my vision for treatment.

A friend and colleague recently said this:

“My mantra is, ‘this is the place where you don’t have to be at your best.’ If people are out of sorts or have a bad hair day, all the more material for the staff to work with.”  

Andrea G. Barthwell, MD, FASAM

Oak Park, Illinois

708-613-4750

www.twodreams.com

 

If we expect people to behave and be at their best, then they probably don’t need treatment and have nothing important to change.

SKILLS

In June 2003, the 3rd edition ever of Tips and Topics, I wrote about “Discovery, Dropout” (D/D) prevention plans for people in early stages of change, those not yet interested in recovery. I also wrote about “Recovery, Relapse” (R/R) prevention plans for people at Preparation and Action for recovery.  In 2015, you still find most treatment providers in general health, mental health and addiction treatment creating treatment plans which assume the client/patient is committed to recovery and relapse prevention.

  • The doctor or nurse writes a prescription for the patient expecting adherence and healthy living. Actually medication non-adherence is widespread with rates ranging from 25% to 50%. Between $100 and $300 billion annually of avoidable health care costs in the US have been attributed to non-adherence.

(Aurel O Iuga and Maura J McGuire: “Adherence and health care costs”. Risk Management Health Policy. 2014; 7: 35-44. Published online 2014 Feb 20. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3934668)

  • Psychiatrists and mental health clinicians document problem #1 as “Psychosis” and problem #2 as “Medication Compliance” in the treatment plan.  However the patient thinks they are not mentally ill, it’s a conspiracy and the medication is poison and part of the plot. No wonder the patient doesn’t take their medication nor show up for sessions.
  • The addiction counselor documents strategies of abstinence, AA meetings and changing drug-using friends when the client simply just wants to cut back, hates AA and sees nothing wrong with his friends. No wonder he drops out of treatment.

What patients and clients actually need is a Discovery, drop-out prevention:

  • To discover for themselves (with our help) that what they are doing with their emotions, behavior and thinking is not getting them what they want.
  • We need to do all we can to prevent them from dropping out of services, so we have a chance to attract them into recovery.

TIP 1

Consider these Sample Strategies for Treatment Plans

  1. List three reasons the court sent you to treatment (D/D).
  2. Write down the most recent incidents involving alcohol and other drugs (D/D).
  3. Identify what happens if you don’t comply with probation requirements and report to group (D/D).
  4. List the positive and negative aspects of substance use (D/D).
  5. Attend at least one AA meeting and see if you can identify with anyone’s story (D/D).
  6. In group, verbalize what things need to change in your life or not (D/D).
  7. Discuss the positive and negative consequences of continued substance use (D/D).
  8. Explore early childhood history of violence through individual therapy once per week. Focus on what kind of role models the client had then, and how this affects relationships now (R/R).
  9. For the next incident of rage and anger, track it. Fill in the date, trigger, physiological signs and your behavior. Then discuss how you could have de-escalated the incident (R/R).
  10. In group, share what has been working to prevent relapse and obtain other suggestions (R/R).

For more on Discovery plans, see SKILLS in the March 2006 edition.

https://www.changecompanies.net/blogs/tipsntopics/2006/03 

 

Related past editions explain aspects of this too if you want to take a look:

February 2013

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

 

November 2012

https://www.changecompanies.net/blogs/tipsntopics/2012/11 

  

TIP 2

Treatment Plan Strategies for Working on Relationships and Hooking Up

 

Referring back to Bob’s question: if the clients are interested in treatment, they will be willing to change their treatment plan in a positive direction using such strategies as:

  1. Talk with a counselor about where relationships and hooking up has affected their life and addiction in the past. Share that in group to receive feedback.
  2. In group, explain what is so great about the new, exclusive relationship. Obtain feedback on whether this relationship will help, hinder or jeopardize recovery.
  3. Have a trial of staying away from the other person for a week. Then have each person in the relationship talk in group about what that experience was like.
  4. In group, talk about examples of past relationships and sexual behavior they got into quickly. Examine how that contributed to problems in their life, both addiction-related or not.  

Once you have done more assessment, there would be many other strategies that might fit better for this client. If they are willing to do this work, treatment continues. Don’t separate them or discharge them. Use the power of the group to implement these strategies.

 

Note of Caution:

You’ll notice that I define good faith working in treatment as “being open and willing to change their treatment plan in a positive direction.” Or as they say in AA “progress, not perfection”. We would like every person from Day 1, to be:

  • perfectly sober, with no cravings or impulses to use and no actual use
  • perfectly delaying gratification for relationships and hooking up and totally focused on recovery
  • perfectly non-depressed, non-psychotic; non-anxious; non-manic
  • perfectly non-angry, irritable and isolating
  • perfectly non self-mutilating, suicidal or impulsive etc. etc.

But if our clients and patients could do all that, they wouldn’t need our help in the first place! So if you have a notion to change their treatment plans by inserting: “Bob and Jane will end this inappropriate relationship and sexual behavior and focus on recovery” and then discharge Bob and Jane when they break their treatment plan, that is “perfection” not “progress”. It is not changing their treatment plan in a “positive direction”, it is expecting perfection and the final outcome immediately.

SOUL

I just have to tell you my Medicare story. (So now you know I’m a senior citizen.) Last year when I joined Medicare, I was looking forward to that much lower monthly premium for health insurance…and yes, it was quite a bit lower. But then new notices came informing me that the bill was going to be higher because of my income. (So now you know I’m not a minimum wage senior citizen.)

 

I was OK with that, because I don’t mind contributing to the greater good if I can afford it. But then the amount I owed kept changing and I dutifully paid what the monthly invoice said. Here’s where the story gets interesting (or is a better word “frustrating”).

  • Invoices would come late with a due date that had already passed; or were so close to the date I received the bill, that it was bound to be delinquent.
  • You can’t pay online, so by the time snail-mail arrived, it was surely late, plus the three weeks it takes for their department to process the payment.
  • So now, each monthly invoice was showing either delinquent amounts owed and/or unprocessed payments I had already made.
  • Then I didn’t receive any invoices for two months. Had I already paid too much in advance, so they didn’t send me a bill? Or did it get lost in the mail? Or had I lost my Medicare? Who knows, because you can’t check your account and payments online – like every other business.

Time to call and talk to someone at Medicare. I called on a whim one night to see what hours they were open and amazingly you can talk to a “live” person- they are open 24 hours a day, 7 days a week. And it is not someone in the Philippines or India. Sounded like a regular ole American.

  • Nice helpful man, but after 7 PM he can’t check the computer records to see what I owe or not. I could call back the next morning and then find out what I owed. But he did tell me I could sign up for Medicare Easy Pay where the payments would come directly out of my bank account. That sounds more like it in the 21st century.
  • But not so fast. He would have to mail me the form to fill out, and that could take 3 weeks; then it could take up to 8 weeks to process my application for Easy (or not so Easy) Pay. Faster, he said, to sign up with my bank for online payment directly.
  • Went to my bank website and in 5 minutes I had signed up and paid a couple months’ premium just to be sure I wasn’t behind. “I’ll check in the morning to see where my account stands”, I said to myself.
  • Next morning at the Medicare call center, there was a nice helpful lady and not a long wait to get to her either. However, she can see what premium I am being charged, but has to send a special request to another department to tell me whether my account is ahead or behind and what has happened to my monthly bills.

“Is there no way that I can go to a website, see my payments and what I owe, just like I do with my credit card, electric and phone bill etc.?”

 

No, I’m sorry, we can’t even see that. I have to send a request to another department and they will call you to let you know where your account stands.”

 

“Could they not send me an email, because what if I miss their call?”

 

Oh, well if they don’t reach you, they will send information in the mail.”

 

“You mean, regular snail-mail, not email?”

 

You get my drift. Now I think it is great that Medicare is open 24/7 and the hold time was very reasonable. BUT I spent at least a half an hour or more with people who receive more than minimum wage and nice government benefits only to find out that they can’t help me. The information I need will take much more time being spent by more government workers who will use last century’s methods to communicate with me.

 I better stop here and recite the Serenity Prayer. But if any of you have the courage and wisdom to make government more efficient, please step forward. This old guy feels a bit hopeless.

Until next time

Glad you could join us this month. See you in late August.

                           

David

Vol. 13, No. 5

Welcome to the August edition of Tips and Topics and to all our new subscribers. Thanks for joining us this month.

David Mee-Lee M.D.

SAVVY

The older I get, the more I think the greatest gift is good health. If you have health insurance, contemplate what it must be like to not have that peace of mind. Regardless of your political party leanings, before the Affordable Care Act (ACA) there were about 47 million Americans who had no health insurance nor peace of mind.

 

The New York Times

(8/12/15, A11, Pear, Subscription Publication) reported: 

  • The number of Americans without health insurance “continues to decline and has dropped by 15.8 million, or one-third, since 2013.”

TIME (8/12/15) reported:

  • Nearly 90% of Americans now have health insurance.
  • Overall, “the percentage of people in the US who were uninsured was 9.2%” during the first quarter of this year.”

I’ve always thought of Medicaid as just for poor and disabled people; and historically it has been an adjunct to state welfare programs. However “Medicaid has evolved….to the nation’s largest health insurer.” (JAMA, July 28, 2015, p.343).

  • “Medicaid insures more than 71.1 million people (an increase of 12.3 million since the first Marketplace open enrollment began) and
  • In 2015, Medicaid is projected to account for $343 billion in total spending.” (JAMA)

Addiction Treatment

Medicaid is playing an increasingly important role as a payer for services provided to individuals with addiction in the United States. There have been some exciting developments regarding The ASAM Criteria in Medicaid’s expanding role……”exciting” for me anyway, because I have been on a mission for 25 years to have The ASAM Criteria accepted as the model for addiction treatment’s continuum of care.

 

Last month, the Center for Medicare and Medicaid Services (CMS) announced new opportunities for states to design service delivery systems for Medicaid beneficiaries with a substance use disorder (SUD). Numerous federal authorities are offering states the flexibility to implement system reforms to improve care, enhance treatment and offer recovery supports for SUD. The ASAM Criteria is mentioned in several places as integral to that service delivery design.

 

Here are excerpts from that announcement. If you want to read more, here’s the link:

http://medicaid.gov/federal-policy-guidance/downloads/smd15003.pdf

  • “An estimated 12% of adult Medicaid beneficiaries ages 18-64 have an SUD.
  • An estimated 15% of uninsured individuals who could be newly eligible for Medicaid coverage in the New Adult Group have an SUD.
  • CMS is committed to helping states effectively serve these individuals and introduce benefit, practice and payment reforms through the technical assistance and coverage initiatives described below.”

“States have compelling reasons to provide Medicaid coverage for the identification and treatment of SUD, many of which are given urgency by the national opioid epidemic. Untreated substance use disorders are associated with increased risks for a variety of mental and physical conditions that are costly.”

  • “In 2009, health insurance payers spent $24 billion to treat SUD. Of those expenditures, Medicaid accounted for 21%.
  • Two of the top ten reasons for Medicaid 30-day hospital readmissions are SUD-related.
  • Individuals with SUD and co-morbid medical conditions account for high Medicaid costs, such that $3.3 billion was expended in one year on behalf of 575,000 beneficiaries with SUD as a secondary diagnosis.
  • Beyond health care risk, the economic costs associated with SUD are significant. States and the federal government spend billions every year on the collateral impact associated with SUD, including criminal justice, public assistance and lost productivity costs.
  • Alarmingly, the rate of fatal drug overdose in the U.S. has quadrupled between 1999 and 2010.
  • Drug overdose has become the leading cause of injury death, causing more deaths than traffic crashes.
  • Other problems also relate to opioid prescribing including opioid exposed pregnancies, drugged driving, and increases in Hepatitis C and in some circumstances HIV from prescription opioid injection.”

“As states expand Medicaid coverage to millions of new beneficiaries that may have been previously uninsured, states are also expanding access to behavioral health services including covering these services in Alternative Benefit Plans as required by the Affordable Care Act. CMS has received a number of requests from states and stakeholders interested in enhancing care for individuals with SUD.”

 

The CMS announcement mentioned examples of practice changes including “Enhancing provider competencies to deliver SUD services with fidelity to industry standard models, such as the American Society for Addiction Medicine (ASAM) Criteria.”

Here are more excerpts from the CMS announcement that align with what The ASAM Criteria has been advocating since the first edition in 1991:

 

Strong Network Development Plan”

“States will be asked to develop a network development and resource plan to ensure there is a sufficient network of knowledgeable providers in each of the levels of care recognized by ASAM and recovery support services. In addition, the state should have the resources to ensure that providers have the ability to deliver services consistent with the ASAM Criteria and provide evidence-based SUD practices. The network should be sufficiently robust so that access can be assured in the event that some providers stop participating in Medicaid, are suspended or terminated.”

 

Care Coordination Design

“Coordination of care design is integral to SUD delivery reform. This entails developing processes to ensure seamless transitions and information sharing between levels and settings of care (withdrawal management, short-term inpatient, short-term residential, partial hospitalization, outpatient, post-discharge, recovery services and supports), as well as a collaboration between types of health care (primary, mental health, pharmacological, and long-term supports and services). CMS encourages states to test how to best achieve care transitions across the care continuum, including aftercare and recovery support services.”

 

“Short-term acute SUD treatment may occur in inpatient settings and/or residential settings. …Inpatient services are described by the ASAM Criteria as occurring in Level 4.0 settings, which are medically managed services. Inpatient services are provided, monitored and observed by licensed physician and nursing staff when the acute biomedical, emotional, behavioral and cognitive problems are so severe that they require inpatient treatment or primary medical and nursing care. “

 

“Residential services are provided in in ASAM Level 3.1, 3.3, 3.5 and 3.7 settings, which are clinically managed and medically monitored services typically provided in freestanding, appropriately licensed facilities or residential treatment facilities without acute medical care capacity. “

 

California was one of the first states to seize new opportunities from CMS for demonstration projects. These projects are approved under section 1115 of the Social Security Act (Act) to ensure that a continuum of care is available to individuals with SUD. Section 1115 demonstration projects allow states to test innovative policy and delivery approaches that promote the objectives of the Medicaid program.

 

The California Initiative

California calls its Medicaid services “Medi-Cal.” This month Medi-Cal received some welcome news from CMS. Here, in part, was California’s announcement on August 13, 2015:

The Department of Health Care Services (DHCS) announces the Center for Medicare & Medicaid Services (CMS) approval of California’s Drug Medi-Cal Organized Delivery System (DMC-ODS) Waiver amendment which provides a continuum of care for substance use disorder treatment services.”

 

As the Chief Editor of The ASAM Criteria who happens to live in California, I can’t help but feel proud that we now have a chance to truly implement the spirit and content of the Criteria in my home state. And who knows- maybe many more states in the USA.

 

TIP 1

If your state is considering enhancing care for individuals with SUD, take a look at what California is just now embarking on in their system of care redesign.

 

Here is the introduction to California’s system re-design states:

 

“The Drug Medi-Cal Organized Delivery System (DMC-ODS) provides a continuum of care modeled after the American Society of Addiction Medicine Criteria for substance use disorder treatment services, enables more local control and accountability, provides greater administrative oversight, creates utilization controls to improve care and efficient use of resources, implements evidenced based practices in substance abuse treatment, and coordinates with other systems of care.

This approach provides the beneficiary with access to the care and system interaction needed in order to achieve sustainable recovery. The DMC-ODS will demonstrate how organized substance use disorder care increases the success of DMC beneficiaries while decreasing other system health care costs.”

 

The State Implementation Plan and Standard Terms and Conditions for the DMC-ODS are located at http://www.dhcs.ca.gov/provgovpart/Pages/Drug-Medi-Cal-Organized-Delivery-System.aspx

 

Reference:

Mann, Cindy and Osius, Elizabeth (2015): “Medicaid’s New Role in the Health Care System” Journal of the American Medical Association (JAMA), Volume 314, No. 4 pp. 343-344.

SKILLS & SHARING SOLUTIONS

If your agency, county or state is preparing to implement The ASAM Criteria, here are some tips to get you started.

 

TIP 1

Involve all systems and stakeholders in the implementation process from Day 1.

 

Whenever I am asked to train or consult for a “kick-off” for implementing The ASAM Criteria, one of the first strong recommendations I offer is to make sure ALL stakeholders affected by The ASAM Criteria are in the room from the beginning.

 

Why is this? Because implementing the true spirit and content of the Criteria affects everything:

* How you engage and attract people into recovery;    

* How you conduct screening and assessments;

* How you collaborate with clients, patients, families and referral sources on individualized treatment;

* How you design, deliver and pay for a continuum of addiction services; and

* How you move people through a disease management continuum of care.

* Not least of all, how you select and train staff on all these processes.

 

Implications for stakeholders

  • Counselors and clinical staff will need to move away from program-driven services to individualized, person-centered, outcomes-driven treatment.
  • Administrators and supervisors must figure out how to use economies of scale to provide a broad continuum of care, to stretch resources to achieve good outcomes.
  • Payers and managed care companies will have to ‘speak’ the common language of The ASAM Criteria – to collaborate with treatment providers on care and utilization management decisions.
  • Quality improvement and auditors must understand the correct application of The ASAM Criteria and what it really means for documentation, treatment plans and continuing care decisions.
  • Referral sources, especially mandated treatment settings like Drug Court and other criminal justice personnel, Child Protective Services, employers and schools, will have to understand that mandating assessment and treatment adherence is the correct stance – rather than mandating a particular level of care and length of stay.

TIP 2

Broaden understanding of the clinical application of The ASAM Criteria beyond intake, admission and level of care placement.

 

Some counselors and clinicians think The ASAM Criteria is a checklist of levels of care to justify admission to the program. Then they think they are done- to pursue treatment as usual. Nothing could be further from the truth, which is why we removed the wording “patient placement” from the 460-page 3rd edition (2013) book.

 

It is much more than initial placement criteria. That’s why there are multiple chapters on application of the criteria to special populations. There are chapters on working effectively with managed care, tobacco use disorder and gambling disorder. Appendices on withdrawal management instruments were added to address Dimension 5, Relapse, Continued Use or Continued Problem Potential.

 

Take a look at www.ASAMCriteria.org and “How to Really Use the New Edition of The ASAM Criteria: What to Do and What Not to Do” Counselor Magazine Nov-Dec., 2013

See more: http://www.counselormagazine.com/2013/Nov-Dec/ASAM_Criteria/#sthash.wOk2zq6r.dpuf

 

There are some proprietary instruments to help you. The Change Companies® is the sole distributor for Evince Clinical Assessments, the field’s most complete system of clinically-driven assessment, diagnostic and patient placement and planning tools compatible with the DSM-5 and The ASAM Criteria – Third Edition.

 

Included in this comprehensive system is the DAPPER (Dimensional Assessment for Patient Placement Engagement and Recovery), the assessment tool most closely aligned with the new ASAM Criteria. To view a description and sample pages click https://www.changecompanies.net/products/?id=DA-T

 

TIP 3

Consider Interactive Journaling to help you use Evidence-Based Practices.

 

Many states now require counselors and programs to use Evidenced-Based Practices. In this new initiative California requires at least two of the following evidenced-based treatment practices (EBPs):

1. Motivational Interviewing

2. Cognitive-Behavioral Therapy

3. Relapse Prevention

4. Trauma-Informed Treatment

5. Psycho-Education

 

What too few realize is that there is actually one evidence-based practice that incorporates most of these EBPs above in one method. Interactive Journaling (IJ) is an EBP on the Substance Abuse and Mental Health Services (SAMHSA) National Registry of Evidence-based Programs and Practices (NREPP)

 

If you missed it, you can read all about IJ in the May 2014 edition of Tips and Topics:

https://www.changecompanies.net/blogs/tipsntopics/2014/05/

 

TIP 4

For a Standardized Assessment learn more about The ASAM Criteria Software.

The ASAM Criteria Software is now branded as Continuum ™, The ASAM Criteria Decision Engine. Continuum ™ provides counselors, clinicians and other treatment team members with a computer-guided, structured interview for assessing and caring for patients with addictive, substance-related and co-occurring conditions. By branding the software as “Continuum” it means The ASAM Criteria isn’t just about assessment at the front intake part of treatment in order to make a placement decision. It means that The ASAM Criteria is about ongoing chronic disease management across a whole continuum of care.

 

The book and Continuum ™ are companion text and application. The text delineates the dimensions, levels of care, and decision rules comprising The ASAM Criteria. The software provides an approved structured interview to guide adult assessment and calculate the complex decision tree to yield suggested levels of care, which are verified through the text.

 

For more information, go to the website www.asamcontinuum.org

 

Reference:

Miller, W. R. (2014). Interactive Journaling® as a Clinical Tool. Journal of Mental Health Counseling, 36(1), 31-42.

SOUL

Have you ever been stuck in gridlock on the highway with no clue why you are now in a parking lot!? You see some drivers pulling out to the shoulder, trying to catch a glimpse of what’s up ahead: “Is it a bad car accident? Or roadwork? A collapsed bridge? Is it 4 lanes narrowing down to 2? Maybe it’s just thousands of people interested in going to the same place as me?”

 

When you hear sirens and ambulances, you guess there is indeed an accident. Then you settle back for the long wait while cars crawl by rubbernecking at human tragedy. What’s frustrating is when you have no idea why you are speeding along at 3 miles per hour.

 

Switch scenes now. You’re sitting on a plane which was late taking off and now late arriving. This is threatening the very close connection to your next plane that you can’t wait to board. You want to get home after a long week “on the road”. Yes, that’s me.

 

Here’s my beef with airplane pilots. They can see perfectly well why the plane is 50 feet from the jet bridge and why we aren’t docking to let connecting passengers race to their next gate. Haven’t they ever been in a gridlocked parking lot on the highway? Don’t they know what it feels like to be stuck- with no idea why we aren’t moving?

 

Yes, they do usually give some brief explanation but:

  • Sometimes it is so general, it doesn’t help: “Folks, we aren’t at the gate yet, so please stay seated with your seat-belts fastened and your luggage stowed.”
  • Then a long silence with no explanation on why we are not at the gate yet. Is it because the gate is occupied by another plane that is nowhere near ready to push back? If so I almost certainly will miss my connection. Or is there a new trainee struggling to operate the jet bridge joystick and wobbling all over the airport, missing alignment with the plane door? Could we be waiting for a tow vehicle to hook up the plane to pull us into the gate? Pilot…..please tell us what is going on!
  • Even when they do tell us something more specific like: “There isn’t a gate agent yet to maneuver the jet bridge” or “There is a plane occupying our gate” or “We’re waiting for a tow vehicle,” they never keep you informed. They are up front looking through the windshield. We passengers have blank walls and no-smoking signs to look at. A few play-by-play updates would be nice: “Looks like the gate agents are busy, still no-one showing up. I’ve called them again.” Or “The plane does look like it is starting to push back, shouldn’t be long now.” Or “I can see the tow operator headed our way.”
  • Worst of all, is when they say: “It’s just going to be a few minutes and we’ll be at the gate” and then you get radio silence with no explanation and no updates AND it certainly is NOT a few minutes.

Maybe I’ve had too many frustrating plane trips lately, but next time I sit next to a pilot traveling to their next assignment, I’m going to bare my SOUL.

Until next time

Thanks for reading this month. See you in late September.                                

David

Vol. 13, No. 6

Welcome to the September edition of Tips and Topics. Thanks to all the longtime readers and to the new subscribers this month.

David Mee-Lee M.D.

SAVVY

Earlier this month, Janelle Wesloh, Executive Director of Recovery Management at Hazelden Betty Ford Foundation asked me about the samples of recovery language which I have included in SKILLS this month. They do sound like things I have talked and written about before:

October 2010 SKILLS: https://www.changecompanies.net/blogs/tipsntopics/2010/10/

April 2009 SAVVY: https://www.changecompanies.net/blogs/tipsntopics/2009/04/

June 2008 SKILLS: https://www.changecompanies.net/blogs/tipsntopics/2008/06/

April 2007 SAVVY: https://www.changecompanies.net/blogs/tipsntopics/2007/04/

January 2006 SKILLS: https://www.changecompanies.net/blogs/tipsntopics/2006/01/

 

We couldn’t find the source except that it appeared to originate with Washington State Department of Social and Health Services published August 2, 2010.  Zephyr Forest, Administrative Assistant for the Division of Behavioral Health and Recovery (zephyr.forest@dshs.wa.gov) was kind enough to try to track down the source, but he couldn’t trace its origins either. In the meantime though, he forwarded some equally stimulating resources some of which I am sharing in SAVVY this month.

 

TIP 1

Compare and contrast a pathology-oriented, deficit-based view of mental health versus a recovery, strength-based system of mental health services.

 

The following comparison was adapted from Ridgway, P. (2004). Research Findings: Key factors and elements of a recovery-enhancing mental health system. Document prepared for “Recovery in Action: Identifying Factors and Trends of Trans-formational Systems” meeting sponsored by CONTAC and NCSTAC. Indianapolis, Indiana.

 

Ridgway offers a comparison of the pre-recovery mental health system and a recovery enhancing mental health system.

 

Pre-Recovery Mental Health System

Recovery Enhancing System

1. Message is: “you’ll never recover” – illness is a lifelong condition.

1. Message is: “recovery is likely” you can and will attain both symptom relief and social recovery.

2. Minimal attention to basic needs.

2. Attention to basic needs, including housing, human and civil rights, income, healthcare, transportation.

3. Focus is on person as patient, client, service recipient.

3. Focus is on success in social roles: parent, worker, tenant. Activities to reclaim and support a variety of social roles are emphasized.

4. Treatment plan and goals are primarily set by staff with minimal input by individual or family. Plans often generic and focus on illness/medical necessity of treatment.

4. Personalized recovery plan is mandated based on person’s individual goals and dreams. Plan is broad and ranging across many domains. Often includes services and resources that are not directly affiliated or controlled by mental health service system.

5. People lack access to the most effective or research validated services.

5. There is ready access to research validated practices and ongoing innovation and research on promising approaches.

6. Peer support is discouraged, lacking, or underfunded.

6. Peer support is actively encouraged, readily available, adequately funded and supported.

7. Coercion and involuntary treatment are common. Staff act “in locus parentae”, over use of guardianships, representative payee and conservatorships.

7. Coercion and involuntary treatment are avoided. People are treated as adults. Temporary substitute decision makers used only when necessary. Advanced directives and other means are used to ensure people have say even in crisis.

8. Crisis services emphasize coercion and involuntary treatment, often use seclusion and restraint which can be (re)traumatizing.

8. Crisis alternatives such as warm lines and respite are available. Staff has been trained to avoid seclusion and restraint and is skilled in alternative approaches.

 

TIP 2

Note how language matters. Consider these alternatives which promote recovery.

 

In the same module of the Washington State Certified Peer Counselor Training Manual

(MODULE 3: CORE PRINCIPLES OF RECOVERY & RESILIENCE), that referenced Ridgway’s work, there was a succinct list on page 37 emphasizing that language matters.

 

“When we talk about mental illness, the words we choose are very important. Respectful language can promote recovery and reduce stigma. A poor choice of words can have the opposite effect. Consider the following word choices:

  • Person instead of patient
  • Challenge instead of failure                                              
  • Opportunity instead of crisis
  • Life experience instead of history of illness                   
  • Strengths instead of weaknesses
  • Recovery path instead of cure
  • Acceptance instead of blame

“The words on the left are positive and have a sense of power to them. They engender hope and possibility. The words on the right are negative. Words can go a long way in facilitating someone’s recovery and combating stigma within and outside of the mental health system.” (page 37).

 

Harris and Felman provided their list of how “language that is commonly used within the mental health system can often be improved. The following are examples of simple, practical ways to reframe the conversation in recovery-oriented ways.” 

  

Rather than these words:       Use words that promote recovery:

1. Refused                                  1. Declined / Repeatedly said no

2. Resisted                                  2. Chose not to / Disagreed with the suggestion

3. Client believes that…           3. Client stated that…

4. Delusional                              4. Experiencing delusional thoughts

5. Paranoid                                 5. Experiencing paranoid symptoms

6. Decompensate                      6. Experiencing an increase in symptoms

7. Manipulative                         7. Seeking alternative methods of meeting needs

8. Noncompliant                       8. Not in agreement with the treatment plan

                                                                 Difficulty following treatment recommendations       

9. Unmotivated                         9. Bored /Has not begun

10. Suffering from…                 10. Has a history of…                      

11. Low functioning                 11. Has difficulty with…

 

References:

1. Washington State Certified Peer Counselor Training Manual (Revised July 2009). “Language Matters” in MODULE 3: CORE PRINCIPLES OF RECOVERY AND RESILIENCE, pp. 37-41. Washington State’s Division of Behavioral Health & Recovery. Prepared by the Washington Institute for Mental Health Research & Training.

https://www.dshs.wa.gov/sites/default/files/BHSIA/dbh/documents/WACertifiedPeerCounselorManualApr2012FINAL.pdf

 

2. Harris, Jamie & Felman, Kristyn (2012): “A Guide to the Use of Recovery-Oriented Language In Service Planning, Documentation, and Correspondence” Mental Health America Allegheny County, 100 Sheridan Square, 2nd Floor Pittsburgh, PA 15206 Phone: 1-877-391-3820 www.mhaac.net

http://www.mhaac.net/Files/Admin/The%20Use%20of%20Recovery-Oriented%20Language%208-21-12.pdf

SKILLS

It takes some practice and skill to avoid falling into the same old pathology-oriented and blaming language we get so used to doing. So here is the recovery language grid to helps re-frame and sharpen your skills. If you are aware of the source, please let me know at davidmeelee@gmail.com.

 

TIP 1

Build your skills to move away from blaming or labeling language to respectful empowering terminology.

 

“The following are some of the terms we have traditionally used to describe people and/or their behaviors. These terms place judgment and blame on the individual and generalize their actions. It is much more helpful to describe the specific situation that a person is facing than to use generic and punitive clinical terms.”

 

 Worn Out Language

Language that Promotes Acceptance, Respect & Uniqueness

 Comments

Max is mentally ill

 Max is schizophrenic

 Max is a bipolar

 Max is…

Max has a mental illness.

 

Max has schizophrenia.

 

Max has been diagnosed with bipolar disorder.

 

Max is a person with…

Avoid equating the person’s identity with a diagnosis. Max is a person first and foremost, and he also happens to have bipolar disorder.

Very often there is no need to mention a diagnosis at all.

 

It is sometimes helpful to use the phrase “a person diagnosed with”, because it shifts the responsibility for the diagnosis to the person making it, leaving the individual the freedom to accept or not.

Alex is an addict

Alex is addicted to alcohol.

Alex is in recovery from drug addiction.

Put the person first.

 Avoid defining the person by their struggles.

Rebecca is brain injured/damaged

Rebecca has a brain injury.

Put the person first.

 Avoid defining the person by their struggles.

Jane is disabled/handicapped

Jane is a person with a disability.

Put the person first.

 Avoid defining the person by their struggles.

Mark is normal/healthy

Mark is someone without a disability.

Referring to people without disabilities as normal or healthy infers that people with disabilities are not normal and not healthy.

Sarah is decompensating

Sarah is having a rough time.

 Sarah is experiencing…

Describe what it looks like uniquely to that individual. That information is more useful than a generalization.

 Avoid sensationalizing a setback into something huge.

Mathew is manipulative

Mathew is trying really hard to get his needs met.

 Mathew may need to work on more effective ways of getting his needs met.

Take the blame out of the statement.

 Recognize that the person is trying to get a need met the best way they know how.

Kyle is non-compliant

 

 

 

 

Kyle is choosing not to…

 Kyle would rather…

 Kyle is looking for other options

Describe what it looks like uniquely to that individual. That information is more useful than a generalization.

Does Kyle agree with your plan?

Megan is very compliant

Megan is excited about the plan we’ve developed.

 Megan is working hard towards the goals she has set.

Being compliant means that someone is doing what they were asked or told to do. The goal of recovery-oriented services is to help the person define what they want to do and work towards it together.

 Someone being compliant does not mean that they are on the road to recovery, only that they are following directions.

Mary is resistant to treatment

Mary chooses not to…

 Mary prefers not to…

 Mary is unsure about…

Describe what it looks like uniquely to that individual. That information is more useful than a generalization.

Remove the blame from the statement.

Allie is high functioning

Allie is really good at…

Describe what it looks like uniquely to that individual. That information is more useful than a generalization.

Jesse is low functioning

Jesse has a tough time taking care of himself.

 Jesse has a tough time learning new things.

 Jesse is still early in his recovery journey.

Describe what it looks like uniquely to that individual. That information is more useful than a generalization.

 Avoid defining the entire person negatively based on the fact that he struggles in some areas.

Michael is dangerous

Michael tends to become violent when he is upset.

 Michael sometimes strikes out at people when he is hearing voices.

Describe what it looks like uniquely to that individual. That information is more useful than a generalization.

 Remove the judgment from the statement.

 Avoid defining the person by the behavior.

Harry is mentally ill chemically abusing (MICA)

Harry is a person with co-occurring mental health and substance use/abuse problems.

Put the person first.

 Avoid defining the person by their struggles.

Sam is unmotivated

Sam doesn’t seem inspired to go back to work.

 Sam is not in an environment that inspires him.

 Sam is working on finding his motivation.

 Sam has not yet found anything that sparks his motivation.

Describe what it looks like uniquely to that individual. That information is more useful than a generalization.

 Avoid defining the person by the behavior.

 Remove the blame from the statement.

Andy is manic

Andy has a lot of energy right now.

 Andy hasn’t slept in three days.

Describe what it looks like uniquely to that individual. That information is more useful than a generalization.

 Avoid defining the person by the behavior.

Kate is paranoid

Kate is experiencing a lot of fear.

 Kate is worried that her neighbors want to hurt her.

Describe what it looks like uniquely to that individual. That information is more useful than a generalization.

Hailey is a cutter

Hailey expresses her emotional pain through self-harm.

 Hailey hurts herself when she is upset.

Avoid defining the person by the behavior.

 Recognize the reason behind the behavior.

 

Jordan has a chronic/persistent mental illness

Jordan has been working towards recovery for a long time.

 Jordan has experienced depression for many years.

Avoid conveying a prognosis.

 It is difficult to accurately predict an individual’s prognosis and it only impedes their progress to define them as someone who will not recover (or will not be in recovery for a very long time).

 

There is no need to address prognosis in describing a group of people or an individual.

Tom is very difficult

Tom and I aren’t quite on the same page.

 It is challenging for me to work with Tom.

Avoid making a judgment, which may be based on your dissatisfaction with the fact the person has not met your expectations (which may be different from what he wants for himself).

Manipulative

 

Grandiose

 

In denial

 

Passive aggressive

 

Self- defeating

 

Oppositional

 

These are often people’s ineffective attempts to reclaim some shred of power while being treated in a system that often tries to control them.

 The person is trying to get their needs met, or has a perception different from the staff, or has an opinion of self not shared by others. And these efforts are not effectively bringing them to the result they want.

These are labels for strategies and perceptions we all have about ourselves, although possibly more subtle and effective.

 We all present information to achieve a desired result to some degree (manipulation).

Or have an inflated opinion of ourselves, or are unable to see or agree with something presented to us by another.

SOUL

Earlier this month I had to eat humble pie twice – all in the same shopping expedition- in the space of one hour. I consider myself a reasonably patient person……but not so fast. Because when it’s getting late and the shops will close soon and I haven’t finished my must-do errands, suddenly some old wisdom rears its ugly head:

                        “Patience is a virtue

                         Possess it if you can

                         Seldom found in women

                         Never in a man.”

 

Well it wasn’t found in this man, this writer, this month anyway.

 

I had just finished buying some printer cartridges at Office Depot before they closed. I wanted to get to next store before they closed too. Stuck behind a driver at a red light, I started fuming and judging his knowledge of the road rules. He just sat there and didn’t seem to know that you can, sir, turn right on red in the USA. Let’s get on with it; there’s no traffic coming; it is quite safe for you to turn on a red light and then I can get going on my errands. He still just sat there, apparently not getting my psychic message to get moving beamed from my car to his.

 

The light turns green. Finally, I’m thinking, he’ll turn now so I can rush to the next store.  But he has already made me waste at least 45 seconds tolerating his stubbornness and refusal to turn right on red. So inconsiderate and ignorant of basic driving rules.

 

Oops! He didn’t turn right, because he was going straight ahead and had never even indicated he was going to turn right. That was all in my head, assuming that just because I was turning right, he must be going that direction too. Sheepishly, I ate some humble pie, noting how easy it is to see the world just through my eyes and perspective.

 

Not 10 minutes later…. I find my self stuck again behind an inconsiderate driver. This time, not stuck at a red light, but crawling along at 15 miles per hour in a 30 mph zone. Don’t they know where the accelerator is? I’m rushing to get to the next store before it closes. Do they really need to choose this time to drive slowly and smell the roses? I’m tempted to move closer and tailgate them to send a not-so-subtle message to “hurry up, will you!”

 

Oops again! Just as I start to speed up towards them, they turn right into the next street. They were not smelling the roses. Ironically they were turning right when I was focused on going straight ahead. That is why they were going slowly, preparing to turn.

 

There was the second slice of humble pie all in less than an hour. I had done it again – seeing the world just through my eyes and perspective. Now, who was the inconsiderate driver?

Until next time

Glad you could join us this month. See you in late October.                              

David

SAVVY

I just returned from Seoul, South Korea, my first trip there. It was fascinating and I’ll tell you more in SOUL from Seoul. The main reason I traveled there was to participate in an International Lifestyle Medicine and Addiction symposium hosted by Sahmyook University. They were celebrating the official opening of their brand new Lifestyle Medicine and Health Promotion Institute.

 

One of the invited keynote speakers was Edward M. Phillips, M.D., Founder and Director, Institute of Lifestyle Medicine, Joslin Diabetes Center, Boston, Massachusetts; and Assistant Professor of Physical Medicine and Rehabilitation, Harvard Medical School. Like addiction treatment, lifestyle medicine is a neglected, yet so important body of knowledge too little taught in medical school and across all the helping professions. Dr. Phillips highlighted some facts and figures which will convince you too it is time to pay more attention to lifestyle medicine and wellness.

 

TIP 1

Review these keynote points and see if you can ignore the need to embrace lifestyle changes in your life and the nation’s.

 

Dr. Phillips opened by a “Call to Arms (and Legs)”. He said:

  • “We know why the majority of the population will die prematurely.
  • We know the root cause of two-thirds of all disease.
  • We know where most of our health care dollars could be saved.
  • Yet: we don’t teach this to doctors and our health care system continues to practicesickness-based care.”

Here are more facts and figures:

  • 70% of cardiovascular disease can be prevented or delayed with dietary choices and lifestyle modifications (Forman D, Bulwer BE, Curr Treat Options Cardiovasc Med. 2006;8:47-57)
  • The World Health Organization states that by 2020, two-thirds of all global disease will be lifestyle-related (Chopra M et al.Bull WHO. 2002;80:953-958)
  • 78% of health care expenditures are consumed by the management of chronic disease (Anderson G, Horvath J.Public Health Report. 2004;119:263-270)
  • The combined effect of lifestyle factors such as physical inactivity, obesity, poor diet, cigarette smoking, and excess alcohol consumption have a significant impact on morbidity and mortality from the resulting chronic disease (Hu FB et al. N Engl J Med. 2001;345:790-797) and leads to the following increases:

* Increases 55% all causes of mortality (van Dam RM et al. BMJ. 2008;337:a1440)

* Increases 44% cancer mortality (van Dam RM et al. BMJ. 2008;337:a1440)

* Increases 72% cardiovascular mortality (van Dam RM et al. BMJ. 2008;337:a1440)

 

I know it’s easy for your eyes to glaze over with all those big picture statistics and wonder what is the impact at the ground level of your daily life. We’ll get to what you can do soon. But first a few more big picture statistics which will inspire you to make even a small change in lifestyle.

 

TIP 2

Take note of the Wellness Dividend for just a 2% change in lifestyle.

  • Annual health care costs in 2019 estimated to be $4.48 trillion 
    (Centers for Medicare and Medicaid Services. National Health Expenditure Data  https://www.cms.gov/NationalHealthExpendData/25_NHE_Fact_Sheet.asp)
  • WHO estimates 66% of health care costs result from lifestyle = $3 trillion annually by 2010 Bull WHO. 2002;80:953-958)

If we made a small change of 2% in weight, activity, smoking, etc. e.g., walking an additional 500 steps a day or giving up the last cookie, the result: 

  • Wellness Dividend of annual $60 billion in cost savings.

SKILLS

So let’s bring this all closer to home- from the big statistical picture to ‘where the rubber meets the road’ in your running shoes or with the fork at your meal table. Dr. Phillips had the audience assess their own health habits.

 

TIP 1

Get with a group of friends or acquaintances and see who is the last person standing.

 

Here are the instructions:

Everybody stands up and if you answer “yes” to any of the questions, sit down and take a seat at that point.

 

Here are the questions:

1. Do you smoke cigarettes? – Sit down if you are a smoker.

2. Is your BMI (Body Mass Index) equal to or greater than 25kg/m2? – Underweight is <18.5; Normal weight = 18.5 – 24.9; Overweight = 25 – 29.9; Obesity = BMI of 30 or greater.

3. Do you eat less than 5 servings of fruits and vegetables/day? – If yes, then sit down.

4. Do you drink more than one drink a day? – “One drink” = 12 ounces of regular beer; 5 ounces of red wine; 1.5 ounces of liquor.

5. Do you do less than 150 minutes/week of physical activity/exercise? – If you are a bit of a couch potato, take a seat…OK to be a couch potato for a moment as you look around and see if anyone is still standing.

6. Finally do you sleep less than 6-7 hours/night? – If you aren’t getting enough sleep at night, that is a tough lifestyle change in our fast paced, over-packed lives.

 

When I did this with a large group, I know I wasn’t the last person standing; and there were very few excellent specimens of lifestyle role models standing after just those six questions. How did you rate with your own health habits and lifestyle?

 

The secret of success is to aim low – so don’t try to change your lifestyle all at once. This is where BJ Fogg, PhD has some great advice – http://www.bjfogg.com

 

TIP 2

Take a look at Tiny Habits ® and become inspired to start with just your 2% or a tiny habit.

 

As Dr. Phillips said, maybe you could start with just 500 steps per day, not 10,000 a day. Or choosing not to take that last cookie or last spoonful of desert rather than promise to never eat desert for the next year.

 

There are a number of methods on the same theme, but here is the Fogg Method:

http://www.foggmethod.com

Step 1: Get specific about what lifestyle change you want to make (e.g., do some push-ups to strengthen my biceps and core.)

Step 2: Make it easy (e.g., plan on a tiny habit of just two push-ups to start with.)

Step 3: Trigger the behavior – what will prompt yourself to remember to do the tiny habit (e.g., after I brush my teeth, I will do two push-ups.)

 

Why is it always hard to obtain as much respect for prevention and lifestyle change as it is for a new surgical laser machine or a state-of-the-art center for cancer treatment? Yet lifestyle change can make such a difference to your health and health care costs.

 

We preach what we need to learn – and I am learning too.

SOUL

It is so fascinating to me to travel the world and see new places and cultures. So here are some “culture shocks” I noted on my first trip to Seoul – SOUL from Seoul if you like. From the variety of people I spoke with, there seemed to be consensus that these observations were true and typical:

  • It is not intrusive or discourteous to ask a person you just met how old they are. In fact, a person may introduce themselves as “I’m David and I am a psychiatrist living in California and I’m 66.” The person’s age tells you how you should address them in the hierarchy of respect. It is not comfortable to address an older person as “David” even if I invite a more familiar greeting
  • People (and I mean adults and children) work long hours. Adults may stay until 8 or 9 PM or even later and it does not look good to leave on time at the end of the day even if you have your work done. Some would never leave before their manager; and it is expected that you go out to meal or drinking with your manager and to stay late if asked – no overtime.
  • Children in high school and even earlier grades finish school in the afternoon and then often attend another afterschool academic program studying until 10 or even 11 PM. This is to achieve excellent grades to compete for the top universities in Seoul that is considered the only acceptable path to getting a good job after graduation.
  • Not unrelated perhaps, the suicide rate in South Korea is the highest among Organization for Economic Cooperation and Development (OECD) countries. http://www.washingtonpost.com/wp-srv/world/suiciderate.html 

 

On the healthcare front there were some surprises too:

  • I sat in on a Laughter Therapy group where cancer patients and others spend an hour a day laughing their heads off as part of their healing process. We actually have this too in the USA, (Google Laughter Therapy and you’ll see Cancer Treatment Centers of America uses it).
  • I visited a post-natal unit on the hospital grounds where mothers can stay for two weeks to rest after delivering their baby. Educational sessions, relaxation, and recuperation prepare the housewife to be ready to take up her busy care of the family.
  • Finally, Seoul has become the plastic surgery capital of the world with many adolescent girls, women and some men having a variety of procedures to create double eyelids and open up their eyes to be wider and more western looking. Nose reshaping; and chin surgeries to create a more V-shape. Coincidentally, I heard an October 20 segment on National Public Radio’s Here and Now program all about this. You can listen in for yourself at:
  • https://hereandnow.wbur.org/2015/10/20/south-korea-plastic-surgery-photos 

There is much more SOUL from Seoul that I could share. But this gives you a taste of South Korea, not to mention my trip to the Demilitarized Zone (DMZ) between South and North Korea. I looked out onto North Korea and wondered if Kim Jong-un, Supreme Leader of North Korea, was staring back at me.

 

I don’t think so.

SHARING SOLUTIONS

As you contemplate your own lifestyle, I want you to know about the Institute for Wellness Education of which I am one of the co-founders. Our desire is to drive cultural transformation so health and wellness become the norm for individuals, communities, and the nation: https://www.instituteforwellness.com/advocates/

 

You may be interested in taking the Level 1 fundamentals course: “Take Charge of Your Life: Be Well to Do Well.” This includes Interactive Journaling using “My Personal Health Journal.” Take a look at the 10 modules in the Level 1 course at: https://www.instituteforwellness.com/wellness-coaches-course-overview/

 

Here’s to your health and well-being.

Until next time

Thank-you for joining us this month. See you in late November.                            

David

Vol. 13, No. 8

To all in the USA, I hope you had a thankful and happy Thanksgiving and welcome everyone to the November edition of Tips and Topics. I’m glad you could join us this month.

 

David Mee-Lee M.D.

SAVVY

I have known Dr. Norman Hoffmann for over 30 years as a friend and colleague. Over the years of many presentations I have enjoyed and appreciated, Norm has shared quotes and quips that provide bits of wisdom as well as humor. Recently, as I listened again, I thought it was time to get some of those into print. So here a few of Norm’s favorites and what they mean.

 

TIP 1

Ponder these quotes and the wisdom they hold as told by Dr. Hoffmann.

 

1. “For every complex problem, there is a simple answer; and it’s wrong.” Attributed to H. L. Mencken.

  • So often people look for a simple answer, or fix, to complicated issues instead of a more comprehensive approach.

 

2. “The truth is rarely pure and never simple.” A line from the play, “The Importance of Being Ernest” by Oscar Wilde.

  • This is similar to the Mencken quote in that things are often more complex than we would like them to be.

 

3. “If your theory conflicts with folklore, recheck your theory.” This is a comment made by Paul Meehl during a graduate school seminar at the University of Minnesota.

  • Folklore is often based on observed associations. The folk explanation for the association might be fanciful, but the association is quite real.

 

4. “For the great enemy of truth is very often not the lie – deliberate, contrived, and dishonest; but the myth – persistent, persuasive, and unrealistic.” By John F. Kennedy in a commencement address at Yale.

  • Myths and misconceptions can often be more damaging than deliberate falsifications.

“Then there are a few for whom I do not know the originator or ones that I have adapted from some recollection.” Here they are:

 

5. “Left unchallenged our beliefs become our truths.”

  • All too often we may have a tendency to go with the myth that is comfortable rather than to consider the truth, which may be disquieting.

 

6. “If you torture a statistic long enough, you can get it to confess to anything.”

  • As one who reads the literature on addiction, I am often disturbed that the numbers underlying the conclusions do not seem to support the contentions of the authors.

 

7. “Beware of a theory that explains everything, but predicts nothing.”

  • One can often come up with any far-fetched idea to explain something, but it is not replicable or predictive.

 

8. Finally, there is my own favorite contribution: “A computer program can make a diagnosis when it is licensed for independent practice in your state.”

  • Too often I find people who want computers to do their thinking for them instead of examining the evidence and thinking for themselves.

 

TIP 2

Enjoy some vague terms often used in addiction and some fanciful definitions of Dr. Hoffmann.

 

1. “Heavy drinker”

  • Someone who weighs 250 lbs. and drinks.

 

2. “Problem drinkers”

  • People who spill more than they swallow.

 

3. “alcohol abuse”

  • Pouring water into good Scotch.

 

4. “Data is not the plural of anecdotes”

  • This addresses the issue of using memorable examples to support a position rather than actual statistics that might be quite different. (David Mee-Lee: Just because you have lots of examples and stories that support your views and perspectives, doesn’t mean you have valid research data.)

 

Norman Hoffmann, Ph.D.

President, Evince Clinical Assessments

E-mail: evinceassessment@aol.com

www.evinceassessment.com

 

Bio:

Dr. Hoffmann is a clinical psychologist who has evaluated behavioral health programs, provided consultations, and conducted trainings for over 35 years. He has worked with private organizations and governmental agencies in a variety of countries. Dr. Hoffmann has developed a number of assessments instruments used throughout the United States, as well as in Canada, Sweden, Norway, and the United Kingdom and authored or co-authored more than 190 publications. Take a look at some of Dr. Hoffmann’s work:

https://www.changecompanies.net/products/?servicearea=12

His faculty appointments include the University of Minnesota and Brown University. Currently he is President of Evince Clinical Assessments and adjunct professor of psychology at Western Carolina University.

SKILLS & STUMP THE SHRINK

Earlier this month, Ian Evans sent me the following message:

 

I was curious about slips when a client is in residential. Recently some programs we deal with have discharged clients who have drunk or used while on their pass. To me, it seems that residential treatment is the perfect place to deal with this issue. The client is in a structured environment, counselors they are familiar with, and in a treatment facility that can help them figure out what happened, why it happened, coping skills for the future, etc.

            I have heard various reasons why: it being unsafe for other clients, there being state guidelines that someone must be discharged if they use while in treatment, etc. I was curious not only your thoughts on this in general, but also if you are aware of any guidelines for residential facilities in these instances.

            I have reached out to the Department of Health Care Services as well, but to me it seems to make the most sense to allow someone to get treated in treatment rather than discharging and creating policies such as the client needs to check in and go to meetings every day for 2 weeks before they can come back to treatment.

Thanks,

Ian Evans MFTI #78016

Clinician I, Adult Forensic Care Team

Yolo County Department of Health Services, California

Work Cell: (530) 681-8165

Voicemail: (530) 666-8099 ext 1803

E-mail: Ian.Evans@yolocounty.org

 

TIP 1

Note how our attitudes and actions about substance use while in treatment does not fit with treating addiction as a disease.

 

Hi Ian:

Your concerns are what I have written and spoken about a lot. Here are some links to what I have written before. You should also look at Appendix B in the latest edition of The ASAM Criteria (2013) pp. 401-410 where we suggest an approach and policy and procedure on use while in treatment. If you don’t have the latest book, I suggest you get it. See www.ASAMCriteria.org for more information.

 

Here are some links. If the links don’t work, go to www.tipsntopics.com and click on the edition on the right hand side Archives:

 

A. Tips and Topics, July 2014:

  • In SAVVY of this edition, I wrote about the steps to consider when a person uses substances while in treatment.
  • In SKILLS, note what taking action means when a person uses while in treatment. It isn’t about discharging a person or transferring to a more intensive level of care.

https://www.changecompanies.net/blogs/tipsntopics/2014/07

B. Tips and Topics, October 2012:

  • In SAVVY of this edition, I wrote about how we don’t treat addiction flare-ups the same way we treat flare-ups of other illnesses like depression, schizophrenia, hypertension, bipolar or panic disorder.
  • I also referenced an interview with William Miller (Motivational Interviewing) who raises the question whether “relapse” is even a useful clinical term.

https://www.changecompanies.net/blogs/tipsntopics/2012/10/31/october-2012-tips-topics

 

 

C. Tips and Topics, November 2012:

  • In SAVVY, look at some alternative terms for “relapse” and try those on for size.
  • In SKILLS in this edition, here’s what to do when a client uses in residential treatment; when discharge is clinically reasonable and when it is not.

https://www.changecompanies.net/blogs/tipsntopics/2012/11/29/november-2012-tips-topics

 

 

D. Tips and Topics, June 2009:

  • In SKILLS, look at what to do when concerned that letting substance-using clients stay in treatment will trigger others and send a message that it is OK to use if there are no “consequences” for use.
  • Also see what to do when you get a poor outcome like a flare-up of use in an addicted client – assess and change the treatment plan like we do with other illnesses.

https://www.changecompanies.net/blogs/tipsntopics/2009/06

 

 

E. Tips and Topics, October 2004:

  • In SAVVY, I reference the constructs in ASAM Criteria Dimension 5, Relapse, Continued Use or Continued Problem Potential which first appeared in ASAM PPC-2R (2001) but is available in The ASAM Criteria (2013), Appendix B, pp. 401-410. These help you assess and treat flare-ups of addiction instead of discharging people.
  • Also in SAVVY, understand the difference between ASAM Criteria Dimension 4, Readiness to Change and Dimension 5.
  • In SKILLS, suggestions on what to do when a person arrives to a group having used alcohol or some other drug; and what to do if there is a positive drug screen.
  • Do clients in early stages of change, need relapse prevention strategies? See the answer in SKILLS.

https://www.changecompanies.net/blogs/tipsntopics/2004/10

 

 

F. Tips and Topics, September 2006 SKILLS section:

  • In SKILLS, look at “Things That Don’t Make Sense” and what to do about them. It will reinforce the suggestions of the previous editions above.

https://www.changecompanies.net/blogs/tipsntopics/2006/09

 

Hope this helps, but let me know if not.

David

 

TIP 2

In a follow up message, Ian raised a common State policy preventing clinicians from treating relapse and flare-ups as assessment and treatment issues.

 

BARCLAYS OFFICIAL CALIFORNIA CODE OF REGULATIONS

Health-Related Services.

Title 9 Section 10572 (e) that states:

 

“(e) No person, who, within the previous 24 hours, has consumed, used, or is still otherwise under the influence of alcohol or drugs as specified in section 10501(a), shall be permitted on the premises except for individuals admitted for detoxification or withdrawal. The licensee shall have specific written rules and policies and procedures to enforce this provision.”

https://govt.westlaw.com/calregs/Document/I49471470D45411DEB97CF67CD0B99467?viewType=FullText&originationContext=documenttoc&transitionType=CategoryPageItem&contextData=(sc.Default)

 

http://www.apartment-manager-law.com/data11/10572-Health.htm

 

Ian’s message:

It may be a huge question I am asking here, but do you see any way of working with the State to amend this so that if a client has a slip while on a weekend pass that they are not told they are discharged and must come back in 72 hours or 2 weeks like some programs do? There’s just something about discharging someone from residential treatment for slipping on a weekend pass and having them go back to the very environment they were using in before treatment that doesn’t sit well with me.

 

Thanks for your time,

Ian Evans

 

Perhaps you have similar regulations in your State or county. I have pledged to Ian that I will do what I can to raise this sticky regulation with the powers that be to start a conversation for change:

  • How can we combat the discrimination and stigma that addiction attracts even in our treatment system?
  • How we can we start treating addiction and flare-ups and poor outcomes the same way we treat other chronic conditions, instead of marginalizing clients and patients – discharging them and contributing to already high dropout and premature discharge rates?
  • What would it take to change attitudes of the general public, criminal justice and especially treatment providers in general health, mental health and addiction treatment to take addiction seriously as an illness needing care, not punishment, rejection, incarceration and discharge?
  • How can we begin to change policies, procedures and regulations to fit the disease of addiction rather concepts of willful misconduct and need for punishment?

Let’s start the conversation.

SOUL

I’m not really an avid sports fan (except maybe for the New England Patriots National Football League, NFL, team). I am much more interested in the psychology of sports than the actual mechanics of why a person or a team wins. So when I heard that the Golden State Warriors (the San Francisco Bay area National Basketball Association, NBA, team) were about to make history, it sparked my interest. Golden State was about to have the best regular season start (16 wins in a row) in the NBA’s 70-year history.

 

As I listened to the sports pundits and commentators opining on why Golden State was so successful, I was intrigued by their explanation and analysis, heard on San Francisco public radio station KQED’s Forum with Michael Krasny. If you are into sports and want to listen, here’s the link: http://www.kqed.org/a/forum/R201511230930

  • Often, when a team wins the NBA championship as Golden State did last year, players start getting inflated egos and entourages. Humility goes out the window. On this team, players have stayed humble and are “just having fun”.
  • A number of the players had been written off in the past as too small to be an effective player; or clearly not a top tier prospect; or late to the game and inexperienced. They all had something to prove and worked hard to debunk the critics. Even with their proven success, they are still “hungry” to win and while confident, are not complacent.
  • “Unselfishness” – Golden State, like other teams, have created success by unselfish play consisting of many “assists” and moving the ball around to all players on the floor. The goal was to score a basket: get the points as a team rather than each player trying to be the star, drive to the basket to get the points on their scorecard.

Humility, fun, hard work, confidence but not complacence, unselfishness and team work – sounds to me like a winning formula for life, not just basketball history.

 

You might be interested to know that the Patriots are one of only two teams out of 32 in the NFL to have a winning start to the season, unbeaten in 10 games so far. I wonder if that is because of humility, fun, hard work, confidence but not complacence, unselfishness and team work too? Some other teams accuse the Patriots of being arrogant and cheaters, but they’re just jealous.

 

Go Pats!

Until next time

Thank-you for joining us this month. See you in late December.

                              

David

Vol. 13, No. 6

Welcome to the September edition of Tips and Topics. Thanks to all the longtime readers and to the new subscribers this month.

David Mee-Lee M.D.

SAVVY

Earlier this month, Janelle Wesloh, Executive Director of Recovery Management at Hazelden Betty Ford Foundation asked me about the samples of recovery language which I have included in SKILLS this month. They do sound like things I have talked and written about before:

October 2010 SKILLS: https://www.changecompanies.net/blogs/tipsntopics/2010/10/

April 2009 SAVVY: https://www.changecompanies.net/blogs/tipsntopics/2009/04/

June 2008 SKILLS: https://www.changecompanies.net/blogs/tipsntopics/2008/06/

April 2007 SAVVY: https://www.changecompanies.net/blogs/tipsntopics/2007/04/

January 2006 SKILLS: https://www.changecompanies.net/blogs/tipsntopics/2006/01/

 

We couldn’t find the source except that it appeared to originate with Washington State Department of Social and Health Services published August 2, 2010.  Zephyr Forest, Administrative Assistant for the Division of Behavioral Health and Recovery (zephyr.forest@dshs.wa.gov) was kind enough to try to track down the source, but he couldn’t trace its origins either. In the meantime though, he forwarded some equally stimulating resources some of which I am sharing in SAVVY this month.

 

TIP 1

Compare and contrast a pathology-oriented, deficit-based view of mental health versus a recovery, strength-based system of mental health services.

 

The following comparison was adapted from Ridgway, P. (2004). Research Findings: Key factors and elements of a recovery-enhancing mental health system. Document prepared for “Recovery in Action: Identifying Factors and Trends of Trans-formational Systems” meeting sponsored by CONTAC and NCSTAC. Indianapolis, Indiana.

 

Ridgway offers a comparison of the pre-recovery mental health system and a recovery enhancing mental health system.

 

Pre-Recovery Mental Health System

Recovery Enhancing System

1. Message is: “you’ll never recover” – illness is a lifelong condition.

1. Message is: “recovery is likely” you can and will attain both symptom relief and social recovery.

2. Minimal attention to basic needs.

2. Attention to basic needs, including housing, human and civil rights, income, healthcare, transportation.

3. Focus is on person as patient, client, service recipient.

3. Focus is on success in social roles: parent, worker, tenant. Activities to reclaim and support a variety of social roles are emphasized.

4. Treatment plan and goals are primarily set by staff with minimal input by individual or family. Plans often generic and focus on illness/medical necessity of treatment.

4. Personalized recovery plan is mandated based on person’s individual goals and dreams. Plan is broad and ranging across many domains. Often includes services and resources that are not directly affiliated or controlled by mental health service system.

5. People lack access to the most effective or research validated services.

5. There is ready access to research validated practices and ongoing innovation and research on promising approaches.

6. Peer support is discouraged, lacking, or underfunded.

6. Peer support is actively encouraged, readily available, adequately funded and supported.

7. Coercion and involuntary treatment are common. Staff act “in locus parentae”, over use of guardianships, representative payee and conservatorships.

7. Coercion and involuntary treatment are avoided. People are treated as adults. Temporary substitute decision makers used only when necessary. Advanced directives and other means are used to ensure people have say even in crisis.

8. Crisis services emphasize coercion and involuntary treatment, often use seclusion and restraint which can be (re)traumatizing.

8. Crisis alternatives such as warm lines and respite are available. Staff has been trained to avoid seclusion and restraint and is skilled in alternative approaches.

 

TIP 2

Note how language matters. Consider these alternatives which promote recovery.

 

In the same module of the Washington State Certified Peer Counselor Training Manual

(MODULE 3: CORE PRINCIPLES OF RECOVERY & RESILIENCE), that referenced Ridgway’s work, there was a succinct list on page 37 emphasizing that language matters.

 

“When we talk about mental illness, the words we choose are very important. Respectful language can promote recovery and reduce stigma. A poor choice of words can have the opposite effect. Consider the following word choices:

  • Person instead of patient
  • Challenge instead of failure                                              
  • Opportunity instead of crisis
  • Life experience instead of history of illness                   
  • Strengths instead of weaknesses
  • Recovery path instead of cure
  • Acceptance instead of blame

“The words on the left are positive and have a sense of power to them. They engender hope and possibility. The words on the right are negative. Words can go a long way in facilitating someone’s recovery and combating stigma within and outside of the mental health system.” (page 37).

 

Harris and Felman provided their list of how “language that is commonly used within the mental health system can often be improved. The following are examples of simple, practical ways to reframe the conversation in recovery-oriented ways.” 

  

Rather than these words:       Use words that promote recovery:

1. Refused                                  1. Declined / Repeatedly said no

2. Resisted                                  2. Chose not to / Disagreed with the suggestion

3. Client believes that…           3. Client stated that…

4. Delusional                              4. Experiencing delusional thoughts

5. Paranoid                                 5. Experiencing paranoid symptoms

6. Decompensate                      6. Experiencing an increase in symptoms

7. Manipulative                         7. Seeking alternative methods of meeting needs

8. Noncompliant                       8. Not in agreement with the treatment plan

                                                                 Difficulty following treatment recommendations       

9. Unmotivated                         9. Bored /Has not begun

10. Suffering from…                 10. Has a history of…                      

11. Low functioning                 11. Has difficulty with…

 

References:

1. Washington State Certified Peer Counselor Training Manual (Revised July 2009). “Language Matters” in MODULE 3: CORE PRINCIPLES OF RECOVERY AND RESILIENCE, pp. 37-41. Washington State’s Division of Behavioral Health & Recovery. Prepared by the Washington Institute for Mental Health Research & Training.

https://www.dshs.wa.gov/sites/default/files/BHSIA/dbh/documents/WACertifiedPeerCounselorManualApr2012FINAL.pdf

 

2. Harris, Jamie & Felman, Kristyn (2012): “A Guide to the Use of Recovery-Oriented Language In Service Planning, Documentation, and Correspondence” Mental Health America Allegheny County, 100 Sheridan Square, 2nd Floor Pittsburgh, PA 15206 Phone: 1-877-391-3820 www.mhaac.net

http://www.mhaac.net/Files/Admin/The%20Use%20of%20Recovery-Oriented%20Language%208-21-12.pdf

SKILLS

It takes some practice and skill to avoid falling into the same old pathology-oriented and blaming language we get so used to doing. So here is the recovery language grid to helps re-frame and sharpen your skills. If you are aware of the source, please let me know at davidmeelee@gmail.com.

 

TIP 1

Build your skills to move away from blaming or labeling language to respectful empowering terminology.

 

“The following are some of the terms we have traditionally used to describe people and/or their behaviors. These terms place judgment and blame on the individual and generalize their actions. It is much more helpful to describe the specific situation that a person is facing than to use generic and punitive clinical terms.”

 

 Worn Out Language

Language that Promotes Acceptance, Respect & Uniqueness

 Comments

Max is mentally ill

 Max is schizophrenic

 Max is a bipolar

 Max is…

Max has a mental illness.

 

Max has schizophrenia.

 

Max has been diagnosed with bipolar disorder.

 

Max is a person with…

Avoid equating the person’s identity with a diagnosis. Max is a person first and foremost, and he also happens to have bipolar disorder.

Very often there is no need to mention a diagnosis at all.

 

It is sometimes helpful to use the phrase “a person diagnosed with”, because it shifts the responsibility for the diagnosis to the person making it, leaving the individual the freedom to accept or not.

Alex is an addict

Alex is addicted to alcohol.

Alex is in recovery from drug addiction.

Put the person first.

 Avoid defining the person by their struggles.

Rebecca is brain injured/damaged

Rebecca has a brain injury.

Put the person first.

 Avoid defining the person by their struggles.

Jane is disabled/handicapped

Jane is a person with a disability.

Put the person first.

 Avoid defining the person by their struggles.

Mark is normal/healthy

Mark is someone without a disability.

Referring to people without disabilities as normal or healthy infers that people with disabilities are not normal and not healthy.

Sarah is decompensating

Sarah is having a rough time.

 Sarah is experiencing…

Describe what it looks like uniquely to that individual. That information is more useful than a generalization.

 Avoid sensationalizing a setback into something huge.

Mathew is manipulative

Mathew is trying really hard to get his needs met.

 Mathew may need to work on more effective ways of getting his needs met.

Take the blame out of the statement.

 Recognize that the person is trying to get a need met the best way they know how.

Kyle is non-compliant

 

 

 

 

Kyle is choosing not to…

 Kyle would rather…

 Kyle is looking for other options

Describe what it looks like uniquely to that individual. That information is more useful than a generalization.

Does Kyle agree with your plan?

Megan is very compliant

Megan is excited about the plan we’ve developed.

 Megan is working hard towards the goals she has set.

Being compliant means that someone is doing what they were asked or told to do. The goal of recovery-oriented services is to help the person define what they want to do and work towards it together.

 Someone being compliant does not mean that they are on the road to recovery, only that they are following directions.

Mary is resistant to treatment

Mary chooses not to…

 Mary prefers not to…

 Mary is unsure about…

Describe what it looks like uniquely to that individual. That information is more useful than a generalization.

Remove the blame from the statement.

Allie is high functioning

Allie is really good at…

Describe what it looks like uniquely to that individual. That information is more useful than a generalization.

Jesse is low functioning

Jesse has a tough time taking care of himself.

 Jesse has a tough time learning new things.

 Jesse is still early in his recovery journey.

Describe what it looks like uniquely to that individual. That information is more useful than a generalization.

 Avoid defining the entire person negatively based on the fact that he struggles in some areas.

Michael is dangerous

Michael tends to become violent when he is upset.

 Michael sometimes strikes out at people when he is hearing voices.

Describe what it looks like uniquely to that individual. That information is more useful than a generalization.

 Remove the judgment from the statement.

 Avoid defining the person by the behavior.

Harry is mentally ill chemically abusing (MICA)

Harry is a person with co-occurring mental health and substance use/abuse problems.

Put the person first.

 Avoid defining the person by their struggles.

Sam is unmotivated

Sam doesn’t seem inspired to go back to work.

 Sam is not in an environment that inspires him.

 Sam is working on finding his motivation.

 Sam has not yet found anything that sparks his motivation.

Describe what it looks like uniquely to that individual. That information is more useful than a generalization.

 Avoid defining the person by the behavior.

 Remove the blame from the statement.

Andy is manic

Andy has a lot of energy right now.

 Andy hasn’t slept in three days.

Describe what it looks like uniquely to that individual. That information is more useful than a generalization.

 Avoid defining the person by the behavior.

Kate is paranoid

Kate is experiencing a lot of fear.

 Kate is worried that her neighbors want to hurt her.

Describe what it looks like uniquely to that individual. That information is more useful than a generalization.

Hailey is a cutter

Hailey expresses her emotional pain through self-harm.

 Hailey hurts herself when she is upset.

Avoid defining the person by the behavior.

 Recognize the reason behind the behavior.

 

Jordan has a chronic/persistent mental illness

Jordan has been working towards recovery for a long time.

 Jordan has experienced depression for many years.

Avoid conveying a prognosis.

 It is difficult to accurately predict an individual’s prognosis and it only impedes their progress to define them as someone who will not recover (or will not be in recovery for a very long time).

 

There is no need to address prognosis in describing a group of people or an individual.

Tom is very difficult

Tom and I aren’t quite on the same page.

 It is challenging for me to work with Tom.

Avoid making a judgment, which may be based on your dissatisfaction with the fact the person has not met your expectations (which may be different from what he wants for himself).

Manipulative

 

Grandiose

 

In denial

 

Passive aggressive

 

Self- defeating

 

Oppositional

 

These are often people’s ineffective attempts to reclaim some shred of power while being treated in a system that often tries to control them.

 The person is trying to get their needs met, or has a perception different from the staff, or has an opinion of self not shared by others. And these efforts are not effectively bringing them to the result they want.

These are labels for strategies and perceptions we all have about ourselves, although possibly more subtle and effective.

 We all present information to achieve a desired result to some degree (manipulation).

Or have an inflated opinion of ourselves, or are unable to see or agree with something presented to us by another.

SOUL

Earlier this month I had to eat humble pie twice – all in the same shopping expedition- in the space of one hour. I consider myself a reasonably patient person……but not so fast. Because when it’s getting late and the shops will close soon and I haven’t finished my must-do errands, suddenly some old wisdom rears its ugly head:

                        “Patience is a virtue

                         Possess it if you can

                         Seldom found in women

                         Never in a man.”

 

Well it wasn’t found in this man, this writer, this month anyway.

 

I had just finished buying some printer cartridges at Office Depot before they closed. I wanted to get to next store before they closed too. Stuck behind a driver at a red light, I started fuming and judging his knowledge of the road rules. He just sat there and didn’t seem to know that you can, sir, turn right on red in the USA. Let’s get on with it; there’s no traffic coming; it is quite safe for you to turn on a red light and then I can get going on my errands. He still just sat there, apparently not getting my psychic message to get moving beamed from my car to his.

 

The light turns green. Finally, I’m thinking, he’ll turn now so I can rush to the next store.  But he has already made me waste at least 45 seconds tolerating his stubbornness and refusal to turn right on red. So inconsiderate and ignorant of basic driving rules.

 

Oops! He didn’t turn right, because he was going straight ahead and had never even indicated he was going to turn right. That was all in my head, assuming that just because I was turning right, he must be going that direction too. Sheepishly, I ate some humble pie, noting how easy it is to see the world just through my eyes and perspective.

 

Not 10 minutes later…. I find my self stuck again behind an inconsiderate driver. This time, not stuck at a red light, but crawling along at 15 miles per hour in a 30 mph zone. Don’t they know where the accelerator is? I’m rushing to get to the next store before it closes. Do they really need to choose this time to drive slowly and smell the roses? I’m tempted to move closer and tailgate them to send a not-so-subtle message to “hurry up, will you!”

 

Oops again! Just as I start to speed up towards them, they turn right into the next street. They were not smelling the roses. Ironically they were turning right when I was focused on going straight ahead. That is why they were going slowly, preparing to turn.

 

There was the second slice of humble pie all in less than an hour. I had done it again – seeing the world just through my eyes and perspective. Now, who was the inconsiderate driver?

Until next time

Glad you could join us this month. See you in late October.                              

David

SAVVY

I just returned from Seoul, South Korea, my first trip there. It was fascinating and I’ll tell you more in SOUL from Seoul. The main reason I traveled there was to participate in an International Lifestyle Medicine and Addiction symposium hosted by Sahmyook University. They were celebrating the official opening of their brand new Lifestyle Medicine and Health Promotion Institute.

 

One of the invited keynote speakers was Edward M. Phillips, M.D., Founder and Director, Institute of Lifestyle Medicine, Joslin Diabetes Center, Boston, Massachusetts; and Assistant Professor of Physical Medicine and Rehabilitation, Harvard Medical School. Like addiction treatment, lifestyle medicine is a neglected, yet so important body of knowledge too little taught in medical school and across all the helping professions. Dr. Phillips highlighted some facts and figures which will convince you too it is time to pay more attention to lifestyle medicine and wellness.

 

TIP 1

Review these keynote points and see if you can ignore the need to embrace lifestyle changes in your life and the nation’s.

 

Dr. Phillips opened by a “Call to Arms (and Legs)”. He said:

  • “We know why the majority of the population will die prematurely.
  • We know the root cause of two-thirds of all disease.
  • We know where most of our health care dollars could be saved.
  • Yet: we don’t teach this to doctors and our health care system continues to practicesickness-based care.”

Here are more facts and figures:

  • 70% of cardiovascular disease can be prevented or delayed with dietary choices and lifestyle modifications (Forman D, Bulwer BE, Curr Treat Options Cardiovasc Med. 2006;8:47-57)
  • The World Health Organization states that by 2020, two-thirds of all global disease will be lifestyle-related (Chopra M et al.Bull WHO. 2002;80:953-958)
  • 78% of health care expenditures are consumed by the management of chronic disease (Anderson G, Horvath J.Public Health Report. 2004;119:263-270)
  • The combined effect of lifestyle factors such as physical inactivity, obesity, poor diet, cigarette smoking, and excess alcohol consumption have a significant impact on morbidity and mortality from the resulting chronic disease (Hu FB et al. N Engl J Med. 2001;345:790-797) and leads to the following increases:

* Increases 55% all causes of mortality (van Dam RM et al. BMJ. 2008;337:a1440)

* Increases 44% cancer mortality (van Dam RM et al. BMJ. 2008;337:a1440)

* Increases 72% cardiovascular mortality (van Dam RM et al. BMJ. 2008;337:a1440)

 

I know it’s easy for your eyes to glaze over with all those big picture statistics and wonder what is the impact at the ground level of your daily life. We’ll get to what you can do soon. But first a few more big picture statistics which will inspire you to make even a small change in lifestyle.

 

TIP 2

Take note of the Wellness Dividend for just a 2% change in lifestyle.

  • Annual health care costs in 2019 estimated to be $4.48 trillion 
    (Centers for Medicare and Medicaid Services. National Health Expenditure Data  https://www.cms.gov/NationalHealthExpendData/25_NHE_Fact_Sheet.asp)
  • WHO estimates 66% of health care costs result from lifestyle = $3 trillion annually by 2010 Bull WHO. 2002;80:953-958)

If we made a small change of 2% in weight, activity, smoking, etc. e.g., walking an additional 500 steps a day or giving up the last cookie, the result: 

  • Wellness Dividend of annual $60 billion in cost savings.

SKILLS

So let’s bring this all closer to home- from the big statistical picture to ‘where the rubber meets the road’ in your running shoes or with the fork at your meal table. Dr. Phillips had the audience assess their own health habits.

 

TIP 1

Get with a group of friends or acquaintances and see who is the last person standing.

 

Here are the instructions:

Everybody stands up and if you answer “yes” to any of the questions, sit down and take a seat at that point.

 

Here are the questions:

1. Do you smoke cigarettes? – Sit down if you are a smoker.

2. Is your BMI (Body Mass Index) equal to or greater than 25kg/m2? – Underweight is <18.5; Normal weight = 18.5 – 24.9; Overweight = 25 – 29.9; Obesity = BMI of 30 or greater.

3. Do you eat less than 5 servings of fruits and vegetables/day? – If yes, then sit down.

4. Do you drink more than one drink a day? – “One drink” = 12 ounces of regular beer; 5 ounces of red wine; 1.5 ounces of liquor.

5. Do you do less than 150 minutes/week of physical activity/exercise? – If you are a bit of a couch potato, take a seat…OK to be a couch potato for a moment as you look around and see if anyone is still standing.

6. Finally do you sleep less than 6-7 hours/night? – If you aren’t getting enough sleep at night, that is a tough lifestyle change in our fast paced, over-packed lives.

 

When I did this with a large group, I know I wasn’t the last person standing; and there were very few excellent specimens of lifestyle role models standing after just those six questions. How did you rate with your own health habits and lifestyle?

 

The secret of success is to aim low – so don’t try to change your lifestyle all at once. This is where BJ Fogg, PhD has some great advice – http://www.bjfogg.com

 

TIP 2

Take a look at Tiny Habits ® and become inspired to start with just your 2% or a tiny habit.

 

As Dr. Phillips said, maybe you could start with just 500 steps per day, not 10,000 a day. Or choosing not to take that last cookie or last spoonful of desert rather than promise to never eat desert for the next year.

 

There are a number of methods on the same theme, but here is the Fogg Method:

http://www.foggmethod.com

Step 1: Get specific about what lifestyle change you want to make (e.g., do some push-ups to strengthen my biceps and core.)

Step 2: Make it easy (e.g., plan on a tiny habit of just two push-ups to start with.)

Step 3: Trigger the behavior – what will prompt yourself to remember to do the tiny habit (e.g., after I brush my teeth, I will do two push-ups.)

 

Why is it always hard to obtain as much respect for prevention and lifestyle change as it is for a new surgical laser machine or a state-of-the-art center for cancer treatment? Yet lifestyle change can make such a difference to your health and health care costs.

 

We preach what we need to learn – and I am learning too.

SOUL

It is so fascinating to me to travel the world and see new places and cultures. So here are some “culture shocks” I noted on my first trip to Seoul – SOUL from Seoul if you like. From the variety of people I spoke with, there seemed to be consensus that these observations were true and typical:

  • It is not intrusive or discourteous to ask a person you just met how old they are. In fact, a person may introduce themselves as “I’m David and I am a psychiatrist living in California and I’m 66.” The person’s age tells you how you should address them in the hierarchy of respect. It is not comfortable to address an older person as “David” even if I invite a more familiar greeting
  • People (and I mean adults and children) work long hours. Adults may stay until 8 or 9 PM or even later and it does not look good to leave on time at the end of the day even if you have your work done. Some would never leave before their manager; and it is expected that you go out to meal or drinking with your manager and to stay late if asked – no overtime.
  • Children in high school and even earlier grades finish school in the afternoon and then often attend another afterschool academic program studying until 10 or even 11 PM. This is to achieve excellent grades to compete for the top universities in Seoul that is considered the only acceptable path to getting a good job after graduation.
  • Not unrelated perhaps, the suicide rate in South Korea is the highest among Organization for Economic Cooperation and Development (OECD) countries. http://www.washingtonpost.com/wp-srv/world/suiciderate.html 

 

On the healthcare front there were some surprises too:

  • I sat in on a Laughter Therapy group where cancer patients and others spend an hour a day laughing their heads off as part of their healing process. We actually have this too in the USA, (Google Laughter Therapy and you’ll see Cancer Treatment Centers of America uses it).
  • I visited a post-natal unit on the hospital grounds where mothers can stay for two weeks to rest after delivering their baby. Educational sessions, relaxation, and recuperation prepare the housewife to be ready to take up her busy care of the family.
  • Finally, Seoul has become the plastic surgery capital of the world with many adolescent girls, women and some men having a variety of procedures to create double eyelids and open up their eyes to be wider and more western looking. Nose reshaping; and chin surgeries to create a more V-shape. Coincidentally, I heard an October 20 segment on National Public Radio’s Here and Now program all about this. You can listen in for yourself at:
  • https://hereandnow.wbur.org/2015/10/20/south-korea-plastic-surgery-photos 

There is much more SOUL from Seoul that I could share. But this gives you a taste of South Korea, not to mention my trip to the Demilitarized Zone (DMZ) between South and North Korea. I looked out onto North Korea and wondered if Kim Jong-un, Supreme Leader of North Korea, was staring back at me.

 

I don’t think so.

SHARING SOLUTIONS

As you contemplate your own lifestyle, I want you to know about the Institute for Wellness Education of which I am one of the co-founders. Our desire is to drive cultural transformation so health and wellness become the norm for individuals, communities, and the nation: https://www.instituteforwellness.com/advocates/

 

You may be interested in taking the Level 1 fundamentals course: “Take Charge of Your Life: Be Well to Do Well.” This includes Interactive Journaling using “My Personal Health Journal.” Take a look at the 10 modules in the Level 1 course at: https://www.instituteforwellness.com/wellness-coaches-course-overview/

 

Here’s to your health and well-being.

Until next time

Thank-you for joining us this month. See you in late November.                            

David

Vol. 13, No. 8

To all in the USA, I hope you had a thankful and happy Thanksgiving and welcome everyone to the November edition of Tips and Topics. I’m glad you could join us this month.

 

David Mee-Lee M.D.

SAVVY

I have known Dr. Norman Hoffmann for over 30 years as a friend and colleague. Over the years of many presentations I have enjoyed and appreciated, Norm has shared quotes and quips that provide bits of wisdom as well as humor. Recently, as I listened again, I thought it was time to get some of those into print. So here a few of Norm’s favorites and what they mean.

 

TIP 1

Ponder these quotes and the wisdom they hold as told by Dr. Hoffmann.

 

1. “For every complex problem, there is a simple answer; and it’s wrong.” Attributed to H. L. Mencken.

  • So often people look for a simple answer, or fix, to complicated issues instead of a more comprehensive approach.

 

2. “The truth is rarely pure and never simple.” A line from the play, “The Importance of Being Ernest” by Oscar Wilde.

  • This is similar to the Mencken quote in that things are often more complex than we would like them to be.

 

3. “If your theory conflicts with folklore, recheck your theory.” This is a comment made by Paul Meehl during a graduate school seminar at the University of Minnesota.

  • Folklore is often based on observed associations. The folk explanation for the association might be fanciful, but the association is quite real.

 

4. “For the great enemy of truth is very often not the lie – deliberate, contrived, and dishonest; but the myth – persistent, persuasive, and unrealistic.” By John F. Kennedy in a commencement address at Yale.

  • Myths and misconceptions can often be more damaging than deliberate falsifications.

“Then there are a few for whom I do not know the originator or ones that I have adapted from some recollection.” Here they are:

 

5. “Left unchallenged our beliefs become our truths.”

  • All too often we may have a tendency to go with the myth that is comfortable rather than to consider the truth, which may be disquieting.

 

6. “If you torture a statistic long enough, you can get it to confess to anything.”

  • As one who reads the literature on addiction, I am often disturbed that the numbers underlying the conclusions do not seem to support the contentions of the authors.

 

7. “Beware of a theory that explains everything, but predicts nothing.”

  • One can often come up with any far-fetched idea to explain something, but it is not replicable or predictive.

 

8. Finally, there is my own favorite contribution: “A computer program can make a diagnosis when it is licensed for independent practice in your state.”

  • Too often I find people who want computers to do their thinking for them instead of examining the evidence and thinking for themselves.

 

TIP 2

Enjoy some vague terms often used in addiction and some fanciful definitions of Dr. Hoffmann.

 

1. “Heavy drinker”

  • Someone who weighs 250 lbs. and drinks.

 

2. “Problem drinkers”

  • People who spill more than they swallow.

 

3. “alcohol abuse”

  • Pouring water into good Scotch.

 

4. “Data is not the plural of anecdotes”

  • This addresses the issue of using memorable examples to support a position rather than actual statistics that might be quite different. (David Mee-Lee: Just because you have lots of examples and stories that support your views and perspectives, doesn’t mean you have valid research data.)

 

Norman Hoffmann, Ph.D.

President, Evince Clinical Assessments

E-mail: evinceassessment@aol.com

www.evinceassessment.com

 

Bio:

Dr. Hoffmann is a clinical psychologist who has evaluated behavioral health programs, provided consultations, and conducted trainings for over 35 years. He has worked with private organizations and governmental agencies in a variety of countries. Dr. Hoffmann has developed a number of assessments instruments used throughout the United States, as well as in Canada, Sweden, Norway, and the United Kingdom and authored or co-authored more than 190 publications. Take a look at some of Dr. Hoffmann’s work:

https://www.changecompanies.net/products/?servicearea=12

His faculty appointments include the University of Minnesota and Brown University. Currently he is President of Evince Clinical Assessments and adjunct professor of psychology at Western Carolina University.

SKILLS & STUMP THE SHRINK

Earlier this month, Ian Evans sent me the following message:

 

I was curious about slips when a client is in residential. Recently some programs we deal with have discharged clients who have drunk or used while on their pass. To me, it seems that residential treatment is the perfect place to deal with this issue. The client is in a structured environment, counselors they are familiar with, and in a treatment facility that can help them figure out what happened, why it happened, coping skills for the future, etc.

            I have heard various reasons why: it being unsafe for other clients, there being state guidelines that someone must be discharged if they use while in treatment, etc. I was curious not only your thoughts on this in general, but also if you are aware of any guidelines for residential facilities in these instances.

            I have reached out to the Department of Health Care Services as well, but to me it seems to make the most sense to allow someone to get treated in treatment rather than discharging and creating policies such as the client needs to check in and go to meetings every day for 2 weeks before they can come back to treatment.

Thanks,

Ian Evans MFTI #78016

Clinician I, Adult Forensic Care Team

Yolo County Department of Health Services, California

Work Cell: (530) 681-8165

Voicemail: (530) 666-8099 ext 1803

E-mail: Ian.Evans@yolocounty.org

 

TIP 1

Note how our attitudes and actions about substance use while in treatment does not fit with treating addiction as a disease.

 

Hi Ian:

Your concerns are what I have written and spoken about a lot. Here are some links to what I have written before. You should also look at Appendix B in the latest edition of The ASAM Criteria (2013) pp. 401-410 where we suggest an approach and policy and procedure on use while in treatment. If you don’t have the latest book, I suggest you get it. See www.ASAMCriteria.org for more information.

 

Here are some links. If the links don’t work, go to www.tipsntopics.com and click on the edition on the right hand side Archives:

 

A. Tips and Topics, July 2014:

  • In SAVVY of this edition, I wrote about the steps to consider when a person uses substances while in treatment.
  • In SKILLS, note what taking action means when a person uses while in treatment. It isn’t about discharging a person or transferring to a more intensive level of care.

https://www.changecompanies.net/blogs/tipsntopics/2014/07

B. Tips and Topics, October 2012:

  • In SAVVY of this edition, I wrote about how we don’t treat addiction flare-ups the same way we treat flare-ups of other illnesses like depression, schizophrenia, hypertension, bipolar or panic disorder.
  • I also referenced an interview with William Miller (Motivational Interviewing) who raises the question whether “relapse” is even a useful clinical term.

https://www.changecompanies.net/blogs/tipsntopics/2012/10/31/october-2012-tips-topics

 

 

C. Tips and Topics, November 2012:

  • In SAVVY, look at some alternative terms for “relapse” and try those on for size.
  • In SKILLS in this edition, here’s what to do when a client uses in residential treatment; when discharge is clinically reasonable and when it is not.

https://www.changecompanies.net/blogs/tipsntopics/2012/11/29/november-2012-tips-topics

 

 

D. Tips and Topics, June 2009:

  • In SKILLS, look at what to do when concerned that letting substance-using clients stay in treatment will trigger others and send a message that it is OK to use if there are no “consequences” for use.
  • Also see what to do when you get a poor outcome like a flare-up of use in an addicted client – assess and change the treatment plan like we do with other illnesses.

https://www.changecompanies.net/blogs/tipsntopics/2009/06

 

 

E. Tips and Topics, October 2004:

  • In SAVVY, I reference the constructs in ASAM Criteria Dimension 5, Relapse, Continued Use or Continued Problem Potential which first appeared in ASAM PPC-2R (2001) but is available in The ASAM Criteria (2013), Appendix B, pp. 401-410. These help you assess and treat flare-ups of addiction instead of discharging people.
  • Also in SAVVY, understand the difference between ASAM Criteria Dimension 4, Readiness to Change and Dimension 5.
  • In SKILLS, suggestions on what to do when a person arrives to a group having used alcohol or some other drug; and what to do if there is a positive drug screen.
  • Do clients in early stages of change, need relapse prevention strategies? See the answer in SKILLS.

https://www.changecompanies.net/blogs/tipsntopics/2004/10

 

 

F. Tips and Topics, September 2006 SKILLS section:

  • In SKILLS, look at “Things That Don’t Make Sense” and what to do about them. It will reinforce the suggestions of the previous editions above.

https://www.changecompanies.net/blogs/tipsntopics/2006/09

 

Hope this helps, but let me know if not.

David

 

TIP 2

In a follow up message, Ian raised a common State policy preventing clinicians from treating relapse and flare-ups as assessment and treatment issues.

 

BARCLAYS OFFICIAL CALIFORNIA CODE OF REGULATIONS

Health-Related Services.

Title 9 Section 10572 (e) that states:

 

“(e) No person, who, within the previous 24 hours, has consumed, used, or is still otherwise under the influence of alcohol or drugs as specified in section 10501(a), shall be permitted on the premises except for individuals admitted for detoxification or withdrawal. The licensee shall have specific written rules and policies and procedures to enforce this provision.”

https://govt.westlaw.com/calregs/Document/I49471470D45411DEB97CF67CD0B99467?viewType=FullText&originationContext=documenttoc&transitionType=CategoryPageItem&contextData=(sc.Default)

 

http://www.apartment-manager-law.com/data11/10572-Health.htm

 

Ian’s message:

It may be a huge question I am asking here, but do you see any way of working with the State to amend this so that if a client has a slip while on a weekend pass that they are not told they are discharged and must come back in 72 hours or 2 weeks like some programs do? There’s just something about discharging someone from residential treatment for slipping on a weekend pass and having them go back to the very environment they were using in before treatment that doesn’t sit well with me.

 

Thanks for your time,

Ian Evans

 

Perhaps you have similar regulations in your State or county. I have pledged to Ian that I will do what I can to raise this sticky regulation with the powers that be to start a conversation for change:

  • How can we combat the discrimination and stigma that addiction attracts even in our treatment system?
  • How we can we start treating addiction and flare-ups and poor outcomes the same way we treat other chronic conditions, instead of marginalizing clients and patients – discharging them and contributing to already high dropout and premature discharge rates?
  • What would it take to change attitudes of the general public, criminal justice and especially treatment providers in general health, mental health and addiction treatment to take addiction seriously as an illness needing care, not punishment, rejection, incarceration and discharge?
  • How can we begin to change policies, procedures and regulations to fit the disease of addiction rather concepts of willful misconduct and need for punishment?

Let’s start the conversation.

SOUL

I’m not really an avid sports fan (except maybe for the New England Patriots National Football League, NFL, team). I am much more interested in the psychology of sports than the actual mechanics of why a person or a team wins. So when I heard that the Golden State Warriors (the San Francisco Bay area National Basketball Association, NBA, team) were about to make history, it sparked my interest. Golden State was about to have the best regular season start (16 wins in a row) in the NBA’s 70-year history.

 

As I listened to the sports pundits and commentators opining on why Golden State was so successful, I was intrigued by their explanation and analysis, heard on San Francisco public radio station KQED’s Forum with Michael Krasny. If you are into sports and want to listen, here’s the link: http://www.kqed.org/a/forum/R201511230930

  • Often, when a team wins the NBA championship as Golden State did last year, players start getting inflated egos and entourages. Humility goes out the window. On this team, players have stayed humble and are “just having fun”.
  • A number of the players had been written off in the past as too small to be an effective player; or clearly not a top tier prospect; or late to the game and inexperienced. They all had something to prove and worked hard to debunk the critics. Even with their proven success, they are still “hungry” to win and while confident, are not complacent.
  • “Unselfishness” – Golden State, like other teams, have created success by unselfish play consisting of many “assists” and moving the ball around to all players on the floor. The goal was to score a basket: get the points as a team rather than each player trying to be the star, drive to the basket to get the points on their scorecard.

Humility, fun, hard work, confidence but not complacence, unselfishness and team work – sounds to me like a winning formula for life, not just basketball history.

 

You might be interested to know that the Patriots are one of only two teams out of 32 in the NFL to have a winning start to the season, unbeaten in 10 games so far. I wonder if that is because of humility, fun, hard work, confidence but not complacence, unselfishness and team work too? Some other teams accuse the Patriots of being arrogant and cheaters, but they’re just jealous.

 

Go Pats!

Until next time

Thank-you for joining us this month. See you in late December.

                              

David

Vol. 13, No. 9

Happy Holidays to everyone and welcome to the December issue of Tips and Topics.

David Mee-Lee M.D.

SAVVY

“Welcome home” he said. And it was good to be home even though I had only been out of the country for nine days and in North Vietnam for seven.

“How long were you in Vietnam?” the immigration officer asked.

Just a week, touristing with my son.”

“Where did you go?”

            “Hanoi, Halong Bay and Sapa.” I said, starting to get a little concerned by the questions. It reminded me of the time I came back from Europe and the officer grilled me about where I had gone and what I did because they mistakenly took me for a drug trafficker (but that is another story.)

“Do you have relatives there?”

            “No, just on a tour.” Then I looked at him and noticed he was Asian like me.

            “Are you from Vietnam?” I ventured.

“Yes” he said. “Why do you think I was asking you where you went?”

 

I didn’t answer that last question. I could have told him about my bad experience coming in from Europe. But to have a nice chat with the officer would have annoyed the next person in line.

 

“Welcome home.” I was back in the USA.

 

TIP 1

Being inspired by the initiative and resourcefulness of people

  • Because he was the 5th child in a poor village family, his parents couldn’t afford to get him much education. U (pronounced Ooo) set about learning English via the Internet, by watching YouTube videos and movies. He was our 21-year-old guide in Sapa (Sa Pa), a frontier mountainous town in the northwest of Vietnam along the border with China. Several ethnic minority groups live there and U led us on treks into H’mong and Giay villages. Knowing that speaking English could get him work as a tour guide, U also realized his language skills would improve as he interacted with tourists.

U is married with a 3-year-old daughter and has ambitions to earn enough money to go to English school and improve on what he has already learned on-the-job. With improved English language skills he plans to get a good paying job in the city (Hanoi) and provide even better for his family than he can in the village.

  • I was standing by a picturesque red bridge that spanned across the Hoan Kiem Lake to the Ngco Son Temple in Hanoi. Selling cards that folded out to reveal cute pop-up paper cuttings of temples, trees, sampan boats and other intricate creations was a group of women imploring tourists to buy. A less aggressive seller was a young woman who stood nearby and seemed more courteous than her peers. I struck up a conversation since she spoke good English.

Flower, I found out, was 28-years-old and 7 1/2 months pregnant. She was earning as much as she could to prepare for the 2 months she would takeoff to have her baby. After that, she said, she would bring her baby with her to the street so she could both care for the baby AND keep selling to tourists. The grandfather of her 5.5 year old son was the babysitter while she earned the money to support the family and her son’s education, which was going to cost her 50 US dollars a month when he was soon to start school. The father of her children apparently was not too reliable.

 

Flower was another inspiring person who, like U, had also taught herself English by watching TV and videos as well as learning most, she said, from talking to tourists. She worked also as an independent tour guide reading up on historical sites around Hanoi in order to explain Hanoi to tourists on walking tours around the city. Her hard self-development work paid off. We booked a walking tour with her, precisely because she spoke such good English. Other tour guides were well-intentioned, however it was a strain sometimes to catch what they were saying. Flower was so easy to converse with; that made touristing with her a relaxed, informative pleasure. And she would earn $20 US dollars for a 3-hour tour. That is half a week’s wages for people who earn $2,000 – $3,000 US a year, an average income!

 

TIP 2

Seeing the world through the eyes of a different culture.

 

Standing by the side of the road in Hanoi watching the dizzying speed, volume and constancy of motorbikes and cycles whizzing past with seemingly no breaks of traffic, trying to cross the street suddenly became a whole new skill to learn. Traffic lights are few and far between. While there are painted crossings at some intersections, nobody seems to obey either walk lights or crossings. You certainly would not cross the street while checking your email or text messages on your iPhone in Hanoi. Crossing the street is a lesson in cultural awareness and courageous assertiveness or you will never cross the street.

 

Here’s how you do it:

  • See if you are lucky enough to be near a “local” and stick by their side and cross with them.
  • If no local guide is around, watch for a slight break in the flow of cars and bikes, then step out into the flow of traffic. Do not wait for a clear path to develop. There will be no such path.
  • Turn your head to face the upcoming traffic. Try to make eye contact with the rider or driver closest to running you down, then proceed calmly ahead. Do NOT stop- or doubt yourself and make jerking stops and starts. That only confuses drivers who possess the skill to know how to time their approach, as long as you keep moving. If you start panicking and stop and start, you’ll cause an accident. That could activate your life insurance.

What I love about international travel is the way it turns your head around. You first grapple with, then understand, and eventually appreciate a whole new way of thinking and being. I can’t say a week in North Vietnam has now made me culturally competent to work with Vietnamese people. What it is is a quick lesson in how a country can forgive or at least forget about the conflicts and consequences of war.

 

A couple of terminology changes I quickly learned:

  • It was the “American War” that ended in 1975, not the “Vietnam War.”
  • America fought the “Vietnamese Communists” not the “Viet Cong” or “VC” which is a bit pejorative.

How do the Vietnamese people view Americans and the USA?” I asked our tour guides. “That is in the past and we do not have bad feelings.” Perhaps that’s because tourism has opened up in Vietnam since the 1990s when most of our tour guides weren’t yet even born. Maybe all has really has been forgiven and forgotten. Maybe it doesn’t make sense to bite the hand that feeds you since tourism brings opportunities for jobs and income that would simply not exist. For whatever reason, I sensed no ill will, only hospitality and graciousness.

SKILLS

Selling souvenirs to tourists is a pretty competitive business, especially with no fixed sales territories, storefronts or rules. I’m talking about the flock of street vendors in developing countries like Vietnam where both selling and buying is survival of the fittest. Observing this revealed lessons I think applies to our work in addiction and mental health.

 

TIP 1

Fundamental to any effective interaction is the quality of the relationship.

As soon as the tour bus pulled up to the Sunny Mountain Hotel in Sapa town, a swarm of village women mobbed us as we attempted to step down off the bus. “Swarm” and “mobbed” are not exaggerations or literary license. One particular village vendor looked me in the eye, implored me to take a good look at her so I would remember her face. I noticed her missing teeth, crossed-eye and big smile. At that point she wasn’t intent on showing me her array of woven bracelets, scarfs or trinkets. She knew I was just getting out of the bus. But she also knew we were about to start our trek into her village.

 

Upon reaching the village again we were mobbed by a flock of women now more intent on the hard sell. But wait! It wasn’t a new group – but actually the same women. And yes- there she was- my particular ‘agent’ staring me in the face reminding me that she had already marked me as her prime customer. Somehow they had all rushed ahead by motorcycle, ready to be right there when arrived at their village.

 

While we trekked through the village, taking in views of terraced rice paddies, water buffalo, pigs, ducks and chickens, right by my side was my ‘agent’…plus a couple of other vendors attempting to edge in on her territory.

 

“Where are you from? How many children do you have? How old are they? How old are you? What do you like to buy?” – some of the questions raised by my ‘agent’ as we walked along together, as if they were part of the tourist group. “America” I said. “Three children.” This evoked a response from this vendor and mother: “I have three children too” and she proceeded to tell me their ages.

 

It became clear the village vendor/’agent’ who, from that very first moment tried to connect with me, was building the relationship, hoping I would buy several crafts. Unfortunately for her, it didn’t work with me because she didn’t check out what I wanted. I was not in the market for any souvenirs. This makes the next SKILLS tip equally as important.

 

TIP 2

Be persistent but person-centered and customer-focused.

 

When I first met ­­Flower selling pop-up cards, I vowed to myself and her that I did not need any more souvenirs I knew would end up in a box of stuff I’d later just give or throw away. However, as we talked more, she clearly was more focused on building the relationship than on a hard sell. I understood her philosophy. “I treat people with respect. If they don’t want to buy, I don’t push them. I believe in karma,” she said.

 

I understood her to mean that how she treated people now would impact and influence her own future and well-being. So she wasn’t about to push me for some quick sale now, only to have it result in some negative impact later. She could tell I wasn’t interested in her pop-up cards. I had communicated sufficiently so she knew I didn’t need any more souvenirs and did not intend to buy. She didn’t mention her wares any further. We just chatted about her son, her pregnancy and life in Hanoi and what she had to do to provide for her family.

 

Over time in this no pressure, accepting interaction, I became so impressed by her hard work and respectful manner I ended up wanting to buy one of her cards. Her manner allowed me to lower my resistance. I actually looked at her cards more carefully. As I did, I realized they were actually very creatively done, worth the dollar or two she was asking for. Such a minor expense to me, but so helpful for her sales.

 

Flower’s respectful persistence and relationship-building had paid off – a pleasant and informative conversation about her life and her family’s in the culture and demands of Hanoi and North Vietnam; plus some much needed income as her due delivery date was

SOUL

Eating dinner out in Hanoi, Taylor and I had a bowl of hot fresh noodles and soup, tofu and lettuce for $3 – that’s $3 for the total bill, not for each of us. If the locals had home cooked that meal, it would probably have been a dollar or two at most. It was amazing how inexpensive a meal could be, but then it would need to be affordable with a yearly salary of $3,000 USD or less.

 

What would it be like to have such a low income? How happy would you be with so little income? It seems your options for a whole variety of issues would be severely limited.

  • No decisions about what travel vacation to do this year – how far can you travel on an income of $2,000/year?
  • Don’t have to decide on French cuisine, Italian or any other gourmet meal – cheap street food is the best eating out experience you could afford.
  • What car to buy? That’s out of the question. If you really save, a used motorcycle could be possible.
  • Christmas shopping? Not even for the fake designer label handbags or ski-wear. Those cheap look-alike, name brands are the darlings of tourists from affluent countries looking for shoes or bags.

Come to think of it, having little money to spend cuts out a whole lot of stress from decisions, decisions, decisions. In fact that was written about in a 2004 Scientific American article entitled “Tyranny of Choice”. Researchers found that more choices and options in affluent countries cause depression for many people. If you want to get to the bottom line lessons, look at the box on page 74. However the whole article is worth reading. http://www.swarthmore.edu/SocSci/bschwar1/Sci.Amer.pdf

 

Too many options and choices can mean depression and stress. No money and no choice can also engender the same experience. For me, I’m grateful I have enough money I can visit other countries and cultures- to remind me how blessed we are to have options. It also reminds me that money and choice are privileges to be managed and respected. More is not necessarily better……or happier.

Until next time

Glad you could join us this month. See you in 2016 in late January. Happy New Year!

                                                                                                                                           

David