Music, music, music

Vol. #13, No.11

Welcome to the February edition of Tips and Topics. Thanks for joining us this month.

David Mee-Lee M.D.


A few years ago, I was part of a small group at a weekend retreat. As part of the team building, we were guided by a professional singer-songwriter to craft a song which expressed our mission as a group. Not only did we write the song together, we even helped as backup singers to the final product. Last I checked it hasn’t hit the top 40 playlist yet.


When I met Kathy Moser recently at a conference and heard what she was doing with Music for Recovery, it reminded me of my previous meaningful experience on the retreat. So I asked her to guest write this month’s edition of Tips and Topics. I guess most of you have not had much experience with how “music is a powerful way to help people choose a useful and joyful life,” as Kathy’s brochure rightfully declares.


Who is Kathy Moser? She’s an award-winning songwriter, a master teaching artist and a person in long term recovery. Her vision is to create a Recovery Artists Institute where people can share ideas and experience and learn how to use all the arts in treating Substance Use Disorders (SUD).


Here is what Kathy is sharing with us about the power of music:



Make music a part of treatment and recovery.


Music has been part of many people’s addiction story. Now you can help make it part of their recovery. Creating music is a potent tool for recovery as it can:


* Reduce stress

* Help rewire the brain

* Build cohesion in a treatment facility population

* Provide sober fun

* Mirror the recovery process


For the past 7 years Music for Recovery (MFR) has been conducting song writing workshops and concerts in treatment centers around the country, including The Meadows, Gosnold On Cape Cod, Caron Texas, Father Martin’s Ashley and more. Clients participate in a two-hour workshop in which they work with the teaching artist to write, rehearse and record an original song on a recovery topic. Over 140 songs have been written and they have been played over 6,500 times by clients after treatment.


Additionally, Music for Recovery has created an interactive recovery themed concert “A Musical Guide to the Landscape of Recovery” which has been performed for thousands of clients. This interactive performance is a musical travel guide to the emotions of early recovery and tools for dealing with them successfully.


Some of the Science Behind the Power of Music


1. In 2015 The Recovery Research Institute (RRI) at Harvard University and Massachusetts General Hospital, led by Dr. John Kelly, worked with Music For Recovery to design a questionnaire to evaluate the effectiveness of this work. Reviewing qualitative evaluations from a series of workshops and concerts, RRI designed a questionnaire to capture quantitative data.


The results of the questionnaire showed that:


Music for Recovery participation is shown to enhance these therapeutic factors in patients undergoing residential treatment for substance use disorders … by mobilizing common therapeutic mechanisms that ultimately enhance the likelihood of long-term recovery.”


RRI used the Grounded Theory Approach to identify common themes centered in Irvin Yalom’s group therapeutic factors. Music for Recovery (MFR) was found to help in the following areas:


* Catharsis (MFR enabled patients to express emotion better)


* Cohesion (MFR led patients to feel a greater sense of community, trust, bonding, and belonging)


* Existential factors (MFR helped patients boost confidence and empower them to make changes)


* Installation of hope (MFR helped patients believe that positive change and recovery was possible)


* Interpersonal learning (MFR helped patients learn more from one another)


* Universality (MFR helped patients feel closer to their peers and more a part of the community).


2.  Over 400 Scientific studies

In March 2013, McGill psychologist and leading mind-and-music researcher Daniel Levitin co-authored the first large-scale literature review of the impact of music on health outcomes. The review of findings of more than 400 scientific studies, showed clinical evidence that playing and listening to music can boost our immune systems and reduce stress.  Additionally, listening to music was found to be more effective than prescription drugs in reducing a patient’s pre-surgery anxiety.




Learn from the experience of others who are using music as part of treatment.


It is not surprising that such an essential element of human culture can play a useful role in helping clients transition into recovery.   In fact, more and more treatment centers are using writing, recording and performing music as a central part of treatment. Here are a few at the forefront:



Recovery Unplugged – has a Creative Director, weekly concerts and a recording studio.



Gosnold on Cape Cod – brings in teaching artists to do regular songwriting workshops and concerts with clients.


Spring Hill Recovery Center – brings in teaching artists to do regular songwriting workshops and concerts with clients.


Right Turn – has performance venue and using songwriting and performance with clients.



Preferred Family Health – ARTC (Achieving Recovery Through Creativity) – has a music studio and instruments, creates music videos and client performances.


New Jersey

Daytop NJ – instrumental music, music video and recording studio program. Music program is fully integrated with clinical work and clients can request music as part of their treatment plans. Clients can collaborate with each other on music projects.



Little Creek Lodge – recording studio on premises. Clients collaborate in writing and recording during their treatment.



Cumberland Heights – has teaching artist on staff, rehearsal room and instruments are available to clients. They can use the music program to do their Step work and clinical work.


Several of these facilities have hired music professionals as integral parts of their treatment team.




Music helps reach and communicate with young people.


With young people being an increasing part of the treatment population, it is important to be able to reach them through the music they enjoy. Interestingly, hip-hop’s history is rooted in positive social change. Although the art form at times celebrates the drug lifestyle, its power is easily turned towards recovery.


A recent article in the NY Times highlighted the increasing use of hip-hop music in therapy around the country, a trend that has been growing since the early 2000s.



Playing music helps the brain.


New studies using fMRI and PET scanners show that playing music is the brain’s equivalent to a full body workout. Although more research is to be done, it appears the artistic and aesthetic aspects of learning to playing a musical instrument are different from any other activity studied, including other arts. Several randomized studies have shown that playing an instrument increases cognitive function.


When you play music:


* Different areas of the brain light up simultaneously.

* It engages practically every area of the brain at once.

* It increases the volume and activity in the brain’s corpus callosum, the bridge between the

    right and left hemispheres, allowing messages to get across the brain faster and through

    more diverse routes.

* It enhances memory functions.

* It increases cognitive function.

* It may enhance executive function, a category of interlinked tasks which includes planning,

    strategizing and attention to detail, and requires simultaneous analysis of both cognitive

    and emotional aspects.


The example of Gabrielle Giffords

It’s already clear that song and rhythm can rewire our brains to overcome brain damage. U.S. congresswoman Gabrielle Giffords was shot in the left side of her skull and awoke from a coma unable to speak, but she’s able to sing. Music therapists used melodic intonation therapy to rewire Ms. Giffords’ language skills, using melody to shift her brain’s language center from the left hemisphere to the right one.


Since many clients with Substance Use Disorders (SUD) have trauma histories, as well as the effects of SUD, playing and creating music can play a role in helping their brain heal and rewire itself.



Contact Kathy:

You can reach Kathy Moser for more details at, 908-591-4541.


Kathy goes on to now provide some tips on how to make music a part of treatment and recovery.



Allow people to bring instruments to treatment. Consider purchasing some guitars and keyboards for clients to use.


* Keyboards and electric guitars can be used with headphones, allowing clients to play without disturbing others.


* “Teach Yourself to Play” books can help clients get started.


* Clients who know how to play are often able to teach other clients.


* Poll your staff to find employees who already have musical training and experience.


* Playing music together can improve the therapeutic alliance.


* Adding music programming can help reduce employee burnout.




Invite clients to consider writing a song or rap about the issues they are working on.

* Record the song for the client using a phone or tablet.

* For clients who like hip-hop there are free instrumentals available on YouTube. Ask the

   clients to help choose beats they like. You can convert these to music files easily and for

   free and download them using

Creativity is essentially a mystery. That’s part of the magic of it. When clients get ready to record and perform this is a great opportunity to work with anxiety, and explore how the body can be used to calm the mind. We reframe this anxiety as courage, when someone is out of their comfort zone they are being brave.


The creative process is messy and non-linear, just like recovery. The facilitator needs to be comfortable with this and confident in bringing the group through the awkward phases.




Provide MP3 players loaded with recovery positive songs.


* Recovery Unplugged in Florida makes this part of the intake process.




Bring in a teaching artist to partner with clinicians to work with the clients as a group to create a song on a recovery topic.


Having clients create and record their own music and lyrics gives them hands-on experience in developing skills directly applicable to their recovery. Used in this way, it is not music therapy, but rather a fun and engaging way to practice specific skills. We give a simplified version of this handout to clients at the beginning of each session and then we check back in at the end to identify which gifts we used.


Gifts of the Creative Process for People in Recovery


The Gift of Process:

Gives us hands-on, low-risk experience of participating in an unfolding process.

* Because recovery is an opaque and long-term process, clients can experience a

    miniaturized version of process through songwriting.  


The Gift of Sober Fun:

It’s great to learn that we can relax, be silly and have a good time without drugs and alcohol.

* We regularly see in the post-workshop evaluations how clients are genuinely surprised to

    find they can have sober fun. I believe having real fun in treatment not only gives clients

    hope for the future, but also makes it easier to do deep work.


The Gift of Repetition:

We can go from not being able to do something to being able to do it, simply by repeating the action a large number of times.

* Because music is fun and important, clients are more willing to give themselves the gift of

   repetition. In music ten is a small number of repetitions.


The Gift of Imperfection:

Perfectionism is not a success tool! Allowing gradual progress from ‘not-that-great’ to ‘slightly better’ to ‘good’ is the path to success.

* We live in a culture where we rarely see the awkward growing phases. When clients feel

    awkward they tend to stop and want to discard their work. Creativity gives a low risk

    opportunity to help midwife them through the awkward periods. We use a series of photos

    of baby eagles, teenage eagles and a soaring eagle; we encourage the clients to not kill the

    baby eagle.


The Gift of Slowness:

Giving ourselves the gift of going one day at a time, one step at a time is one of the most powerful tools for successful recovery.

* Part of what makes the recovery process hard is that it is very slow. People with SUD tend

   to want instant results.   When clients are learning to deliver lines, especially in rap music,

   we can help them perceive slowness as a gift, not a punishment.


The Gift of Walking in the Unknown:

There usually comes a time when it feels like it’s not working. The important thing is to keep taking actions in the direction you want to go, even if you can’t see how it’s going to work out.

* People with SUD are often strong starters and when they encounter a period where they

   are not achieving immediate results they tend to stall. Having a set time period to finish a

   song helps to keep moving through that period.


The Gift of the Group:

The more different types of people you have, the more solutions are available. Tolerating differences leads to success.

* We use a photo of the crew of Star Trek. We tell clients: when you are on a mission the last       thing you want is people who are just like you.   We have seen over and over that

    songwriting helps build cohesion in the group.


The Gift of Service:

Keeping in mind that the project we create can be of service to others helps us do a better job.

* Whatever creative project you choose, consider adding a service element, as this calls

   people to a higher level.


The Gift of Mistakes:

What look like mistakes can often lead us to unexpected places when we remain open and relaxed and keep going. America, X-rays and chocolate chip cookies were all discovered by mistake.

* People tend to tense up and freeze when they think they’ve made a mistake. In creativity

   mistakes can be amazing. There’s a great book called “Mistakes that Worked.” I show the

   clients a copy of it and tell the story of how chocolate chip cookies were invented. We invite

   clients to pause when they’ve made a mistake; we ask whether that might be a chocolate

   chip cookie.


The Gift of Completion:

Addiction and perfectionism robbed many of us of completion. Creativity lets us practice finishing what we started.

* Providing access to the finished product helps people remain connected to their treatment

   experience when they go home plus having an additional way to share the experience with

   family and friends. We post the songs on SoundCloud.


Whenever I see your smiling face, I have to smile myself because I love you…..” As I write this, it’s Valentine’s Day so an appropriate line to open up with…..right?  But there’s an even greater reason this song, written and performed by one of my favorite singer-songwriters, James Taylor, opens up SOUL this month.  It always gets my foot tapping, puts a smile on my face and reminds me how music can set the mood.  It brings back memories and has such a powerful influence.


James Taylor has been a favorite of mine for 40 years and this song appears on the album JT (1977).  He has experienced the ravages of addiction and the fruits of recovery.  Last year James Taylor was presented at the White House with the Presidential Medal of Freedom, the nation’s highest civilian honor.


If you want to see him sing “Your Smiling Face”along with the lyrics, here’s the link.  This is not how he looked in 1977, but neither do I.  I am such a fan, that I even named my son, Taylor, after him and it wasn’t Taylor Swift.  She wasn’t even born yet.


I marvel at the creativity and artistry of people who can sing and entertain us.  My most recent joy, amongst a rash of really young children who never cease to amaze me, is Angelina Jordan from Norway.  Start watching her YouTube videos and you’ll be hooked.  Watch her sing “Fly Me To The Moon” when she was 8 years old!  You’ll be astounded.  Just one more: “What A Difference A Day Makes”   She’s bilingual also.


Alert** The following is a proud father sharing:

Music has always been a central part of our family.  All three of our children played the violin, cello and flute respectively, and for all three, music is still an important element of who they are and what they do.  They still keep their day-jobs though.  The music industry is brutal.


Taylor has written and performed many songs.  However if you’d like to hear him cover another songwriter’s song and then enjoy one he wrote while traveling in Cambodia, here’s the link. Don’t be confused by the cute little boy photo he posted:


Mackenzie or her performing stage name, Kenz, has recorded songs I am still coming to understand!  They are not exactly the style of James Taylor nor Taylor Mee-Lee, but many enjoy the techno sound.  Take a listen if you dare:


For a more traditional sound you can see her sing the National Anthem at AT&T Park, for a San Francisco Giants and Chicago Cubs baseball game:


Music, music, music.



Here are links to articles and programs Kathy shared to help you learn more about using music in treatment and recovery.

1. Recovery Research Institute Study on Music for Recovery

Special thanks to Dr. John Kelly, Harvard professor and Director of the Recovery Research Institute, and his graduate students for their dedication and efforts.

To download the study and backing technical documentation please click on each of the files here: FINAL RESULTS, Rationale, Constructs, Questionnaire 

2. Music and the art of recovery


3. Achieving Recovery Through Creativity


4. Recovery Unplugged Florida


5. Music for Recovery


6. Right Turn


7. Little Creek Lodge


8. Beats, Rhymes and Life: Organization Pioneering Hip-hop therapy


9. Article about Academic review of 400 studies on music and the brain

Until next time

I hope you enjoyed and were educated by this guest edition this month. See you in late March.



March 2016

Vol. #13, No. 12

In this issue

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

David Mee-Lee M.D.


Getting Real about Gambling Disorder and Speeding again

Vol. 14, No. 1

Welcome to the beginning of our 14th year of Tips and Topics. It is hard to believe thirteen years ago I published our first Tips and Topics.  Thanks for starting a new year with us.

David Mee-Lee M.D.


I recently received this message from a long-time Tips and Topics reader:


“Hi Dr. Mee-Lee:


I’ve enjoyed Tips and Topics for a number of years and sometimes use excerpts from it as teaching and supervision tools for our students. I was also present for your keynote address to the National Conference on Problem Gambling (NCPG) last year and appreciated your thoughts about removing Substance Use Disorders and Gambling Disorder from their separate silos to help addictions clinicians and programs develop stronger competencies in both areas.


I do have a suggestion for Tips and Topics. Most of the insights in your newsletter relate well to the challenges counselors face working with problem gamblers and their family members, yet almost invariably when Tips and Topics refers to addictions, only Substance Use Disorders (SUDs) are mentioned. I’m wondering if, in the spirit of your keynote address to the NCPG conference, Gambling Disorder can be included, where appropriate. It could help raise the consciousness about this among your readers.


Thanks for taking the time to read and consider this.



Director, Problem Gambling Services

Lewis & Clark Graduate School of Education and Counseling

4445 SW Barbur Blvd. Suite 205

Portland, Oregon 97239



I can’t always respond to all suggestions readers make, but in this one, Rick has a point. I’ve talked before about addiction being more than just substance-related. Moreover, in The ASAM Criteria (2013) on pages 357-366 we even have a whole chapter on Gambling Disorder. Yet I have written or spoken of gambling hardly at all in Tips and Topics.


So this month’s edition fixes that problem a bit. I will share excerpts of my presentation on July 10, 2015 at the 29th National Conference on Problem Gambling in Baltimore, Maryland: “Getting Real about Gambling Disorder: How The ASAM Criteria Can Help“.



Why Consider Gambling Disorder?


American Society of Addiction Medicine (ASAM) Definition of Addiction


* The Definition of Addiction adopted by the ASAM Board of Directors in April 2011 states that persons with addiction can be seen as “pathologically pursuing reward and/or relief by substance use and other behaviors.” One of those “behaviors” is gambling.

* This definition does not state that Alcohol Addiction, Opioid Addiction, Nicotine Addiction and Gambling Addiction are separate conditions. It states that addiction can be involved with various substances and behaviors. (Nicotine addiction is the other neglected addiction).

* People with addiction manifest a pathological pursuit of reward or relief, and have a “disease of brain reward, motivation, memory and related circuitry” which is “characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response.”  


Statistics on Gambling Disorder


* Gambling Disorder is widespread and often co-exists with substance-related disorders as well as other mental disorders. Various estimates indicate that 1-2% of U.S. adults and 2-4% of U.S. adolescents are diagnosable with Gambling Disorder. (The ASAM Criteria, 2013)

* Lifetime prevalence is about 0.4%-1% – females about 0.2%; males about 0.6%; African Americans about 0.9%; whites about 0.4%; Hispanics about 0.3% (DSM-5, page 587, 2013)

* “Up to half of individuals in treatment for gambling disorder have suicidal ideation, and about 17% have attempted suicide.” (DSM-5, page 587, 2013)

* For 6-9 million Americans, gambling is a damaging behavior that can harm relationships, family life, and careers. (SAMHSA –



Getting Real about Health Coverage for Gambling Disorder


(The ASAM Criteria 2013, page 358)

* In contrast with substance use disorders, it is currently uncommon for commercial or governmental health plans to offer payment for treatment in residential or inpatient levels of care unless there are co-occurring medical or psychiatric problems, which would, in and of themselves, justify reimbursement for such placements.

* Most insurance companies that do not categorically exclude coverage for the treatment of gambling disorder have had benefits for the treatment of gambling disorders. But those benefits do not include payment for residential or inpatient treatment unless there is another, primary diagnosis such as major depressive disorder. It is the major depressive disorder which generates the reimbursement, not the gambling disorder. A state or local drug and alcohol authority could elect (and some do) to pay for the treatment of gambling disorder, regardless of level of care.

* Even partial hospitalization or intensive outpatient treatment programs for gambling disorder have historically been considered a “non-covered benefit”; patients needed to meet criteria for a substance use disorder or a separate mental disorder in order for payment to be authorized when the treatment focus would otherwise be the person’s pathological gambling.  

* “Across all states, there was a lack of uniformity regarding what types of problem gambling services were funded. Some states funded a comprehensive array of services ranging from prevention through multiple levels of treatment, while other states provided only one service (e.g., a problem gambling helpline or a prevention program).”

* “Among state agencies this variability in services provided was often rooted in the legislation that originally established the problem gambling program. Some states had legislation that restricted the use of funding to specific service areas. Another driving factor for which services were funded was linked to budget pragmatics, such as having insufficient funds to expand the range of services offered.” (2013 NATIONAL SURVEY OF PROBLEM GAMBLING SERVICES, March 2014)



Getting Real about Staff Credentials and Competence for Gambling Disorder


(The ASAM Criteria 2013, page 358)

* Staff providing treatment to patients with gambling disorder should have a state-sponsored or -approved Gambling Counselor Certification.

* Not all states have such credentialing – some states accept a national credential such as the National Certified Gambling Counselor (NCGC), provided by the National Council on Problem Gambling.

* State certification or licensure as an Alcohol and Drug, Chemical Dependency, or Substance Abuse Counselor should not be considered a substitute for or equivalent to a Gambling Counselor Certification.

* In the future, the evolution of professional training and professional certification, possibly being influenced by the 2011 ASAM Definition of Addiction, may mean that all addiction counselors will receive sufficient training in addiction associated with gambling, and thus separate certification will not be necessary. But at this time, there are relatively few well-trained and certified Gambling Treatment counselors.



Getting Real about Filling Gaps for Gambling Disorder



Survey participants were asked to identify one item as their state’s “greatest obstacle in meeting service needs to address problem gambling.”


* “Inadequate funding” was most frequently identified as the largest gap.

* The second most commonly endorsed service gap was a lack of public awareness about problem gambling.

* Problem gambling treatment availability.

* Need to increase the number of treatment providers.

* Improve research.

* Increase the number of prevention providers.

* Improve information management services.

* Increase the size of administrative staff.



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



Prepared by Problem Gambling Solutions, Inc. for Association of Problem Gambling Service Administrators (APGSA) and the National Council on Problem Gambling (NCPG). March 2014


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:


“The Definition of Addiction” Adopted April 12, 2011.


Note the following about gambling:

  • Gambling problems are assessed under ASAM Dimension 3, Emotional, Behavioral or Cognitive Conditions and Complications.
  • Gambling commonly co-occurs with substance use disorders (SUD).
  • Either gambling or substance use may act as a trigger for relapse to the other disorder.
  • Screening for gambling problems should be a routine part of SUD assessment.



Getting Real about Screening and Assessment for Gambling Disorder

(The ASAM Criteria 2013, page 361)


The purpose of screening is to conduct a preliminary inquiry to rule an individual “in” or “out.” If “ruled in,” the next step is to perform a comprehensive diagnostic assessment using the DSM-5 criteria for Gambling Disorder.


Once a Gambling Disorder diagnosis is established, the next question – answerable by use of The ASAM Criteria – is: What is the severity of the disorder? Severity of illness guides the clinician to an intensity of service recommendation for the patient.

  • There are over 27 instruments for identifying disordered gambling, though there is debate about them and what they measure.
  • An appropriate instrument should be able to screen for gambling disorders in both the general population and a population of persons who have a substance use disorder.

Two screening tools are recommended.


A. The first is the two-item “Lie/Bet Screen.”

* Advantage is that it is only two questions, and is more likely to be used in community and clinical settings where clinicians feel overwhelmed with current assessment responsibilities and other paperwork.


The “Lie/Bet” two item questionnaire are:

1) Have you ever had to lie to people important to you about how much you gambled?


2) Have you ever felt the need to bet more and more money?


B. The second and better-known and researched screening instrument is the South Oaks Gambling Screen (SOGS), a 16-item scorable questionnaire, which is in the public domain and can be found on the Internet.




Compare and Contrast ASAM Multidimensional Assessment for Substance Use Disorders versus Gambling Disorder. 

ASAM Multidimensional Assessment (The ASAM Criteria 2013, page 362-363)        

Here are examples of questions that would be asked in a multidimensional assessment of individuals with substance use disorders; and questions as they would apply to individuals with gambling disorders. The italics identify the differences.  There are such common characteristics between assessment of both disorders, with the least overlap being in Dimension 1: Acute Intoxication and/or Withdrawal Potential. The assessment questions of the other dimensions are generally a very close match.


ASAM Criteria Dimension 1:  Acute Intoxication and/or Withdrawal Potential

Sample Questions:

1. Substance Use Disorder:

  • Are there current signs of withdrawal?

1. Gambling Disorder:

  • Are there current signs of withdrawal (restlessness or irritability when attempting to cut down or stop gambling)?


2. Substance Use Disorder:

  • Does the patient have supports to assist in ambulatory withdrawal management if medically safe?

2. GamblingDisorder:

  • Does the patient have supports in the community to enable him/her to safely tolerate the restlessness or irritability when attempting to cut down or stop gambling?

3. Substance Use Disorder:

  • Has the patient been using multiple substances in the same drug class?

3. Gambling Disorder:

  • What forms of gambling has the individual engaged in?  Has the patient also been using psychoactive substances to the point where alcohol or other drug withdrawal management is necessary?


ASAM Criteria Dimension 2: Biomedical Conditions and Complications

Sample Questions:

1. Substance Use Disorder:

  • Are there current physical illnesses, other than withdrawal, that need to be addressed or which complicate treatment?

1. Gambling Disorder:

  • Are there current physical illnesses, other than withdrawal, that need to be addressed or which complicate treatment? Does the individual manifest any acute conditions associated with prolonged periods of gambling (e.g., urinary tract infection)?

2. Substance Use Disorder:

  • Are there chronic illnesses, which might be exacerbated by withdrawal (e.g., diabetes, hypertension)?

2. Gambling Disorder:

  • Are there chronic medical conditions such as hypertension, peptic ulcer disease, or migraines that might be exacerbated by either cessation or continuation of the gambling behavior?


ASAM Criteria Dimension 3: Emotional, Behavioral or Cognitive Conditions and Complications

Sample Questions:

1. Substance Use Disorder:

  • Do any emotional/behavioral problems appear to be an expected part of addiction illness, or do they appear to be separate?

1. Gambling Disorder:

  • Do any emotional/behavioral problems appear to be an expected part of the gambling disorder, or do they appear to be separate?

ASAM Criteria Dimension 4:  Readiness To Change

Sample Questions:

1. Substance Use Disorder:

  • If willing to accept treatment, how strongly does the patient disagree with others’ perception that s/he has an addiction problem?

1. Gambling Disorder:

  • If willing to accept treatment, how strongly does the patient disagree with others’ perception that s/he has a gambling problem?


ASAM Criteria Dimension 5:  Relapse, Continued Use or Continued Problem Potential

Sample Questions:

1. Substance Use Disorder:

  • How aware is the patient of relapse triggers, ways to cope with cravings, and skills to control impulses to use? 

1. Gambling Disorder:

  • How aware is the patient of relapse triggers, ways to cope with cravings, and skills to control impulses to gamble?o accept treatment, how strongly does the patient disagree with others’ perception that s/he has a gambling problem?


ASAM Criteria Dimension 6:  Recovery Environment

Sample Questions:

1. Substance Use Disorder:

  • All Recovery Environment questions similar between SUD and gambling disorder. An additional question listed for Gambling Disorder

1. Gambling Disorder:

  • Are the patient’s financial circumstances due to the gambling or associated legal problems an obstacle to receiving or distraction from treatment, or a threat to personal safety (e.g., loan sharks)?


What do January 2006, May 2010, October 2011 and April 2016 all have in common? Before you feel bad these might be some historical events you should know about, let me hasten to say that these dates only matter to ME.


You might be thinking: So why are you talking to me about dates that only matter to you? Because, there but for the grace of God go you. Actually, as I think about it, it has nothing to do with the “grace of God”. It has all to do with inattention, lack of commitment and risky behavior.


I did it AGAIN! I landed a speeding ticket this week, driving in Maine after a full day of training in Portland, Maine. If you’ve been a Tips and Topics reader for some years, you may remember the speeding topic has come up before in SOUL. Here are the links if you want to feel superior to me:

January, 2006

May, 2010

October 2011


I don’t have a speeding addiction. That’s not “denial”; it is just a fact that by comparing my speeding with the “Lie/Bet” two item questionnaire for gambling disorder, I am zero-zero. I understand that’s a screening tool for gambling addiction not speeding, but it is comparable, trust me. I compared my speeding with the diagnostic criteria for gambling disorder and I didn’t come close to the required threshold for addiction. As well, I don’t want to trivialize the devastating disease and real tragedy of substance-related and gambling addiction by throwing around the word “addiction” and my speeding.


This is not to say, however, that I can sound like a person not yet in recovery from addiction. Here are reasons I am not addicted to speeding:

  1. Three of the four times I received a speeding ticket, I was driving a rental car. In my familiar car at home, I can feel when I’m speeding. (Oh, so they don’t have speedometers in rental cars that you can look at and monitor your speed?!)
  2. In the 2010 incident I was driving a brand new Prius, not yet used to the feel of speeding like in my old familiar car. (Oh, so again, the Prius didn’t have a speedometer to look at and monitor your speed?!)
  3. I thought I was following the flow of the traffic, so I bet I wasn’t the only one speeding. Why didn’t they catch them? It was probably racial or professional profiling, picking on Australian-born Chinese psychiatrists. (Yeah, right.)
  4. This latest speeding ticket was only for 79 mph in a 70 mph zone. Well actually the police officer took pity on me. Since it was decades since I have had a violation in Maine, he reduced my “speed” from the 83 mph to 79 (and saved me some dollars.) (79 mph and certainly 83 mph are both breaking the law and are both speeding – 70 mph is 70 mph, not 79 mph or 83.)
  5. The police are just trying to raise revenue by ticketing good citizens like me. They should be out there stopping real criminals like burglars and murderers. (So your illegal behavior is not as bad as those crimes, so you should get a break?!)

I surrender. My inattention, lack of commitment to not speeding, and risky behavior got me the ticket. I’m telling you now in hopes that my fine, my bank account and my public confession will change my speeding ways.

Interactive Journaling:

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Until next time

Thank you for joining us this month. See you in late May.



Mainstreaming COD into AA/NA; Hong Kong

Vol.14, No. 2

Welcome to the May edition of Tips and Topics. Welcome to all the new readers who joined this month; and to our longtime readers too.

David Mee-Lee M.D.


I received a question that arose from a recent workshop I did on Co-Occurring Mental and Substance Use Disorders (COD). This month I am combining SAVVY with a STUMP THE SHRINK question. This centers on “mainstreaming” people with co-occurring disorders to use Alcoholics Anonymous (AA) and Narcotic Anonymous (NA) as support groups even though they have mental health issues in addition to alcohol or other drug issues.


Hi David:

I have been a subscriber of your newsletter for several years and have been to a few of your presentations. I recently attended the conference in Portland. I have been in the field of Substance Use Disorders (SUD) treatment for many years. I know the tremendous value of AA/NA but one of my greatest challenges has been mainstreaming. Can you tell me more about how this is accomplished? How about a few “Tips”?





Why consider “mainstreaming” people with COD into AA/NA?


Firstly, I am using the term “mainstreaming” as is done in the education field. Previously students with special learning needs were kept separate from the mainstream of regular classes. Mainstreaming combines those with special needs with all students. Here are reasons to consider introducing AA/NA to people with COD:

  • Everyone needs as much support and recovery groups as possible. In many areas, AA and NA are the most available and accessible groups.
  • Correctly prepared, people with COD can receive the help they deserve and need at 12-Step groups, while still respecting the mission of each group.
  • Even if AA and NA members consider themselves single-focused on addiction (alcohol or other drugs), some actually have mental health issues themselves. They could benefit from mingling with people identified as dealing with COD.



Issues to address when preparing people with COD to attend AA/NA


Introducing 12-Step groups to anyone should be much more than referring them with an admonition: “You should go to 90 meetings in 90 days.” But if you consider mainstreaming in COD treatment, it takes even more preparation for those with addiction and mental illness:

  • Is the person sufficiently stable in their mental illness to use good judgment about when and what to speak about at a 12-Step group? – If the client is too unstable in their psychosis, personality, bipolar or mood disorder then this is not the time to be mainstreamed.
  • Have you identified which AA/NA groups in the area are open to welcoming people with COD? – You wouldn’t want to set a person up for being confronted by an “old-timer” who is a purist.
  • Has your client had previous positive or negative experiences with AA/NA? – If positive, can your client re-kindle those skills and resources (getting a sponsor and names and numbers; returning to a home group etc.)? If negative, can they be coached through how to deal with any anxieties or negativity they still harbor?



Note the AA-approved literature: “The AA Member – Medications and Other Drugs”


Some “old-timer” at an AA meeting may tell a client: “You shouldn’t be taking those drugs from those psychiatrists”; “You’re chewing your booze and should stop those medications” or words to that effect. Note the balanced approach in the following excerpts:


Because of the difficulties that many alcoholics have with drugs, some members have taken the position that no one in A.A. should take any medication. While this position has undoubtedly prevented relapses for some, it has meant disaster for others…..


It becomes clear that just as it is wrong to enable or support any alcoholic to become re- addicted to any drug, it’s equally wrong to deprive any alcoholic of medication, which can alleviate or control other disabling physical and/or emotional problems.” (Page 6, revised 2011 edition).


You can read the whole pamphlet at:



I am not a member of AA/NA or any other 12-Step group, though I have attended open meetings to learn more. I have great respect for the power of mutual help groups and 12-Step groups in particular, having seen thousands moved and changed by the fellowship of AA, NA and other groups. My experience comes from working with patients and clients who have taught me about 12-Step groups. However if I have misrepresented meetings you attend that may be more open to COD, let me know and teach me.


Not all people with COD have the same co-occurring mental health issues, therefore different issues must be addressed when considering mainstreaming in AA/NA.



Diagnosis-specific suggestions when linking people to AA/NA


Here are a few common diagnoses and mental health issues which require different preparation for people you try to mainstream in AA/NA:


1. Schizoid or socially-avoidant people

Usually when you link a person to AA/NA, you advise something like: “Go early, sit up front, stay late, talk to people, get involved.” For the more avoidant, schizoid or shy person fearful of even getting to a meeting, you might say the opposite:

  • “Go late, sit at the back, leave early, don’t talk to anyone or get involved, but go. Don’t not go.”
  • “Once you feel a bit more comfortable, go a minute early, sit in the second back row, stay a minute longer but don’t talk to anyone.”
  • “When you feel more comfortable, go a few minutes early, third back row, stay few minutes longer, smile and say ‘hi” to someone but don’t talk.”
  • “Then arrive on time, stay after and start talking to someone.”

The idea: Ease into attending meetings at a pace that feels safe and in control. Be sure to go, rather than avoid meetings and staying stuck.


2. People with Borderline Personality Disorder

To a newcomer, a welcoming AA member may say something like: “Glad you are here, welcome. Here’s my name and number, call me anytime.” A person with Borderline Personality Disorder (BPD) or psychodynamics may have poor boundary issues and end up sapping the energy and goodwill of the AA member. When they call their sponsor, they may get voice mail or an answering machine.


To ensure there is a sponsor ready to listen, you may need to advise such a client to be working with three sponsors:

  • Sponsor #1, who is burning out, drained by the many calls that seemingly never satisfy the endless needs for nurturance and support.
  • Sponsor #2 with whom the client is actively working, who still has energy to help; and has not yet been impacted by all the calls for nurturance and support.
  • Sponsor #3 is still fresh and doesn’t know the client well yet. They offer their name and number for help 24 hours a day, 7 days a week; “call me anytime” unaware of what may lay ahead.

With these 3 sponsors, the client is taking responsibility to always have someone available to whom s/he can reach out.


3. Women (and men) who too quickly fall into counterproductive relationships

Kristen McGuiness wrote about “The 13th Step: People Who Prey on Newcomers” (2011) and spoke about “thirteenth stepping” when someone with more than a year of sober time hits on a person with less than a year: “Some AA members try to get fresh recruits on their backs before they’re on their feet.” Read more at:

  • Even though it may feel good to be wanted, wooed and dated, early sobriety is no time for launching into romantic or sexual relationships.
  • You will want help women and men recognize this vulnerability in themselves. Help them practice how to respond to a 13th stepper coming onto them. Too late to be thinking about what to say in the heat of the moment; use assertiveness training to learn how to say “no”.
  • A woman might want to go to more Women’s AA meetings.
  • At regular meetings, have a female on each arm to guard against temptations to “hook up.”
  • If in doubt as to whether advances from an AA member are innocent or sinister, share the concern with a trusted ally, sponsor or person of the same gender.



Coaching tips for people with COD when they attend AA/NA


Teach these skills to your clients:

  • To identify those people at a meeting who are more open to talking about COD – listen for a speaker who mentions mental health issues and not just addiction. Approach them privately. If an AA/NA member is more welcoming and understanding about mental health issues, ask that person about other members who are similar.
  • To handle an AA/NA member who may confront them for being at the meeting because they have mental illness not just addiction.
  • To respect the others’ opinion and not be defensive or antagonistic.
  • To reassure the member that they are not there to disrupt the meeting and have the same needs for recovery support as everyone.
  • To express that they will be careful not to detract from the main mission of the meeting.
  • To recognize the similarities with other speakers even if the speaker does not drink or drug the same as they do. For example, someone may talk about alcohol, though your client has a benzodiazepine problem.
  • Note the effects of addiction on family, friends and work; and how they are similar to your client’s family, friends and work problems, even though the drug or substance used is different.


Hong Kong is in my top ten list of favorite places to visit and people-watch and culture-watch. This month was my sixth trip, reviving nostalgic memories of a visit as a pre-teen with my parents, brother and sister, to ensuing trips as an adult for work and play.


These are a few of my favorite things: the trains, food and shopping.


The fast, efficient, accessible Mass Transit Railway (MTR) system is truly a rapid transit system. Lighted arrows show you the direction the train is headed. Flashing lights alert you about the next stop and even which side of the train the doors will open.


Missed the train?  No problem. Another one will arrive in five minutes or less.

I know other countries have similarly efficient rapid transit. How is it the USA seems so far behind similarly wealthy and populous countries?


Then there’s my favorite desert – not too sweet, uniquely Asian and still searching to find it in the USA – fresh mango, sago and black jelly pieces (that’s it on the end at the far right of the photo) for $39 Hong Kong dollars, about $5 US.  I relished eating my first on within two hours of arriving in Hong Kong.



Of course there’s the shopping. Whether you want the look alike fake name brand bags or clothes, or the real (and expensive) item, it is all there. You can wander for hours up long, crowded streets with zillions of vendors; or stroll in air-conditioned luxury shopping malls.

 How can you resist mixed silk and wool suits for $130? Not the real thing from Italy, but looks pretty good nevertheless. The label didn’t say Messina “Made in Italy” but Messina “Made by Italy” – they couldn’t even get the English right in the fake label. Imagine that, I have a suit made by Italy! But hey, it had “Messina” and “Italy” in the label so that sounds good. I bought it anyway!

There are many tourist sites too numerous to mention. I’ll end by sharing my experience in an authentic and well-regarded Beijing restaurant. Their specialty is tasty Peking Duck and unique handmade noodles. Feet away from our table was the talented chef demonstrating his special noodle-making skills, tossing and flinging it all in the air with twists and turns. You weren’t there, but you can see it on YouTube!

hope I am asked back to Hong Kong to train more health-care professionals seeking addiction counseling certification. If you are looking for a place to visit, you know where I would recommend.

Until next time

Glad you could join us this month. See you again in late June.

All the best,


Readers’ Responses on Mainstreaming COD into AA/NA; the magic hotel elevator

Vol.14, No. 3

Welcome to the June edition of Tips and Topics. I’m glad you could join us this month.

David Mee-Lee M.D.


Last month I provided a few tips on “mainstreaming” people with co-occurring addiction and mental disorders (COD) into Alcoholics Anonymous (AA) and Narcotic Anonymous (NA) as support groups. If you missed it, you can check out the May 2016 edition: May 2016 Tips and Topics


There were a number of readers who took the time to write and give feedback, corrections and further suggestions. Here is their wisdom and perspectives as a follow-up.



Readers in long-term recovery share about their experience and advice


Reader #1

Hi, My name is Lynda and I have 31 years clean. I also am an LCSW and CADC. (Social Worker). I am very active in NA as well as AA. I agree with your article except how NA/AA may tell people not to take medication. That is an outside issue and it has been years since that kind of thought process has been around. If anyone has said it, it is rare and an individual’s opinion. Even in the recovery literature it says, “We are NOT doctors”.  

Lynda K. 31 years clean in NA/AA


My response

Thanks, Lynda for writing and for the feedback.  I’m glad to hear that it is rare that anyone would say anything about medication.  I know the recovery literature has been more advanced in that thinking but wasn’t sure if old-timer members had moved on.

Thanks for the info.



Reader #2

As a longtime member of AA, I want to thank you for a wonderful piece on integrating newcomers into the program. We have two kinds of members — those who know they have COD and those who think they are exempt (but are not) — we all have issues, whether we face them or not. Remember our expression, “some are sicker than others”! As a thinking person, I try to maintain the spirit of the Big Book and also debunk some of the nonsense that has grown up in the rooms. AA’s 12th step says “practice these principles in ALL our affairs” — to me, that means accept all comers with love, without discrimination as to what substance they used — or what “problems other than alcohol” they may have.

Phyllis B



Reader #3

Hi David:

I read with great interest your article on Mainstreaming. I would add to your list that the 3rd Tradition of AA states that the only requirement for membership is a desire to stop drinking. I remind persons of this Tradition when I suggest AA meetings. As a long time member of AA (42 years) I have seen many transitions while still maintaining the “singleness of purpose” that helps us survive and thrive. Just as we AA’s have accepted persons with other addictions, we are beginning to hear more persons share that they have been treated for mental disorders. The important thing to remind persons attending AA is that all are welcome but we focus on our problems with alcohol in an AA meeting. If he or she does not have an alcohol problem, then another meeting is more appropriate. Every meeting is different, but my bias is towards meetings that concentrate on “recovery” – what happened, and what it is like now – with that approach the drug of choice or behavior is not emphasized.

Susan B


My comment

Lynda K, Phyllis B and Susan B have between them, many decades of long-term recovery.  I appreciate their perspective on newcomers with COD attending AA/NA.  Just as “every meeting is different” as Susan said, different members may have different perspectives too.


Reader #4 below shares his view. I have excerpted and edited his message as English is not his first language, but I wanted to share his gratitude for long-term recovery and his perspective too.



Reader #4

I would like to share information on choosing 12-Step support group meetings, coming from my 15 1/2 years of experience.  In choosing a 12-Step Anonymous meeting an individual has to be informed of the language of the 12-Step meeting.  What I mean by that is, in certain meetings like AA you have to identify as an alcoholic to speak from the podium and they promote mainly discussing and sharing about alcohol.   If you don’t speak about alcohol, a member will point that out in whatever way fits their personality and it can cause embarrassment to the newcomer.


In NA when you speak from the podium or should I say “Share your Experience, Strength and Hope” there is certain language/words that are used and their concept about the disease of addiction is different. They don’t believe “Once an addict always an addict”.  They seem to believe at some time or another you are cured.  Their NA booklet teaches differently from AA concepts of the 12-Step program.  As for speaking from the podium in NA it is not favorable to use the word “sober”.  They use the word “clean”.  You are shot down, yelled at, and not in an appropriate way, embarrassed.   Surely the newcomer will feel “less than” and inadequate, and probably never attend a 12-Step meeting again.


I did not read in your information about Cocaine Anonymous (CA).  In their 12-Step meetings they have adopted the 12-Step program outlined in AA.   The meetings are warm and welcoming, and they welcome you to come as you are.  They allow you to share your experience, strength and hope in any way that is comfortable for you.  You do not have to walk on eggshells in Cocaine Anonymous.  “We are here and We are Free” Please visit  I love Cocaine Anonymous and the 12-Step program outlined in the Big Book of Alcoholics Anonymous.  It got me in contact with a Power that was greater than me, that Power I choose to call God.  I understand this is not a religious program but a spiritual program that saved my life after 29 years of drugging.


I am currently attending a local university completing my Masters degree as an Marriage and Family Therapist in October 2016. God is Good! 

DH – “Willing to be of Clean and Sober Service”


My comment

Finding the meeting that is right for you takes some experimentation and willingness to try different groups.  So when a person says, “I tried AA or NA and didn’t like it” or “It didn’t work for me”, check out how many meetings and locations they tried. Too often they respond with something like: “I went to a couple of meetings 3 years ago.”



Reader #5

Dear Dr. Mee Lee,

I read with great interest your article on “mainstreaming” people with co-occurring disorders into AA/NA meetings.  As a recovering 12-step member with a co-occurring mental health issue – and a peer certified recovery coach who works in the addictions field – I can assure your readers that many, many people with substance use disorders also have co-occurring behavioral health disorders.  People with CODs are welcome at any Open 12-step meeting, and at Closed meetings if they believe or know they have a problem with drugs or alcohol.

While several of your diagnosis-specific tips for clients attending their first meeting are on point, your suggestion that someone with Borderline Personality Disorder (BPD) work with 3 sponsors is not something 12-step groups endorse. T he problem with multiple sponsors is that the sponsee can “play” sponsors against one another, much like children play parents against the other – getting a “No” from Mom, and seeking a “Yes” from Dad.  Because of this possibility, 12-Step fellowships suggest working with one sponsor.

Your suggestion to recognize similarities with others rather than differences is one of the most important things a newcomer can do. Addiction is one disease that manifests in a multitude of ways.  Whether an individual abuses alcohol, street drugs, club drugs, marijuana or prescribed medications, he or she can typically identify with the feelings of despair and desperation that brings us to the rooms of AA, NA and other 12-step groups.  This identification allows a newcomer – with or without a COD – to hear the life-saving message of recovery that these support groups offer.

Thank you for your ongoing commitment to the fields of addiction and behavioral health. 

Lisa B


My response

Thanks, Lisa, for all that information. Yes, I understand your points about the importance of one sponsor; and I should be careful as that was a bit of tongue in cheek, though a suggestion I had thought of as possibly viable. What should someone with BPD actually do? Would they just end it with the sponsor who might be burning out and start with a new one? Thanks for your advice.



Not all mutual help groups are 12-Step.  Consider SMART Recovery and other groups too

Reader #6

I just read your article on mainstreaming people with COD into AA/NA meetings.  I am an ardent supporter of SMART Recovery and urge you to refer to SMART and other alternative support groups such as Women for Sobriety and others.  The 12-Step model while being around for a long time doesn’t work for many people.  All too often the “keep coming back” admonition is counterproductive.  If people know that there are other groups whose approach is self-empowering, the chance of achieving sobriety is increased and your helping to educate the public through your publications will help that.


I was introduced to SMART Recovery about 5 1/2 years age when I was a patient in Cincinnati. I attended regularly and after about a year I took the facilitator training course offered by SMART.  I have been facilitating meetings since that time including one, which another facilitator and I started in the local county jail.  In January 2015 I began a term as one of the board of directors for the SMART national organization and am now the interim secretary.


I would be happy to do what I can to promote SMART, either by providing further information myself or asking the President Dr. Tom Horvath and or Treasurer and founder Dr. Joe Gerstein to do so.


Thank you

Bill Stearns

Reader #7

David, great advice regarding Schizoid/Avoidant personalities.  I have met one or two who do well with online meetings.  I’ve recently begun a SMART recovery meeting at our treatment program. Any thoughts?


My response and comment

I think it is great that you are starting a SMART Recovery group; and thanks for mentioning the option of online meetings. We need as many options as possible to give choices to match what works for people.


Two readers shared thoughts and skills coming from their long-term recovery.



Consider these tips to pass along to your clients and staff team


Reader #8

Greetings, David:

I’m glad you addressed the topic of introducing 12-Step (especially AA and NA) fellowships to clients with co-occurring mental health issues.  I especially appreciated your specific suggestions pertinent to particular diagnoses.


Some other thoughts that seem relevant:

1. Look for fellowships in your area that specifically invite individuals with co-occurring disorders such as Dual Recovery Anonymous (

2. Invite local fellowships to offer Hospitals & Institutions panels at your facility. (Meeting people who attend local meetings in this way can make it easier for someone to attend those meetings because they will already find a familiar face.)  Have staff available to debrief clients about how they felt about the panel afterwards.

3. If possible, take clients to some local meetings so they can become familiar with them (but be respectful: sensitive to the size of the meeting so that your clientele does not dominate it, and prepared to address clients’ possible disruptiveness).

4. Encourage clients to go to meetings together so that they can offer each other mutual support and thereby feel more comfortable than showing up in a roomful of strangers.  Having one or more “trudging buddies” helps stabilize and sustain meeting attendance.

5. Demystify some of the 12-Step meeting/fellowship arcana using psychoeducation:

 * How do I introduce myself during a meeting? (To avoid shaming, alert clients to language: people at AA meetings often are touchy about having participants introduce themselves as “addicts” or even “alcoholic/addict”; NA meeting members, likewise, can be feisty about participants who introduce themselves as “alcoholics.”)

 *  Why do people always introduce themselves, every time they speak, by adding “addict” or “alcoholic” to their name?

 *  What if I don’t feel like saying prayers or saying the word God?

 *  Why are most meetings so careful to discourage or curtail “crosstalk” and whyis this important?

 *  What is the role of, and what are appropriate expectations from, a sponsor?

 *  Do I have to say I believe in God to be a part of a 12-Step fellowship? How do Ideal with feeling excluded if I’m a non-believer?

 *  If I am called upon to speak by the person leading a meeting and I do not want to talk, how do I say no?

*  When the (7th tradition) basket is passed for donations, how do I avoid feelingshame if I do not have enough money to contribute?


6.  People who work with a substantial number of clients they wish to refer to 12-Step fellowships should themselves gain familiarity by attending an array of meetings and having the best possible working knowledge of the steps.

7.  For clients adamantly resistant to 12-Step fellowships, seek out other community mutual aid groups but investigate the quality of meetings before making a referral. Some of these “secular” support groups are not peer-led and organized by traditions that curb zealotry; some of their self-selected leaders are incompetent or inappropriate.

Michael G


My comment

There are a lot of good practical tips for clients and team members in what Michael G listed. Worth passing onto others.



Reader #9

Dr. Mee-Lee,

Your tips on offering some AA/NA etiquette programming are excellent.  We do a lot of that in our program, and it does help. Thanks.

Offhand, the only additional tips I would offer regarding how to prepare COD clients for AA or NA:

1. I would encourage them to focus on the truly basic reason we go, to “share experience, strength and hope.”  Anything at all that departs from that central focus could be seen as a product of our merely human natures.  We should practice tolerating and forgiving.

This relieves us of the worry brought about by having to memorize a list of responses to various eventualities.  And it’s good practice for a sober life.

2. I encourage my very mentally ill clients to do exactly as you advised – just go. Desensitization can set in, in a positive fashion, as some of the good stuff rubs off.  But, I have had schizophrenic clients’ misguided attempts to work the 4th and 5th steps, build themselves up to such a state of over scrupulous introspection, that they developed unnecessary delusions and hallucinations e.g., visualizing archangels in the sky, brandishing golden tablets and swords and whatnot.  I told one guy to just stop working the steps, just “don’t drink, go to meetings, and fellowship.”

3. All my clients I advise – be yourself.  Just be yourself sober.  Don’t worry.  Be honest, change just enough today to stay sober today, and take it easy.

My client Kevin, IQ 72, said, “I don’t understand the steps.  I don’t know what you are talking about when you talk about the steps.  But I know that when I drink, I get drunk, drive a car, and go to jail.  So I’ll come here instead.”  And all the guys with college degrees shut up and listened to Kevin.

Anyway, thanks, and nice work.

Anonymous Mike W


My comment

More good practical tips for clients and team members in what Anonymous Mike W wrote, especially in serving people with severe mental illness.


I consider myself a well-traveled, somewhat road-warrior type used to all kinds of travel situations.  But…. earlier this month when I stayed at the Anaheim Marriott Hotel in California, I was blown away by the elevators.  I had never seen anything like it before.


How often, in a large high-rise, multi-floor hotel, have you stood at the base of a bank of elevators after pushing the “UP” button, only to see all the elevators ascending to other floors and nothing coming down to pick you up any time soon?  Or there are six choices of elevators, and you wonder which one will reach you first as you track their progress through each floor (of course when you want it in the Lobby level, it is on the 20th floor).  A bell rings signaling an elevator car door has opened.  You look around trying to find which one it is, only to see the doors shut.  You’ve missed that one and now the process starts all over again.


This does not happen at the Anaheim Marriott (no royalties were paid for product placement in this SOUL section).  Here’s what intrigued and delighted me:

  • You go to the elevator lobby with six labeled elevator cars (A, B, C, D, E & F) just as in a regular old-fashioned elevator setup.
  • Previously you would press an UP or DOWN button and patiently wait for a door to open.  NOW here’s what you do…. you punch your desired floor number into a keypad (where the old UP and DOWN buttons used to be) e.g., “10”.
  • Immediately in the mini screen of the keypad device a letter (A – F) appears with an arrow pointing you left or right, in the direction of where the elevator doors will open. The notification is instant and the arrival is surprisingly soon after.

If I didn’t explain that very well, through the wonders of the internet, I found this link that explains more (if you are really into this): Thinking outside the elevator box   

Every time I used the elevator that conference week, I remained equally impressed with the efficiency and effectiveness of these new “magic” elevators.  Want the 10th floor? Just punch in “10” and very quickly the elevator was whisking me to the 10th floor.  No floor number buttons to further search and press inside the elevator.  No missed elevator cars because the mini screen told me which of the A – F doors to wait for and where.


This may be way too much information about a silly little elevator story.   Perhaps this is something you probably have to touch and experience for yourself to get the full impact.  But for an old road warrior, who thought he had seen just about everything USA hotels had to offer, this was a truly novel experience.


Next time you visit a high-rise, big city hotel notice how inefficient the elevator experience is – unless, that is, you are at the Anaheim Marriott Hotel, California or the Sheraton in downtown New Orleans. (Now I’ll hear from scores of readers who’ve seen these elevators for years and I’ll know how naïve I really am.)

Best Practices; Alterations; Jim Gaffigan

Vol. #14, No.4

Welcome to all the new subscribers to Tips and Topics and to our long-time readers too. Glad you can be with us for the July edition.

David Mee-Lee M.D.


Jennifer Harrison, PhD., LMSW., CAADC is a social worker and chemical addictions counselor.  She is on the faculty at the School of Social Work, Western Michigan University in Kalamazoo and is a member of the Michigan Fidelity Assessment and Support Team (MiFAST).  Her clinical practice is in behavioral and physical medicine.  In 2010, Jennifer helped me pull together some of my best Tips and Topics over the years all in one place in a book: “Tips and Topics: Opening the Toolbox for Transforming Services and Systems“. You can see more on the Tips & Topics book at:


Recently Jennifer sent me “some materials that I think are a starting point for a future Tips and Topics edition, highlighting some research on best practice implementation, sustainability, and alteration. Please take this as only ideas, and of course feel free to edit as you choose.” So I am sharing with you her selection of research.


In 2007, I wrote about evidence-based practices (EBP) and how the research finds that the therapeutic alliance predicts treatment outcomes even more potently than the EBP used.


It got some readers thinking and I included their comments and my responses in the October 2007 edition of Tips and Topics.


Here’s what Jennifer Harrison wrote and referenced:


In behavioral health, it’s important to hear the clinical wisdom that exists in the field, and develop research questions based upon those insights. This leads to:

  • Research
  • Translation of what we know works in research settings into
  • What can actually be used in clinical practice. (1)

Best practices for people with co-occurring mental illness and substance use, or co-occurring disorders, are important in part:

  • Because co-occurring disorders are so prevalent. For example, people with schizophrenia or bipolar disorder have an over 50% risk of also having a substance use disorder, as compared to only 16% of the general population (2)
  • Because when people have co-occurring disorders, the outcomes in many areas, including hospitalization, arrest and incarceration, homelessness, unemployment, and even HIV infection, are much worse compared to people with either a mental illness or substance use disorder alone. (3,4)

Integrated Dual Disorder Treatment (IDDT) is one evidence-based practice for individuals with severe co-occurring disorders with a toolkit developed by SAMHSA, the Substance Abuse and Mental Health Services Administration. IDDT uses a full multi-disciplinary team of professionals (doctors, nurses, case managers, addiction, housing, and employment specialists). Services are offered based upon key modalities:

  • Addressing stage of readiness of the client
  • Employing motivational interviewing
  • Family education and
  • Active outreach. (5, 6)

How we implement, sustain, and alter IDDT and other best practices for people with co-occurring disorders can have a big impact on their recovery and wellness.




Think about implementation of best practices. Are you committed to implementing this practice to the gold standard of care?


In one study of IDDT implementation across an entire state, IDDT was implemented at high fidelity by over 50% of teams by a third review, so could achieve that gold standard with work. But there was also significant variation in individual areas of the best practice, with some teams doing better on having a full multidisciplinary team and time-unlimited services, but struggling with family services and self-help liaising. (7)




Think about sustainability of best practices. How can you sustain this practice over time, and not let the practice erode to something very different from when it started?


In a study about IDDT sustainability over 7 years of implementation across a state, IDDT fidelity improved over time. We got better the longer we practiced, and generally did not lose steam with sustainability. Interestingly, those IDDT teams that adopted IDDT later had higher baseline fidelity scores. This brings up the issue of organizational or statewide system of care support for implementation and sustainability of best practices. (8)  


Dr. Jennifer Harrison continues:


Often, best practices can feel like they are created in an ivory tower of academia, and as such not well related to the real demands of practice. In the real world we cannot, as in a research methodology, neatly exclude people from treatment to manage our variables in practice. Or there may be additional priorities beyond what the best practice specifies. As a result, when best practices are translated into real practices, they are often changed or altered to meet local or clinical needs.



When you are changing a best practice to meet your local needs, be intentional about those changes, and measure the outcomes.


Altering best practices is often necessary, but should be done intentionally. Your organization or team should make the decision “even though the best practice says this is the way we should implement; we are deciding to add/subtract/change this component for this reason.” And then, you have the opportunity to create practice-based research, to study the effects of your alteration, and perhaps improve the best practice over time.


Here is an example of altering a best practice:

IDDT was not explicitly designed with the inclusion of peers, but like many evidence-based practices, the practice has been altered in its implementation in some areas to include peers. In the state of Michigan, IDDT was systematically altered since 2007 to add peer specialists, people with lived experience with mental illness and/or substance use disorders.


The result of this alteration?

In a study of the relationship between teams having peers and IDDT fidelity, teams with peers had higher fidelity than teams without peers, and there was a significant difference between teams with part-time peers and full-time peers on their teams. Only teams with full-time peers had mean fidelity at the high fidelity range. This is also clinically significant, remembering that high fidelity is associated with improvements in clinical outcomes. (9)




1. Fixsen, D.L., Naoom, S.F., Blasé, K.A., Friedman, R.M., & Wallace, F. (2005). Implementation Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication #231).


2. Hunt, G.E., Siegfried, N., Morley, K., Sitharthan, T., & Cleary, M. (2013). Psychosocial

interventions for people with both severe mental illness and substance misuse. Cochrane Database of Systematic Reviews, 10, 1-258.


3.  Lai, H.M., Sitharthan, T., & Huang, Q.R. (2012). Exploration of the comorbidity of alcohol use disorders and mental health disorders among inpatients presenting to all hospitals in New South Wales, Australia. Substance Abuse, 33(2), 138-45.


4. Drake, R.E., O’Neal, E.L., & Wallach, M.A. (2008). A systematic review of psychosocial research on psychosocial interventions for people with co-occurring mental and substance use disorders. Journal of Substance Abuse Treatment, 34, 123- 138.


5. McHugo, G. J., Drake, R. E., Whitley, R., Bond, G. R., Campbell, K., Rapp, C. A., & Finnerty, M. T. (2007). Fidelity outcomes in the national implementing evidence-based practices project. Psychiatric Services, 58(10), 1279-1284.


6 .Substance Abuse and Mental Health Services Administration (2010). Integrated treatment for co-occurring disorders evidence-based practice (EBT) kit. Rockville, MD: Author.


7. Harrison, J., Curtis, A., Cousins, L., & Spybrook, J. (2016). Integrated Dual Disorder Treatment implementation in a large state sample. Community Mental Health Journal. In Press. DOI: 10.1007/s10597-016-0019-1.


8. Harrison, J., Spybrook, J, Curtis, A., and Cousins, L. (2016). Integrated Dual Disorder Treatment: Fidelity and implementation over time. Social Work Research. In Press.


9. Harrison, J. (2015). “I’ve been there too”: Peers in co-occurring services and relationship with fidelity. Proceedings from the International Symposium on Evidence in Global Mental Health, held January 7-9, Kerala, India, 170-177.


m excited. I’m going to a comedy show August 5 and I thought I had missed out on tickets. However the email advertisement popped into my Inbox the other day. I thought I would just check if any seats had opened up since last I saw that the show was sold-out. There they were. Two seats together, front row, section 6. Marcia and I were in!!


If you don’t know Jim Gaffigan, it’s time for a laugh (if you share my kind of humor). Actually, I’ve run into a bump before when I’ve been all enthusiastic about a comedian and showed the video to friends, only to see stone faces and not a peep of a chuckle. So here’s a link to Jim Gaffigan’s piece on visiting McDonald’s. I enjoy it every time and maybe you will too.


I’ve been to my fair share of comedy shows over the years. My favorites are the ones who can make you think while they make you laugh. There’s a real art to changing attitudes and opening minds and hearts by sneaking in through the back door of humor.  For me, Jim Gaffigan does that.  So does Jerry Seinfeld and I’m sure you have your favorites too.


Some comedians get laughs (not from me) by being loud, crude, bombastic, insulting and egotistical – and no, I’m not talking about Donald Trump….although I don’t like politicians either who act like that.


In behavioral health training, Scott D Miller, Ph.D. is my favorite “edutainer” (educator and entertainer). Scott will educate you about Feedback Informed Treatment and change your whole attitude about how to track outcomes and the balance between the therapeutic alliance and EBPs. But you’ll be entertained in the process as he dismantles some of your fixed ideas and attitudes.

I’ve even received some complimentary evaluations in my 20 years of full-time training that my sense of humor makes the training day go down a little easier. But I better be careful, because I don’t like egotistical trainers either, although I am proud of my humility.


Anyway, enjoy Jim Gaffigan. I know we will next week at his show. 

Lifestyle, Sick-care; MI training; Acceptance

Vol. #14, No.5

Welcome to the August edition of Tips and Topics. This edition is coming quite a bit earlier than usual as I have some exciting news on Motivational Interviewing training to share with you.

David Mee-Lee M.D.


It’s nearly 40 years since I graduated from my psychiatry specialty training in Boston and then entered private practice. Hard to believe. I am a physician, psychiatrist and addiction treatment specialist. Over the years, I have been focused on illness, disease, pathology and sick-care. There is still much to do to improve health care for all. However over the past few years, I have added a focus to my attention: the need to move from a sick-care and health-care system to one of health, wellness and well-being.


That’s why a few years ago, I became a co-founder of the Institute for Wellness Education (IWE) whose mission is “to help drive cultural transformation so that health and wellness become the norm for individuals, communities, and the nation.”



People’s difficulty changing lifestyle and behavior increases costs and fuels a sick-care system.

  • Chronic disease treatment accounts for over 75% of national healthcare expenditures.
  • Half of adults do not receive recommended preventive care and screening tests (guidelines for age and sex).
  • On average, 50% of people with chronic diseases do not comply with their treatment plan.
  • Productivity losses (personal & family health problems) cost U.S. employers, on average, $225.8 billion/year.
  • Individual lifestyle determines 50% of health status and 60-75% of health costs.

Living a life of health and wellness doesn’t just feel good; it does good for everyone associated with you at home, work and play. We all know the old saying of “an ounce of prevention is worth a pound of cure.” As much as we know this, millions still struggle to change habits and embrace lifestyle change. It is going to take a cultural transformation, not just a few new nutritional, exercise and stop-smoking programs.



Change is hard as evidenced by these estimated statistics.

  • 33% of patients don’t fill prescriptions given to them by their doctors

(Tamblyn R, Eguale T, Huang A, Winslade N, Doran P. The Incidence and Determinants of Primary Nonadherence With Prescribed Medication in Primary Care: A Cohort Study. Ann Intern Med. 2014;160:441-450. doi:10.7326/M13-1705.)

  • 50% of people drop out of therapy after the initial session

(Premature discontinuation in adult psychotherapy: A meta-analysis. Swift, Joshua K.; Greenberg, Roger P. Journal of Consulting and Clinical Psychology, Vol 80(4), Aug 2012, 547-559.)

  • 92% of people set New Year’s resolutions and don’t keep them

(University of Scranton. Journal of Clinical Psychology, December 27, 2015.)

  • 50% of dieters lose weight only to gain back what they’ve lost, plus more

(Wing RR, Phelan S. Long-term weight loss maintenance. Am J Clin Nutr. 2005 Jul;82(1 Suppl):222S-225S.)

  • 50-75% of people with diabetes don’t adhere to their prescribed regimen of care

(García-Pérez L-E, Álvarez M, Dilla T, Gil-Guillén V, Orozco-Beltrán D. Adherence to Therapies in Patients with Type 2 Diabetes. Diabetes Therapy. 2013;4(2):175-194.

Peyrot M, Barnett AH, Meneghini LF, Schumm-Draeger PM. Insulin adherence behaviours and barriers in the multinational Global Attitudes of Patients and Physicians in Insulin Therapy study. Diabet Med. 2012 May;29(5):682-9.)

  • 50-90% of people relapse after a period of recovery following treatment for a substance use disorder

(Moos RH, Moos BS. Rates and predictors of relapse after natural and treated remission from alcohol use disorders. Addiction (Abingdon, England). 2006;101(2):212-222.)


Change doesn’t have to be out of reach for anyone. Where’s the problem? It is that most people who want to change don’t know how. Or, initially they aren’t even considering making changes, but may be forced into it by external factors.


One of the most common barriers to change is ambivalence. It’s “yes, but” thinking:

  • “I’d like to get exercise, but I get home from work late and then have to take care of my kids.”
  • “I’d like to cut back on my drinking, but it’s what I do when I hang out with my friends.”
  • “My doctor told me I have to lose weight, but they don’t understand that everyone in my family is big-boned.”

Motivational Interviewing is an evidence-based approach helping people get beyond “yes, but.” It helps people change behavior…for good…on their own terms and in their own way, the only way change will really “fit” and “stick.”


In my 14 years of writing Tips and Topics, I have often shared solutions to improve knowledge (SAVVY) and SKILLS. This month I am excited about new learning opportunities, which will improve your knowledge and skills in Motivational Interviewing (MI). I know many of you have had trainings on MI and you may think you have it down.


Too often it all makes sense in the workshop, but…… translating that workshop knowledge into real practice change in your counseling or therapy sessions can be a whole new ballgame.



Take a look at a brand new learning opportunity on Motivational Interviewing from IWE.


At IWE, we’re putting convenient, evidence-based online training into the hands of people across the nation. Our courses give people (whether professionals in healthcare or other industries, or everyday people trying to do better at home, work, or in the community) the science-based tools to make change happen that fits each individual and change that sticks.


Here’s my invitation: Consider boosting your staff’s skills and effectiveness by enrolling them in a new motivational interviewing course the IWE team and I have created. Perhaps you know someone interested in helping people change?   

  • At home as a parent or family member
  • At school as a teacher, guidance counselor or principal
  • In the community as a concerned citizen or wellness coach
  • At work as a human resource person, team leader or co-worker

This MI course was designed to make sense to ALL, not simply healthcare professionals.


It offers the critical elements that make training in MI a success:

1. Convenient scheduling:

The online course can be accessed 24/7 from any computer, laptop, table, or phone; and students have up to 12 months to finish the course.


2. Effective learning format:

The course features a rich variety of learning activities: interactive practice, video demonstrations, concise and practical explanations, illustrations, and live teleconferences for skill building.


3. Rigorous training:

The course is designed to promote extensive deliberate practice because it’s the kind of practice that leads to real mastery.


4. Affordable:

Students get the benefit of a rigorous, interactive course with live feedback…. without having to take time off from work or travel for a workshop “blitz” often leaving students with lots of great ideas but not enough practice.


Surf the website link to learn more about the course. Be sure to scroll to the end of the web page to see some attractive special discount, sign-up deadlines you won’t want to miss. 

Click here for IWE’s MI Modules and Time-Sensitive info




Take a look at Train for Change, Inc.’s approach to skill retention and organizational change.


Train for Change (T4C), Inc., is a sister company of The Change Companies. T4C offers training solutions, which build on and go beyond skills training for individuals to promote real changes in organizations and leaders. More on this approach here: T4C’s Comprehensive Approach


At T4C, there are:

  • Onsite training and e-Learning modules.
  • Strategies that promote systems change – like Change Agent and Supervisor Training.
  • An array of training and implementation strategies for ASAM Criteria and Motivational Interviewing.

You can see more detail at:  T4C’s Array of Training Opportunities


Both T4C and IWE use knowledge from adult learning principles; organizational development; and systems and culture change to create effective and efficient learning opportunities.


Recently, I was delivering a Motivational Interviewing (MI) training. I was discussing people ambivalent about stopping smoking. Here’s what I said: I would always first recommend someone stop smoking. However, if in our continued conversation, it became clear the individual was ambivalent about ceasing, I’d say they should continue to smoke if they want.


A workshop participant challenged me with this question: “Isn’t that just being manipulative and using reverse psychology?” I acknowledged it can sound that way, however intent is everything. My approach with a client is from a place of acceptance of their autonomy to make decisions about his/her own life and health. And anyway, I am truly powerless over making him/her change.


“Acceptance” is such an easy word to throw around. In the current edition of Motivational Interviewing (pages 16- 19, 2013) however, Miller and Rollnick break “acceptance” down into four parts – easy to list, but not so easy to actually live/practice in our work with people:    

  • Absolute Worth – full respect for whom the person is as a unique individual.
  • Accurate Empathy – “ability to understand another’s frame of reference…and that it is worthwhile to do so.”
  • Autonomy Support – “honoring and respecting each person’s…right and capacity for self-direction.”
  • Affirmation – “to seek and acknowledge the person’s strengths and efforts.”

Acceptance is part of the true spirit of MI. There is a new e-Learning module from Train for Change out to guide you in understanding all about the Spirit of MI.  Here’s the link: The Spirit of MI training  It’s the middle course in the top row of learning opportunities.


A few years ago at a workshop, another participant shared phrasing his supervisor had taught him, and which I said I would “steal” and teach myself:

“How is what I am doing with this client at this time, helping them to help themselves?”

In other words: our work with people is not about our brilliant insights and confrontations of clients’ knowledge deficits and thinking errors. It is not about teaching them what is wrong with them; and then having them do what we think they should do and be.


What is it about? It’s about partnering with them in a self-change process within an atmosphere of acceptance, compassion and discovery. That takes a lot of SOUL.



Miller, William R; Rollnick, Stephen (2013): “Motivational Interviewing – Helping People Change” Third Edition, New York, NY. Guilford Press.

Borneo, Malaysia; Nature nuggets; Addiction in SE Asia; Travel tips; Culture

Vol. #14, No. 6

Welcome to the September edition of Tips and Topics… or what I did on my summer vacation.

David Mee-Lee M.D.


Last week, I returned from my first trip to Borneo and Malaysia. I was fortunate to be invited to participate in a keynote, workshop and panel discussion at the 4th Asia Pacific Behavioural and Addiction Medicine Conference (APBAM 2016) at the University of Malaysia Sabah in Kota Kinabalu. 

If you are like me, Kota Kinabalu is not a travel destination at the top of one’s bucket list.

Yet it was the starting point for a fun and meaningful work/vacation experience I’ll share with you this month.  And unless you are a student of international affairs, your first thought about Malaysia might be the fateful 2014 flight of Malaysia Airlines Flight 370 which mysteriously disappeared from radar and still has not been located.

As you might expect, there is much more to Malaysia than missing planes and the “Wild Man of Borneo.”


A brief primer on Borneo and Malaysia

  • Borneo is the world’s third largest island and is home to three countries: Malaysian Borneo, Brunei, and Indonesia.
  • Malaysia is located in Southeast Asia and is made up of 13 states and 3 federal territories. It is a country with two regions separated by the South China Sea: Peninsular Malaysia (West Malaysia) and Malaysian Borneo (East Malaysia).
  • Peninsular Malaysia shares a land and maritime border with Thailand and maritime borders with Singapore, Vietnam and Indonesia.
  • Malaysian Borneo is made up of two states: Sarawak and Sabah.
  • The capital of Sabah is Kota Kinabalu, the international gateway to Sabah.
  • Sabah and its main city, Sandakan, is where you can experience some of the richest wildlife areas found anywhere in Southeast Asia. 

Sandakan is where the wildlife, tourist part of my trip began.  It was hot and muggy, being just 6 degrees north of the Equator.


Nature nuggets from the Wild Animal Borneo tour

Here a few highlight anecdotes that stood out for me:


To watch the young babies and others up to age 4 or 5 years swing from rope to rope in the “nursery” of the Sepilok Orangutan Rehabilitation Centre was fascinating.  As they feel more adventurous there is nothing stopping them from venturing over to where the grown-ups hang out.


Lunch time for the big guy 



A family affair

  • We had an unusual and spontaneous treat. A 5 year old orangutan curiously explored contact with tourists and come out to the Sepilok entrance to take a look at all of us who were looking at him! Then he scurried up a tree right near the entrance.  We witnessed something that can’t be planned.

Our curious young guy came to watch us watch him

  • The Centre’s keepers teach the young ones many of the skills they need to survive in the jungle on their own. But what we saw was something keepers can’t teach; he must have learned from watching an adult.
  • Once he reached a comfortable height in the tree, he bent a branch into a semicircle arc. Then he started breaking off other branches, laying them in the leafy bent branches building himself a little temporary bed.
  • My guide said he would relax there for a few hours until it got cooler.  Then he would hunt for food.  Sure enough when we returned he was gone, having had a nice afternoon snooze.

Finished making his relaxation bed  and peered out to see what the tourists were doing 


Proboscis monkeys

“Proboscis” means long nose and you can only see this monkey in the wild, in Borneo. So of course I was curious: Why the long nose?   I was told that proboscis monkeys are like dogs; they don’t sweat, so have to dissipate heat through their long nose. I’m not sure that is correct, having checked in Google. I did see that idea mentioned, but mostly different explanations for the long nose. (Perhaps my guide’s explanation is an example of that joke which goes around in travel circles- that guides have a lot of information but only sometimes is it true!).


The daddy Proboscis monkey with his harem 

  • The long nose seems to be more of a sex symbol – males who have the longer nose are more attractive to females.

The male leader of the family with his big nose

  • Males have longer noses than females; and adult males have longer noses than young guys.

Mother proboscis monkey with her shorter nose and baby

  • In times of danger, blood rushes to the nose and alters the resonance of the monkey’s calls of danger, which makes the warning calls more effective and more attractive to female proboscis monkeys.
  • Proboscis monkeys can swim and are pretty good at it. So a long nose helps breathing when jumping in the river to escape predators like the Clouded Leopard.
  • On our jungle river rides searching for birds, monkeys and crocodiles in the evening, we saw scores of proboscis monkeys finding their ideal sleeping spot high up in the trees nearest to the river.  This gives them an escape route should a leopard climb the tree in hot pursuit. The proboscis monkeys just jump into the river and swim away.


Night jungle walks – I was ready for almost anything: dressed head to toe in clothing infused with odorless and invisible insect protection to keep out mosquitoes; wearing knee-high rubber boots and even higher cotton socks you tie tight around your leg to discourage leeches jumping on your ankles; and topped off with generous sprays of insect repellent.

  • The high rubber boots were a must in the muddy jungle floor of rain forests where it can rain at a minute’s notice. In fact we had to cut one walk short as our guides could hear the spray of rain increasingly and quickly moving in our direction.
  • As the sound of rain grew stronger, they said: “That’s it. We have to go.” We had to run ahead of the sound to make it back just before being totally drenched.
  • But when we weren’t slipping and sliding or dodging torrential downpours, we were seeing multicolored, beautiful birds sleeping on tree branches just a few inches from our eyes and camera.  Keep quiet -and they’ll continue sleeping while you watch.
  • Four-legged animals are easier to spot at night. Just swing a flashlight around and look for glistening eyes.


Turtle Islands Park

A 45 minute speedboat ride from Sandakan whisked us to one of three turtle islands, Selingan Turtle Island. There, mother green turtles come ashore at night to lay their eggs and we tourists observe them up close and personal.

  • Upon arrival on the island, you see a field of little green circle mini-fences protecting each mother turtle’s 80-90 eggs which have been replanted here. This gives the hatchlings a chance to survive predators.

Little green mesh towers protect the transplanted eggs from predators as they await to hatch

  • The reservation rangers are dedicated to protecting the turtles.  At night, they check the beach for the first arrival onshore.  This can be anything from 9 PM to midnight or later depending on how bright the moon is, and how high the tide is.
  • We all waited with anticipation for the first call of “Turtle time!” We then rushed to see the first mother lying in a big sandy pit she had dug out; she was ready to start dropping ping pong ball- sized eggs in the deep hole she had prepared.

Ping pong size eggs – 90 eggs about to be transplanted

  • Watching her lay her eggs is the first of three parts of the turtle island experience.
  • We were lucky- the conditions were ideal to come ashore- a dim moon and a high tide.  The female turtle came in early so we didn’t have to wait up until midnight.
  • The second part of the experience was to see the 90 eggs we just saw laid transplanted into a new deep, man-made sand “nest”

Soon these eggs will be inside a green mesh hole ready to hatch


The hatchlings

In the afternoon when it cools, you keep your eyes on the inside of those little green mesh towers. A stirring in the sand suddenly reveals a little baby turtle.  More and more appear; the rangers collect these in a basket to prepare for the third phase of our turtle adventure.    


Newly hatched baby turtles about to experience the big sea 

  • As we all scurry to the water’s edge, the ranger passes around the basket


of newly hatched baby turtles. We marvel as he gently tips the basket to release them to the sea.

  • You’ve probably seen video of  of hatchlings race as fast as they can to splash for the first time into the water.
  • Sadly, only about I in 1,000 will survive to adulthood.


A disappointment

Despite several river excursions, scouring the riverbanks to see crocodiles, I glimpsed -for just a few seconds -the head of one as he slipped below the surface. (Or was it a she?) All those floating logs though gave plenty of fodder for my imagination: “I think that was a crocodile I just saw.”

I did see relatively fresh tracks of where elephants had crossed the river, but no actual elephants on the move. Oh well, back to the zoo.



Addiction and mental health in Southeast Asian countries


The working part of my trip to Borneo centered on Kota Kinabalu or KK as it is popularly known. (Much easier to say). It is the state capital of Sabah and home to the University of Malaysia Sabah.  Attitudes about addiction as a treatable disease have years (and maybe a decade) to go before there is the will to expand treatment. Drug use and certainly trafficking are crimes taken very seriously.  Here are just a few bullet points about complex problems in Southeast Asia.

  • Several tourist brochures carried this Advisory in a bold red text box:
    “In Malaysia, the Possession and Trafficking of Illegal Drugs carry the Death Penalty.”
  • Psychiatric patients, I was told, suffer almost equal discrimination and in treatment settings are called “inmates” and are “released” from hospital – not “patients” to be “discharged” or “transferred”.
  • Addiction “patients” do two years or longer in residential treatment – first offense, six months; second 6 – 24 months; third offense – years and maybe the key is thrown away.
  • We in the USA may think we face a workforce problem, but these Southeast Asian countries have very few counselors or “allied health professionals” as they call them. The need is great, but helpers are few.
  • We still struggle here with parity for addiction and mental health treatment, but addiction treatment is hardly on the healthcare menu screen of services in many places.
  • I met many dedicated local and ex-pat professionals from the USA, UK, and Australia doing their best to influence attitudes, raise consciousness, educate about addiction and mental health and develop staff and services.
  • My admiration goes to them acting as “missionaries” in the best sense of the word, not literally in the jungles, but certainly in the jungles of sparse healthcare resources and negative and cultural attitudes about addiction and mental health.


Perhaps you are happy to enjoy a “staycation” at home – no planes to catch (or pay for); no rental cars, hotel rooms or expensive restaurants to drain your bank account; no worries about who will look after your pets, plants and valuables. You’re at home taking it easy.

However if you are like me and find traveling to foreign countries fascinating and fun, then here are a few tips on foreign travel.


Travel tips for an overseas vacation

Foreign currency

You’ll need cash immediately you exit Immigration and Customs formalities – for taxi, train fare or a quick snack.  You can probably use a credit card for many things, however, if at all possible, I avoid using credit cards in foreign countries.  It’s bad enough -at home- to discover your credit card information has been hacked, and has been charged a flow of expenses you don’t recognize at all.  I feel even more vulnerable in a foreign country. You do not want to be waiting for a new credit card to be sent to you from all that distance.

  • Find a bank or investment institution that allows you to draw out cash in local currency from most bank ATMs , ones using the current currency exchange rates with no commission or bank ATM fees. I have successfully used a Schwab High Yield Investor Checking Account. (This is not a paid endorsement; there probably are other competitors I haven’t researched.)
  • Figure out ahead of time the money conversion math so you are prepared to do quick arithmetic and roughly know what something costs.  I had it easy in Borneo;  a quick division by 4 converted 100 Malaysian Ringgits into 25 US dollars equivalent. 1 Ringgit equaled about 25 US cents.
  • You can avoid the mental math method by simply using a currency conversion app on your smartphone. But that leads to my next tip:

SIM Cards

One of my first purchases is to switch out my iPhone SIM card for a local SIM card. This gives me gigabytes to check email on my phone, make phone calls and use apps or directions guides like Google Maps.

  • Use a reputable digital network company so your phone will likely work even in more remote areas of the country.
  • Having a local SIM card means you avoid the roaming feature of your home mobile phone network, which is much more expensive than a local SIM card and network.
  • Do you have the Skype app on your phone?  It is an inexpensive way to make international calls to family and work back home.
  • Better still for calling home, check if your hotel has free Wi-Fi service (most do these days); then call home using Skype on your laptop computer.  That makes communication (computer-to-computer) free, rather than incurring expensive roaming fees or long distance telephone charges. 


Google the local customs about tipping. Do the math and research what tip percentage is customary.

  • Don’t assume you should use the same percentage formulas you use in the USA. Many countries don’t even have tipping as a general custom; or expect tips only in certain situations.
  • If you obtain foreign currency from a local bank ATM, they will be in large denomination bills. Change that into smaller coins or notes to be prepared with tip money, if needed.
  • Keep some tip money loose in your pocket or outer pocket of your handbag.  Avoid pulling out your wallet or purse displaying a wad of big denomination bills. Locals, especially unsavory characters looking to relieve you of your wallet, know what color notes are worth what amounts. At first you are oblivious just acquainting yourself with the coins and notes.  You may not initially realize the wad of green or blue notes represents quite a lot of money.

Electrical outlets

Before you leave home, check  the voltage and electrical outlet plug style used in your foreign destination country.

  • You can buy an adapter plug at airport shops before you leave or when you get there.  But I like to be prepared and buy ahead of time – and it’s less expensive on the internet.
  • Remember that whatever adapter plug you insert into the electrical outlet in the foreign country is not an electrical transformer that can convert your 110 volt hairdryer into the 220 or 240 volt system in the new country. All you’ll end up with is a fried hairdryer if it doesn’t say that your hairdryer works for a range of voltage systems from 110-240 volts.
  • If you are using a computer or other device that clearly indicates that it has a range from 110 to 240 volts, then you can safely just use the electrical outlet plug adaptor without concern of harming your laptop or another device.


From the USA to Southeast Asia – learning from our mistakes and experience

At the conference in KK, many of the countries represented are still quite early in developing addiction and mental health services.  Simply because we, in the USA, have been providing services for decades, doesn’t necessarily mean that longer means better than another country earlier in the developmental process.  I do happen to believe many things we do in the USA are indeed better.  But they better be better, because we’ve had more resources and more years to learn from our mistakes and celebrate our successes.

An old Chinese proverb says something like: “The foolish man learns from his own mistakes. But the wise man learns from the mistakes of others.”

Recognizing the many needs for services, but still early in their process, they are eager to learn.  I shared a few recommendations to help them learn from our mistakes:

1. In many countries there is a tendency to think the gold standard of addiction treatment is residential treatment. I  recommended they put greater emphasis on developing a broad range of community-based outpatient and supportive living services, in addition to residential and inpatient levels of care.

  • The USA also still thinks of residential levels first. As States react to the opioid crisis in the USA, the cry goes out for more beds, when we really need more community outreach, recovery supports, living environments, intensive care management and assertive community treatment for addiction just as is available more for severe mental illness.
  • Still too often, residential treatment is considered primary care and outpatient services just aftercare or continuing maintenance care.  As these countries design services from the ground up, I recommended they consider all levels of care important but if anything, put more emphasis on building community supports and services than large residential facilities. 

2. In a punishment-oriented culture, there is already a focus on long lengths of stay in residential and controlled environments for those caught using and dealing drugs. While it is true that longer lengths of stay help achieve good outcomes, that length of stay doesn’t need to be all in the one level of care e.g., residential. 

  • Just as we have historically had long lengths of stay (LOS) in residential levels in the USA, these countries would do well to not repeat our mistakes.
  • I encouraged them to focus on a broad, flexible continuum of outpatient and residential levels of care and to move clients through that disease management according to progress and outcomes.
  • Unlike our USA history of treatment, I recommended they plan for no fixed lengths of stay in any one level of care; and manage people in a broad continuum of services with variable LOS.

3. The USA at the Federal agency level still seems to not embrace addiction as a diseasethat manifests for some as alcohol and for others with drugs such as methamphetamine, heroin, nicotine etc.; and for still others, as gambling disorder. There is still in the USA a distinction between alcohol and other drugs. Hence the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA) exist as separate entities as if people come with just a drug problem or just an alcohol problem.

  • I recommended they notice how they already are predisposed to keep alcohol and other drug problems separate. In China, for example, people with alcohol problems are treated under the Department of Health. But those with other drug problems are treated under the jurisdiction of the police and criminal justice.
  • Decreasing stigma and discrimination about addiction has been hard enough in the USA. However in Malaysia, Singapore, Vietnam and other Southeast Asia countries, reducing stigma and discrimination has even a greater uphill battle when drug use alone has such severe legal and incarceration “treatment” consequences.


You don’t have to travel overseas to understand different cultures.  But if you do have the opportunity to travel and see firsthand different people, customs, houses, joys and challenges, it sure comes alive.  Walking myself through some of the villages of Malaysia allowed me to really grasp what conference presenters face as they described their outreach projects to the villages.  What did I learn?  

  • In the villages, the main activity at the end of the day is a gathering of the families and friends to enjoy music on their guitars; and drink alcohol served from large jars on the ground circling the happy group.
  • Just about everyone in the village learns early on how to distill their own alcohol (e.g., home-made rice wine) so they are not dependent on spending huge sums of money, or having to travel to the local liquor store, which is not local anyway.
  • Alcohol is embedded in the social fabric of daily life. That can happen in our culture too, but when there aren’t a lot of options for activities in the village, music and alcohol rise to the top.
  • Conference presenters explained that teaching and expecting abstinence in the village is futile and naïve. They had to think what would be first steps that would work to start to change the culture and practices of everyone.
  • They started engaging the mothers and other women in an educational and change process. Women are the ones who traditionally draw from the large jars of alcohol and keep everyone’s cup full.
  • Once the women were engaged to make some changes, the first strategy was to move the jars away from the circle of music, laughter and drinking. The alcohol was then placed on a table away from the socializing, which meant, no more refills right where you sat. Want a refill? Sorry, you have to get up and go get it.
  • This small but significant change has started to shift the culture of drinking. 

One more anecdote on culture:

Singapore is up there for sophisticated, cosmopolitan and expensive living – nothing like the Malaysian villages. Singapore, however, is not advanced in their attitudes and treatment of their people with addiction. (How many strokes of the cane do you think you should get for your second flare-up of addiction?) There is still a very punitive and incarceration approach, thanks (I was told) to some expert psychologists from the USA. Some years ago they came, by request, to consult to government officials about what to do about addiction.  They declared that treatment for addiction doesn’t work; and this has been the “scientific” advice driving “treatment” ever since.

More enlightened addiction treatment specialists in Singapore recognized the importance of developing better community resources and mutual help groups for those trying to establish recovery in this cosmopolitan society. There are Alcoholics Anonymous and Narcotics Anonymous meetings.  But local people in recovery don’t relate well to meetings attended mostly by white ex-pats from the USA, Canada, Australia and the United Kingdom. What to do?

  • Harnessing the passion of the Chinese, Malay, Indian and other diverse ethnicities in the recovery community, they started mutual help groups much more inviting to local people.
  • Building on that growing community, more outpatient resources have blossomed to balance the government’s predominantly punitive and “lock them up” approach in Singapore and in the other Southeast Asian countries.

It was humbling to meet dedicated people running Non-Government Organizations (NGOs) and faith-based treatment programs who were countering the widespread negative attitudes about addiction and mental health.  Often on very limited resources and support, they respond courageously to the increasing need for services.

This is a time, in our current culture of fear, when some would respond by building walls, demonizing certain people and oversimplifying complex issues.  I am in awe of the people and the work they do in NGOs, humanitarian aid agencies and other outreach projects not only in Southeast Asia, but the Middle East, Africa and all around the world where it is not so safe and comfy as California or your neck of the woods.

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

Vol. #14, No. 7

David Mee-Lee M.D.


Upcoming Conference:

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

Hope to see you there.


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

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

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


Review how attitudes and terminology about addiction, perpetuates stigma

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

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

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

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

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

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

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

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

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

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

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

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

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



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

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

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

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

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

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

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



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

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

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

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

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

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



Consider these Addiction and Public Policy Issues

Public policy implications:

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

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

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

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

4. Eliminate waiting lists.

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

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

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


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


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

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

Dr. Mee-Lee,

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

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

Paul Kiernan, LADC Clinical Services Specialist

Division for Behavioral Health

Bureau of Drug and Alcohol Services

Clinical Services Unit

Concord, NH

Email address:


My response:

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

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

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

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

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

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

Paul’s Reaction to my Response

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

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

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

Thank you


ASAM Criteria Level 3.3 and Dealing with Behavior Problems

Another question from Paul

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

My response:

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

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

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

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

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

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

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

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

Paul’s Reaction to my Response

Dr. Mee-Lee,

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

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

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

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

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

Again I am so grateful for your correspondence.




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:


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

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

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

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

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

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

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

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

Until next time

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


The ACE Study; the 3 E’s, 3R’s plus 4th R; 5 components; Attraction, not promotion.

Vol. 14, No. 8

Welcome to the November edition of Tips and Topics. Thanks for joining us this month. 

David Mee-Lee M.D.


In August this year, I presented at the Detroit Wayne Mental Health Authority’s 2nd Annual lnterdisciplinary Conference, “Raising the Bar”. One of the side benefits of my work is to be able to listen to other conference speakers for free! It is always satisfying to hear a topic from the “horse’s mouth.”  This is what happened when I heard Robert Anda, M.D. present on the Adverse Childhood Experiences (ACE) Study.

Dr. Anda played the “principal role in the design of the ACE Study, served as its Co-Principal Investigator, and authored or co-authored more than 70 publications from the Study.” (  It was a treat to hear it from the person there from the start and who made it all happen. (When I train on The ASAM Criteria, I let people know that on that topic, I have been there from the start too.  As Chief Editor that work was commenced in the 1980’s.  When people hear an ASAM Criteria presentation from me, they too are hearing it from the “horse’s mouth”, preferably that part of the anatomy, not another part!) 

Dr. Anda shared a fascinating anecdote about how the term “Adverse Childhood Experiences” got its name.  He was with a colleague at McDonald’s (he must eat at the same gourmet restaurants as I do.) They were discussing what to call this study on trauma. “Trauma” seemed too easily confused with physical accidents because this study was all about emotional trauma and its profound impacts on development and health.

“Childhood” as part of the terminology was easy, he said.  This was all about what happened in one’s childhood.  “Adverse” was also fairly easy too, as traumatic experiences certainly caused many negative effects.  The “Experiences” part took a bit of brainstorming – “environments” popped up in their conversation back and forth. However, they thought, that term could be confusing, since it focuses attention on where a person lives. Was it about the family or significant others in the environment? or the cultural environment? or poverty? or inner city or suburban?  or what environment?

Then they happened on “Experiences” and liked it. Why?  This term focused the attention back on the person affected and not the external “environments”.  This allowed them to study and quantify on the ACE score how many childhood experiences the person had had, without having to make the person delve into the emotion and details and pain of the actual trauma.

So there it is: That’s how it became to be known as the Adverse Childhood Experiences (ACE) Study. 

Here are some interesting and meaningful nuggets I was furiously scribbling down listening to Dr. Anda speak.  They are in no particular order of importance.  


Ponder how important hope is in health and well-being

Dr. Anda opened his presentation referencing a 1993 paper he had written on “Depressed affect, hopelessness, and the risk of ischemic heart disease (IHD) in a cohort of U.S. adults.” He found that hopelessness significantly predicted who would die from a heart attack and even predicted the increased risk of nonfatal IHD. This was in a group of more than 2,800 initially healthy men and women from the National Health Examination Follow-Up Survey (NHEFS).

  • This study indicates that depressed affect and hopelessness may play a causal role in the occurrence of both fatal and nonfatal IHD.

As we counsel with clients who have had ACEs, Dr. Anda stressed that being trauma-informed in our work is to create a different path of hope, meaning and purpose for the people we serve. The message to clients, he said, should encompass:

  • It is not what is WRONG with you.
  • It is what HAPPENED to you.
  • Create a different story of your life by getting an accurate accounting of adverse childhood experiences through your ACE score.
  • You can shift from shame, confusion and hopelessness to hope, meaning and purpose.


What is an ACE Score?

“Dr. Anda created The ACE Score Calculator, allowing individuals to calculate their own ACE Scores, based on the original scoring criteria of the ACE Study.

To use this survey, add up all of the YES responses. The sum is the ACE Score. The ACE Score can range from “0”, meaning no exposure to the ten categories of child abuse and trauma investigated by the Study, to “10”, meaning exposure to all ten categories. The Study found the higher the ACE Score, the greater the risk of experiencing poor physical and mental health, and negative social consequences later in life.”

Finding Your ACE Score

While you were growing up, during your first 18 years of life:

1. Did a parent or other adult in the household often or very often…Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?

If yes enter 1 ________

2. Did a parent or other adult in the household often or very often…Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?

If yes enter 1 ________

3. Did an adult person at least 5 years older than you ever…Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?

If yes enter 1 ________

4. Did you often or very often feel that …No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?

If yes enter 1 ________

5. Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

If yes enter 1 ________

6. Were your parents ever separated or divorced?

If yes enter 1 ________

7. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit at least a few minutes or threatened with a gun or knife?

If yes enter 1 ________

8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?

If yes enter 1 ________

9. Was a household member depressed or mentally ill, or did a household member attempt suicide?

If yes enter 1 ________

10. Did a household member go to prison?

If yes enter 1 _______

Now add up your “Yes” answers: _______ This is your ACE Score.


Review how persistent stress changes brain architecture

Dr. Anda referenced the Harvard University Center on the Developing Child.

“Extensive research on the biology of stress now shows that healthy development can be derailed by excessive or prolonged activation of stress response systems in the body and brain.  Such toxic stress can have damaging effects on learning, behavior, and health across the lifespan……When we are threatened, our bodies prepare us to respond by increasing our heart rate, blood pressure, and stress hormones, such as cortisol. “

  • Stress of severe and chronic childhood trauma releases hormones (adrenaline and cortisol) that physically damage the developing brain.
  • These flight, fight or fright (freeze) hormones in the Limbic system work well if there is a vicious dog chasing you (flight); or if cornered, to help you fight; or stop breathing and freeze in fright if a predator is nearby and you are trying not to be detected.
  • The adrenaline and cortisol shuts off the thinking prefrontal cortex of the brain to focus on the immediate need to run, fight or freeze.
  • But if the stress is now a daily event (witnessing or experiencing violence, belittling or verbal abuse, sexual and boundary issues etc.) not a one-time, unusual event like facing a bear or vicious dog, then the emergency response system activates over and over again every day.
  • The stress hormones, when turned on for too long day after day become toxic. When a child is always ready to fight or flee the prefrontal cortex that is needed to form a sentence or do a math problem becomes stunted. Emergencies take precedence over doing math or writing an essay.
  • With this overstimulation of the limbic system, the brain begins to dissociate and disengage in the state of hyperarousal survival mode. This affects learning and adaptive coping functions.


Take a look at “Resilience- The Biology of Stress & The Science of Hope”

This film was an official selection of the Sundance Film Festival. “Resilience chronicles the promising beginnings of a national movement to prevent childhood trauma, treat toxic stress, and greatly improve the health of future generations.”

See the trailer for the film: 

Dr. Anda highlighted the importance of building resilience and hope in schools, prisons and the creation of self-healing communities.  He referenced work that is being done in Washington state.


1. Anda R, Williamson D, Jones D, Macera C, Eaker E, Glassman A, Marks J. (1993): “Depressed affect, hopelessness, and the risk of ischemic heart disease in a cohort of U.S. adults.” Epidemiology Jul;4(4):285-94. 

2. Center for Disease Control and Prevention. (2010): “Adverse Childhood Experiences Reported by Adults – Five States, 2009,” Morbidity and Mortality Weekly Report 2010 No. 59, pp 1609-1613.

3. Felitti & Anda (2010): “The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders, and sexual behavior: Implications for healthcare,” in R. Lanius and E. Vermetten, Eds., The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease. Cambridge University Press, 2010.

4. Porter L, Martin K, and Anda R (2016): “Self-Healing Communities- A Transformational Process Model for Improving Intergenerational Health” June 2016 Publisher: The Robert Wood Johnson Foundation.


In September, I presented at the Mental Health Recovery Summit 2016 Moses H. Cone Memorial Hospital, in Greensboro, North Carolina. Kelly Graves, Ph.D., Associate Professor, North Carolina A&T State University also presented on trauma and shared some succinct definitions and guidelines.


Understand the 3 E’s of trauma

Event – There is an Event or series of Events that trigger the emergency response system of the individual.

Experienced – Those Events or series of Events are Experienced by the person as harmful and threatening.

Effects – The Effects on the person are adverse on the individual’s functioning physically, emotionally, mentally, socially and spiritually. 


Facilitate Trauma-informed care and trauma-specific services – The 3 R’s + 4th R of trauma-informed cultures

Trauma-informed: “A trauma-informed approach to the delivery of behavioral health services includes an understanding of trauma and an awareness of the impact it can have across settings, services, and populations. It involves viewing trauma through an ecological and cultural lens and recognizing that context plays a significant role in how individuals perceive and process traumatic events, whether acute or chronic.

In May 2012, the Substance Abuse and Mental Health Services Administration (SAMHSA) convened a group of national experts who identified three key elements of a trauma-informed approach:

(1) Realize the prevalence of trauma and its widespread impact.

(2) Recognize the signs and symptoms of trauma and how trauma affects all individuals involved with the program, organization, or system, including its own workforce.

(3) Respond by putting this knowledge into practice and update policies, procedures, and practices in all settings. (SAMHSA, 2012, p 4).

(“Trauma-Informed Care in Behavioral Health Services” Treatment Improvement Protocol (TIP) Series 57. Page xix, 2014).

4th R: Resist Retraumatization e.g., heavy confrontation in a Therapeutic Community; male nurse coming into a female client’s room at night for routine bed checks triggers the trauma-affected client – inform clients with trauma histories about routine procedures; ensure female staff enters the room.


Promote 5 core components for healing in all services

Dr. Graves identified a common core of conditions across different lists of services that promote healing. She summarized this common core into five components:

1. Safety – the client must have a sense of safety in any counseling relationship. This can be a challenge for people who have been exposed to daily adverse experiences and are living in a state of hyperarousal.

2. Trust – when parents, relatives or other neighborhood acquaintances have repeatedly abused the client and violated boundaries, trust does not come easily.

3. Collaboration – creating hope and healing communities requires collaboration across systems and disciplines, but most importantly collaboration between the client and clinician.

4. Choice – clients should have real choice in the pacing and planning of treatment; and even in more mundane things like the date and time for the next appointment.

5. Empowerment – for too long, clients with significant ACEs have had to endure the memories, pain and limitations of past trauma by themselves. Empowerment upholds hope and healing. 


1. Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women” Treatment Improvement Protocol (TIP) Series 51. DHHS Publication No. (SMA) 09-4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.

2. Center for Substance Abuse Treatment. “Trauma-Informed Care in Behavioral Health Services” Treatment Improvement Protocol (TIP) Series 57. DHHS Publication No. (SMA) 14-4816. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.


Although I am not a member of any 12 Step program, there is much wisdom in so many of the sayings and slogans. One in particular that is so meaningful in general as well as in the work of  motivational enhancement and stages of change is: “Attraction, not Promotion.”  

You cannot push, pressure, persuade, prescribe and pester someone into real and lasting change. Only as you inspire and attract people to think and act differently will you initiate a process of change.

I broke my long held rule and belief in “attraction, not promotion” in last month’s pre-election SOUL section. I spoke out about my political views on the election in hopes of persuading undecided voters and readers of Tips and Topics.  In my defense, I did warn readers that if they had already decided to vote for President-elect Trump, they should stop reading as I didn’t want to argue or alienate them. (But of course saying that is like telling a child not to shake or touch the Christmas presents under the tree until Christmas Day.) 

*  One reader wrote me: “I think you should not have voiced your political opinion here, in your monthly newsletter“and in retrospect I think I agree. It distracted from my mission and purpose of Tips and Topics.

*  Another reader said: “I have been a faithful reader of your tips and topics. I don’t appreciate your views on politics and now It makes me question your abilities.

That got my attention. Were my views on politics actually a reflection on my abilities as a trainer/consultant?  It made me think about the role and responsibilities in leadership and public discourse.

I responded to those who wrote to me, however I won’t share my responses as I deleted the emails! (That’s a joke – OK enough of election rhetoric).

Here is something I did say in my response and say again now:

The bottom line for me as regards writing this in Tips and Topics is that I am sure everyone who bothers to read Tips and Topics are all people of good will who want the best for the people we serve in our work; and the best for our country.  While we may differ on a number of things, there is much more that binds us together in the values and vision we have for America. I am sad that this election seems only to have drawn us further apart both within the Republican party and across parties.  I hope that once the election is over that everyone will rally to bring us together for the greater good of the country.” 

Incidentally, the “faithful reader of Tips and Topics” who questioned my abilities ended her response to my message to her with: “So I thank you for allowing me to share my thoughts and have a good discussion.  I look forward to your tips and topics in the future.”

I may have done too much political “promotion” for the preferences of some readers, but I’m glad we can move on together.

Happy Thanksgiving everyone!

Dr. Vince Felitti and the roots of the ACE Study; Expressive writing; Interactive Journaling; Pen, pencil and paper planners

Vol. #14, No. 9

Welcome to the December edition of Tips and Topics. I wish you all a great Holiday Season.

David Mee-Lee M.D.


Last month, when I wrote about the work of Dr. Robert Anda and his pioneering work on the Adverse Childhood Experiences (ACE) Study, Steve Allen, PhD, a licensed clinical psychologist and an instructor in the certificate program in Alcohol and Drug Abuse Studies at University of California Berkeley Extension wrote to me. November 2016 edition  

 Dr. Allen, who was the founder and Program Director of the Kaiser Permanente Chemical Dependency Recovery Program at Vallejo, California for 20 years, and served for ten years as Kaiser’s Northern California Chair of Chiefs of Chemical Dependency Services, pointed out that I had neglected to acknowledge Dr. Vince Felitti who was really the inspiration for the early work that birthed the ACE Study.

 So, better late than never, I asked Steve to give me his up close and personal perspective on the roots of the ACE Study; and tell of his own experience with Dr. Felitti and the ACE studies at Kaiser. By so doing we can give Dr. Felitti his due recognition, respect and thanks for all he did to educate us about ACEs.


Hear about the firsthand, front seat on the roots of the ACEs Study

 “When I read David’s Tips and Topics for November, I was happy to see that he was addressing the Adverse Childhood Experiences work. However, I was surprised that he said Dr. Robert Anda was “there at the start,” and that Dr. Vince Felitti and his Kaiser work was not even mentioned.

For those who may not be familiar with Kaiser Permanente, it is the largest prepaid, non-profit, healthcare delivery system in the United States, with the bulk of its services concentrated in California. Kaiser has always provided mental health and chemical dependency services alongside its other medical services. From 1989 until my retirement from Kaiser in 2010, I was privileged to be their Chemical Dependency Services Chair for Northern California. During that time, Dr.Felitti was a physician in Kaiser San Diego’s Department of Preventive Medicine.

Which makes me “there at the start,” too, though I was not aware of it for some time.

Early Discoveries

During the 1980s, in the San Diego Kaiser Weight Program, the physicians made the counter-intuitive observation that patients who were successfully losing weight were the most likely to drop out of treatment. Subsequent exploration with these patients revealed that the great majority of them had unrecognized problems dating back to childhood. Obesity with these people provided hidden benefits; it often was sexually, physically, or emotionally protective for them.

 This led to further exploration of Kaiser’s general medical patients, which revealed an unexpectedly high prevalence of adverse childhood experiences. It was at this point that Dr. Felitti invited Dr. Anda and his group at the Centers for Disease Control to design and analyze the series of large-scale studies which documented the prevalence and the astonishing health implications of these childhood experiences.

The Study Sample at Kaiser

The study sample was a group of 17,000 middle-class Kaiser patients, of mixed gender and ethnicity, who were asked the ACE questions as part of a comprehensive medical examination. In terms of prevalence, the study found that less than half of them had an ACE score of 0 (no adverse childhood experience); and one in 14 had a score of 4 or more! That meant there was a lot more trauma history in our patients than we had suspected. (See “Finding Your ACE Score” in last month’s Tips and Topics.) Your ACE Score


In terms of astonishing health implications, it was found that the compulsive use of nicotine, alcohol, and injected street drugs– as well as a host of other medical problems– increased proportionately in a strong, strikingly graded manner as ACE scores increased.   For example:        

Results for nicotine and injected drug dependence were quite similar, as well as those for chronic obstructive pulmonary disease (COPD), ischemic heart disease, asthma, depression, and other conditions– always a strong, graded increase in conditions as ACE scores increased.

Dr. Felitti’s Mission started at Kaiser

The original article on this study was published in 1998, but long before that, as soon as the results became clear, Dr. Felitti began visiting all of the Kaiser medical facilities to present his findings. This was how I had the opportunity to meet him and to be blown away by the information he was presenting.

He returned a couple of more times after that, with more information and a stronger case. He was on a mission to make all of us at Kaiser attentive to this important connection in the patients we were seeing. Most memorable to me was his presentation to all the Northern California Chemical Dependency staff on ACE and addictions, which convinced me to always use the ACE questions as part of our comprehensive assessments of addicted patients.

I’m including links to the original study

Original Study

and to the information he presented on addiction

Dr. Felitti’s presentation 

as well as a more recent paper confirming these findings with a much larger (54,000 people!) and a more representative sample. Recent larger study

Thank you, David, for the opportunity to give credit to this great man!”


A couple of weeks ago an article by Sammy Caiola, Health Reporter for my local Sacramento Bee (SacBee) newspaper caught my eye. The headline read: “Is the pen still mightier? The pros and cons of loose leaf vs. laptop”.  

Sammy’s SacBee article

Sammy talked about how “writing on paper has a long list of benefits that have largely been forgotten in the age of laptops, iPads and tablets…Journaling has been shown in multiple studies to improve aspects of mood and health, including reduced blood pressure and stress hormone levels, fewer physician visits, improved memory and better eye health.”


Use expressive writing and journaling in the treatment of trauma

Sammy interviewed Jan Haag, a professional creative writer and chair of the journalism department at Sacramento City College for the article. “Regardless of the medium, the most important thing is that people continue to write expressively in whatever way is comfortable…..That’s especially true for people who have experienced trauma, she said, which is why hospitals and therapy groups have long relied on journaling as a tool for coping with stress.”

“Talking about things is therapeutic and helpful, but writing about it and watching grief become art under your hands is a huge and inspiring feeling,” Haag said. “Translating that pain into art is one of the most important things. If nothing else, you’ve gotten it out of you and on the page so it’s not festering inside you. It’s the same thing with real joy.”

In the October 2010 edition of Tips & Topics, I excerpted a Wall Street Journal article by Gwendolyn Bounds: “How Handwriting Trains the Brain Forming Letters Is Key to Learning, Memory, Ideas”. (The Wall Street Journal. October 5, 2010.) She articulated how writing by hand is more than just communication. It engages the brain in learning and has a unique relationship with the brain in composing thoughts and ideas.

October 2010 edition


Use Interactive Journaling ® as an Evidence-Based Practice (EBP) to enhance person-centered change and trauma-informed care

“Interactive Journaling (IJ) as a clinical tool combines elements of bibliotherapy (the presentation of therapeutic material) with structured reflective writing” (Miller, 2014).  Interactive Journaling is on the Substance Abuse and Mental Health Services Administration’s National Registry of Evidence-based Programs and Practices (NREPP).   

In 2014, I wrote an article about Interactive Journaling ® (IJ) that explains how IJ finds the right balance of the structure of EBP with the central importance of the therapeutic alliance to enhance positive self-change.

Interactive Journaling article

In the May 2014 edition of Tips & Topics, Interactive Journaling ® was the focus and how to use IJ in Impaired Driving classes, addiction treatment and mental health settings, as well as with criminal justice populations.

May 2014 edition

For trauma related Journals, here are what The Change Companies has for your consideration:

*    “Trauma in Life – Women”: Trauma in Life Journal

*    “Traumatic Stress & Resilience – Men”: Traumatic Stress & Resilience – Men


*    “Perspective” (Claudia Black):


*    “VOICES” (Stephanie Covington):


*    The MEE Journal System  – the practice of Interactive Journaling® is supportive of trauma informed care in many aspects, including IJ’s reinforcement of personal empowerment and its ability to provide a safe vehicle for communication and self-expression.

MEE Journal System


Discover how Interactive Journaling is also effective in promoting wellness in all people, not just clinical populations

I asked Dr. Deborah Teplow, CEO and co-founder of the Institute for Wellness Education (IWE) to explain how IWE incorporates Interactive Journaling® into its level I coaching certification training, Take Charge of Your Life: Be Well to Do Well. The course is online and supplemented with live teleconferences.

Here’s is what Deborah had to say:

We use journaling in two ways:


We use My Personal Health Journal to enhance students’ ability to make positive, lasting change in their own wellness.

 My Personal Health Journal 

Journaling corresponds to four (physical, nutritional, financial, and emotional wellness) of the ten units on wellness in the online component of the course. For each of the four units, students complete all the activities in the journal on their own and then participate in online discussions with other students about their journaling experience.

Survey Question #1

In a recent survey, we asked students to rate the value of journaling in their own lives. The results were overwhelmingly positive. (See next page for survey results.)

In response to the following questions, “What would you tell people about what you got out of journaling, or the potential benefits they may get out of it,” students reported the following:

Results on Question #1

*    “I would tell them that it was a life changer and I feel better as a person now.”

*    “Journaling helps you put your thoughts into words, helps you think through the options you have/options you can create for yourself, and it makes it nice to see everything laid out in front of your eyes.”

*    “I would tell them that I learned that small steps can have a big impact. For example, every time I pass my locker, I take a deep breath. This helps me de-stress throughout the day.”

*    “I would tell them that awareness is everything in accomplishing their goals and this program definitely fosters awareness.”

*    “I learned that change doesn’t have to be difficult. It can be easy if you incorporate making changes into your daily life.”


The second way we use journaling is to train students to lead group journaling sessions. Students are trained through live skills practice and rehearsal (“real play”) during weekly teleconferences.

Our graduates lead “Journal Clubs” using My Personal Health Journal and several titles from the “Keep It Direct and Simple” series in a variety of settings, including houses of worship, high schools, and public-health agencies.

 Keep It Direct & Simple 

Survey Question #2

Please rate (1 = strongly disagree, 7 = strongly agree) the impact of journaling on your self-change process.

Results on Question #2

1.    “Helped me think about my overall wellness.”

2.    “Gave me valuable insights into the self-change process.”

3.    “Enabled me to set goals that are important to me.”

4.    “Gave me new strategies to help support behavior changes I wanted to make.”

5.    “Helped me appreciate how small steps can lead to big changes.”

6.    “Led me to make behavior changes that have “stuck.”

7.    “Overall, I found interactive journaling helpful.”

On average, participants endorsed a level of agreement that favored the “strongly agree” side of the scale.


Here is the latest information on IWE’s wellness coaching courses

Institute for Wellness Education – Wellness Coaching


Miller, W.R (2014). Interactive journaling as a clinical tool. Journal of Mental Health Counseling, 36,(1).


A lot of people use an electronic calendar for their appointments and work schedule. Not me. I have been buying the same AT-A-GLANCE ® Weekly Appointments planner for the last 30 years or more. There are real advantages to going digital and paperless, but I am just old-fashioned.


My trusty weekly planner

Here are a few reasons I like to write with my pen or pencil in my paper planner:

  • I like to use a pencil for tentative appointments rather than writing in pen. I can immediately see it is a tentative appointment waiting confirmation. (I know, I could type in a digital calendar in a different font or color to indicate a tentative appointment, but how is that any less work than just using my pencil?)
  • When I am on the phone planning an appointment, I can keep talking while I grab my planner and leaf though the pages of weeks looking for an open spot. No need to place my cell phone on speaker mode while opening the digital calendar, swiping through the weeks to find a date and time. Just see-at-a-glance while talking.
  • If I want to check back on what airport or airline I used for the same location six months ago or even last year; and which hotel I stayed at, all that is right on the page to see. I know I could copy and paste that information into the digital calendar too, but I think the time to do that is not much different; and I think, harder to retrieve quickly.

Pen, pencil, planner 

When it comes to “To Do” lists, no Wunderlist or digital reminder apps for me. I have a page in my pocket paper planner to write on my “To Do” list as tasks arise. Then from that general list I make my daily list of things to do specifically that day. It is such a satisfying feeling to take my pen and scratch out each task as it is done.

Inevitably, there are items on the list I didn’t get to and scratch off the list. This is a visual reminder that once again, I was overambitious and over scheduled myself – sort of like a journal page to initiate a change process to slow down and smell the roses.

This holiday season will you be putting pen or pencil to paper for all those personal holiday greeting cards? Or will you send out a general holiday newsletter by email to all your family and friends like we’ll be doing? Is that progress or have I just now succumbed to the impersonal, keyboarding digital age?

 Happy writing….