January 2017

Vol. 14, No. 10
In this issue


Enduring principles as healthcare changes
Customer & team values
Marchers’ messages

David Mee-Lee M.D.


(more…)

March is Problem Gambling Awareness Month; Guest writers; Scott Stevens

Vol. #14, No. 12

Welcome to the March edition of Tips and Topics.  March is Problem Gambling Awareness Month. March means it’s time to #HaveTheConvo during Problem Gambling Awareness Month (#PGAM)!  

NEW this month – There are now links to social media at the end of Tips & Topics (see at the end)

David Mee-Lee M.D.

SAVVY

March is Problem Gambling Awareness Month, a local and national campaign to heighten awareness to the issue of problem gambling with this year’s theme being “Have the Conversation.”

In the April 2016 edition of Tips and Topics, I wrote about Gambling Disorder – why consider it; getting real about screening and assessment, health coverage, staff credentials and competence, and filling treatment gaps. You can see more at: April 2016 Tips & Topics

In honor of Gambling Awareness Month, two guest writers are leading the conversation on gambling in Tips and Topics this month: Daniel J. Trolaro who is the Assistant Executive Director and George Mladenetz, Treatment Coordinator for the Council on Compulsive Gambling of NJ (CCGNJ).

George writes first about the impact of stigma with respect to Gambling Disorder and other addictive disorders.

TIP 1

What is stigma; and why it is important to know about stigma when working with gambling disordered individuals.

Stigma:

  • A mark or sign of a perceived deviation from the norm; entails shame and discreditation.
  • Stigma comes from within, from the public, even from the Recovery and Treatment communities.

Why it is important to know about stigma:

  • Most experts agree the biggest barrier to addiction treatment faced by individuals is stigma. This serves as a major barrier to problem acknowledgement, disclosure, treatment-seeking and recovery (Hing, N. Russell, A., Gainsbury, S., Nuske, E. Journal of Gambling Studies 2016; 32:847-864).
  • For 6-9 million Americans, gambling is a damaging behavior which can harm relationships, family life and careers (SAMHSA). Blog on Gambling Disorder
  • It is estimated only about 9% of individuals with gambling disorder ever make it to treatment. It is believed stigma has much to do with this.
  • Many individuals experiencing gambling disorder say the stigma they face is often worse than the disorder.
  • People with gambling problems feel ashamed and stupid and believe other people perceive them as stupid, selfish, people who hurt their families (Dr. Annie Carrol, Australian National University, Center for Gambling Research).
  • Research indicates problem gambling is not well understood by the community in the way substance use disorders are; this also contributes to stigma associated with having a gambling problem.

TIP 2

Be mindful of stigma and words. Here are some examples of stigma in Gambling and Substance Use Disorders.

Stigma and Words

  • Stigmatizing words often devalue, discourage, isolate, misinform, shame and embarrass.
  • Better language can advance people’s understanding of gambling disorder as a public health issue, a psychological disorder, which is treatable.
  • Words have power – “they have the power to teach, the power to wound, the power to shape the way people think, feel and act towards others.” (Otto Wahl)

  Examples of Gambling and Substance Use Disorder Stigma

  • Defining individuals by their disorder, e.g., gambling addict; degenerate gambler; gamblerholic; alky; junkie; pothead
  • Hurtful words and comments, e.g., “You are a degenerate gambler!”
  • Sensationalizing gambling addiction, e.g., National Enquirer stories about Ben Affleck, Michael Jordan, Pete Rose and Charles Barkley gambling excessively.

TIP 3

Combat stigma by changing our language to recovery terminology.

Combating Stigma – Watch our language!

  • The term “addict” is frequently used with individuals suffering from gambling disorder or other types of addiction.
  • It is not for counselors and others to define how individuals who have gambling disorder and/or substance use disorder or those in recovery choose to identify themselves.
  • For many people in early recovery, the term “addict” is a helpful way of identifying symptoms and issues and finding a way to connect in a healthy way to promote change.
  • However, the “addict” label suggests the whole person is the problem rather than the problem being the problem.

We can take a stand against stigma by changing the way we think, talk about and treat people with gambling addiction.

Language of Recovery

“The most respectful way of referring to people is as people.” (ATTC Southeast HHS Region 4, 2012)

Examples:

Current – Alex is a gambling addict.

Alternative – Alex is a person with gambling disorder.

Reasoning – Put the person first; avoid defining the person by his/her disease.

 

Current – Jennifer is in denial about her gambling disorder.

Alternative – Jennifer hasn’t internalized the seriousness of her gambling disorder.

Reasoning – Remove the blame and stigma from the statement.

 

Current – Mark has to attend Gamblers Anonymous and other self-help groups while in treatment.

Alternative – Mark has to attend Gamblers Anonymous and other mutual aid groups while in treatment.

Reasoning – Removing the stigma and using a strength-based term (ATTC Southeast HHS Region 4, 2012)

 

TIP 4

How to create “Gambling Stigma Reduction Initiatives”

Here’s what it takes to create “Gambling Stigma Reduction Initiatives”:

  • Understand the “whys” problem gambling is stigmatized.
  • Gain knowledge of how characteristics of gambling disorder and individuals suffering from gambling disorder are publicly perceived.
  • Implement the theme of this year’s National Problem Gambling Awareness Month – “Have the Conversation.” Engage clients experiencing substance use disorders and/or mental health disorders to determine if they also might be involved in problem gambling.
  • Use de-stigmatizing language in order to help them feel more at ease in disclosing their gambling habits and possible gambling related problems.
  • Communicate positive stories of people with gambling disorder to address the social stigma of gambling addiction.
  • At a structural level, implement training and education programs targeting community partners, professionals, social workers, substance use disorder professionals, teachers and even medical school students to change gambling stigma.
  • At a personal level, talk about gambling addiction amongst our friends and family members to hopefully address the misperceptions about gambling disorder, treatment options and long term recovery.

Bio: George Mladenetz has worked in the field of substance use disorder and mental health for over thirty years within the New Jersey Department of Human Services, Division of Mental Health & Addiction Services. George possesses a Master’s degree in Counseling from Trenton State College (currently The College of New Jersey). He has been licensed as a Clinical Alcohol and Drug Counselor (LCADC) since 2005 and is an International Certified Gambling Counselor (ICGC- I). As Treatment Coordinator for the Council on Compulsive Gambling of NJ (CCGNJ), he monitors the operations of eight (8) subcontracted treatment providers who serve disordered gamblers and/or family members/significant others. George’s experience in working in the addiction treatment field has helped him realize how important it is that individuals entering treatment for any type of disorder be screened for gambling disorder as too often the “hidden illness” of gambling disorder goes undetected.

References:

  1. Central East Addiction Technology Transfer Center Network. Anti-Stigma Toolkit: A Guide to Reducing Addiction-Related Stigma, 2012.
  2. CSAT, Substance Use Disorders: A Guide to the Use of Language, revised April, 2004
  3. Hing,N., E.Nuske, S. Gainsbury, A. Russell. Perceived Stigma and Self-Stigma of Problem Gambling: Perspectives of People with Gambling Problems. International Gambling Studies, Vol. 16, Issue 1, 2016.
  4. Livingston, J.D., T. Milne, M.L. Fang, E. Amari. The Effectiveness of Intervention for Reducing Stigma Related to Substance Use Disorders: A Systematic Review. Addiction (Abington, England) 107 (1) 39-50, 2012.
  5. Massachusetts.gov The Official Website of the Office of Health and Human Services. State Without Stigma. Retrieved from “Stop Addiction; State Without Stigma,” 2012.
  6. Mee-Lee, D. Tips and Topics, Vol. 14, No. 1, April, 2016. https://www.changecompanies.net/blogs/tipsntopics/2016/04/
  7. Petry, N.M. Pathological Gambling. American Psychological Association, 2006.
  8. Office of National Drug Control Policy. Changing the Language of Addictions. Announcement for Public Comments, 2016.
  9. Southeast Addiction Technology Transfer Center Network. The Most Respectful Way of Referring to People is as People, 2016.

SKILLS

Daniel echoes the theme for this year’s Problem Gambling Awareness Month for having the conversation about gambling.

TIP 1

Because gambling is considered an invisible addiction, addiction and mental health counselors are encouraged to screen for gambling disorder.

Why an “invisible” addiction?

  • There are no smells or track marks easily identifiable.
  • There are no blood tests, urine screens or hair follicles to detect gambling disorder.
  • Gambling Disorder is officially classified in DSM-5 by the American Psychiatric Association as an addictive disorder, though gambling problems can easily be camouflaged as ordinary and unremarkable behavior. 

When clinicians and counselors screen for gambling disorder, this leads them to “have the conversation” with their clients; otherwise, it may go undetected.

TIP 2

Family members can “have the conversation” with those who show signs of gambling disorder.

Problem gambling is a public health issue. It affects relationships, families, businesses and communities. Because Gambling Disorder can be camouflaged as other problems, families and communities might not see gambling as the problem in:

  • Health issues (physical and emotional)
  • Increased risk of suicide
  • Increased domestic violence
  • Financial losses and bankruptcies
  • Workplace issues

TIP 3

Individuals who find gambling is causing negative consequences in their life can “have the conversation” with gambling helplines to direct them to valuable resources that can help.

If you or someone you care about has a gambling problem, call 800-GAMBLER or visit us on the web at www.800gambler.org for additional information and resources. Support, treatment, and hope is available 24 hours a day.

Legislators and the gambling industry can “have the conversation” with each other and with State Gambling Councils, to better understand how to minimize harm while identifying and employing responsible gaming strategies. Gambling problems are too devastating to individuals and society to allow them to go unnoticed and unattended. We all need to have the conversation!

Bio: Daniel J. Trolaro is the Assistant Executive Director for the NJ Council on Compulsive Gambling. He graduated from The College of New Jersey with a BS in Finance and a concentration in Economics. He also holds his MS in Psychology from California Coast University. Dan has spoken around the state and country about internet and mobile device gambling, emerging trends and the warning signs for disordered gambling. Whether speaking on treatment options, prevention strategies, responsible gaming or recovery resources, Dan discusses the concept of addiction switching, co-occurrence, and behaviors associated with this devastating addiction.

SOUL

A couple of months ago, I ran into a new neighbor who had just moved next door. We exchanged neighborly greetings. When he heard my work focused on addiction, he told me of an article he had just read in the December 2016 issue of The Atlantic, “How Casinos Enable Gambling Addicts”.

It is a comprehensive article and you may not get time to digest it all in one sitting. But it is well worth the education on the not-so-innocent big gaming industry. At the very least, follow Scott Stevens’ story.

 “On the morning of Monday, August 13, 2012, Scott Stevens loaded a brown hunting bag into his Jeep Grand Cherokee, then went to the master bedroom, where he hugged Stacy, his wife of 23 years. “I love you,” he told her…….” Don’t miss the rest of the story at The Atlantic article on compulsive gamblingThe Atlantic December 2016

 Addiction is such a devastating illness. For so many, those afflicted by addiction themselves or as family and friends, it just seems bad behavior that they should just stop. If only it were that simple.

We’re becoming a little better at empathy and understanding for people with addiction manifested as a substance use disorder. When it come to gambling disorders, we are not there yet….it’s just as cunning and baffling and devastating as substance-related disorders.

Ask the family of Scott Stevens.

SHARING SOLUTIONS

Interactive Journaling:

 page-001 “Safe Bet” – Problem Gambling Prevention and EducationThis 32-page Interactive Journal is designed for individuals at risk for problem gambling behaviors. Safe Bet challenges individuals’ common conceptions about gambling, helps individuals recognize their motivations for their gambling and offers tips and strategies to replace or diminish harmful gambling behavior. The Journal motivates individuals to take on the responsibility of making healthy gambling choices in the future.

Minimum purchase of 25

Take a look: https://www.changecompanies.net/products/?id=SB1

 

page-001 “Safe Bet Facilitator Guide”This 48-page facilitator guide provides quick and easy to use reference for facilitation; offers core activities and alternative strategies; highlights key journaling activities with mini-pages.

Here it is: https://www.changecompanies.net/products/?id=SBF

To order: The Change Companies at 888-889-8866; www.changecompanies.net

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

Vol. #15, No. 1

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

David Mee-Lee M.D.

SAVVY

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

 

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

 

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

 

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

 

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

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

 

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

SKILLS

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

SOUL

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

 

 

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

 

 

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

Until next time

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

Questions about addiction, treatment and criminal justice; culture change; Stump the Shrink

Vol. #15, No. 2

Welcome to May edition of Tips and Topics. We’re glad you could join us.

David Mee-Lee M.D.

SAVVY

Earlier this month, I had the opportunity to present to a mixed audience of criminal justice teams and treatment providers. The focus was on engaging mandated clients into accountable, sustainable positive change to reach the goals everyone wants: increased public safety, decreased crime and safety for children and families. Because of the mix of important stakeholders there were apparent clashes in mission, attitudes, policies and procedures.

How do you marry into one coherent approach the perspectives of judges, prosecuting and defense attorneys, probation and parole personnel, law enforcement, court coordinators and case managers, treatment providers and not least of whom, clients, participants and their families?

In the process of training and talking together, there were many issues raised explicitly or implicitly in the questions, attitudes and dilemmas voiced.

TIP 1

Here are questions that highlight conflicting perspectives on what is “addiction” and addiction treatment……and my attempts to answer them.

Q 1. Is addiction really a disease or isn’t it just willful misconduct?

I can certainly understand the difficulty of embracing the American Society of Addiction Medicine’s (ASAM) definition: “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.”

ASAM Definition of Addiction

The behavioral manifestations (and often “bad” behaviors and acts) of this brain disease are so egregious, in-your-face threatening public safety, that it can seem nothing short of willful misconduct needing punishment.

But I would encourage those doubtful about addiction as a brain disease to speak with recovering physicians, lawyers, judges, pilots and any other person who has been afflicted with addiction. Ask them about the dangerous, reckless and unfathomable things they did when in the throes of addiction. Why would a physician who has spent hundreds of thousands of dollars in medical school and countless hours of study, internship, residency training and daily practice jeopardize his license and career to get high on fentanyl, or drink before seeing patients or while on emergency call?

How does it make sense to lose family, finances, health and even face death in willful misconduct, to use a legal or illegal drug to get high, if it isn’t a brain disease which results in individuals chasing after whatever will activate the brain reward system or provide relief?

Q 2. If they don’t stop using, treatment is fine; but at some point enough is enough and you have to kick them out of drug court and lock them up?

If you just look at the behavior of a person with addiction, you may see a person who lies, cheats, breaks laws and appears to lack good moral values.

  • An understandable (but counterproductive) reaction of society is to punish such antisocial behaviors and approach a person with addiction as “a bad person” to be punished.
  • The productive attitude to achieve public safety and real lasting change is to “realize that good people can do very bad things, and the behaviors of addiction are understandable in the context of the alterations in brain function.”

Q 3. If you do individualized treatment, won’t participants scam the system? If we don’t treat them with all the same expectations, won’t they all try to get around the rules as much as they can?

If you think “individualized treatment” means just allowing participants to pick and choose what parts of the program they will participate in; and not have any expectation of accountability to follow a treatment plan, then I can understand your concern.

But..

“individualized treatment” is about collaborating on a treatment plan that matches the specific needs of the participant, makes sense to the participant, and therefore has the best chance to actually work and succeed.

Treatment isn’t about rules, phases, behavior control and punishment. It is about holding a person accountable for changing their beliefs, attitudes and lifestyle such that they are:

  • Better parents – if getting their children back is what they want.
  • Better citizens – if getting out of jail or off probation is what they want.
  • Less impulsive and out of control- if not getting arrested is what they want.
  • Mentally stable, sober and in recovery – if getting housing or a job or happiness is what they want.
  • Better workers or partners – if keeping a job or relationship is what they want.

Q 4. These people have criminogenic thinking and antisocial behavior. How will they change if you are soft on them in treatment? Don’t they need to know who’s the boss?

Helping people change their thinking and behavior only has lasting, sustainable results if the person is an actual participant in the process. Good treatment isn’t being “soft” on people; it is expecting good faith effort to work on thinking and behaviors that are pro-social at a pace which brings actual change, not passive compliance.

The judge, treatment court, probation and parole, and any mandating agency certainly has the power of the “boss”; and should use that power:

  • Not to prescribe and define the treatment e.g., level of care, length of stay, numbers of AA meetings etc. That is outside their scope of practice.
  • To enact graduated sanctions for lack of good faith effort in treatment as evidenced by passive compliance, active or passive non-adherence to individualized treatment plans. Partnership with treatment providers ensures treatment is accountable and not “soft”.

SKILLS

In the September 2014 edition of Tips and Topics, we covered in more detail problem- solving courts. Tips & Topics September 2014

TIP 1

Questions about dealing with substance use and positive drug screens

Q 1. Using illegal drugs is criminal behavior. How can we just let that go without consequences? They picked up the drug and used.

If a participant uses substances while in treatment – legal or illegal drugs – you don’t just “let that go”. Using substances for a person with addiction is not good and indicates a poor outcome in treatment just like getting suicidal is a bad outcome for a person with major depression; or a spiking high blood pressure is a poor outcome for a person with hypertension.

The “consequences” of poor outcomes is to assess what went wrong and change the treatment plan. If you believe addiction is an illness characterized by loss of control of impulses and cravings to use drugs against ones better judgment, then yes, they did pick up the drug and use….but:

  • The person with severe suicidal depression also picked up the razor blade to slash their wrists; or the bottle of pills to overdose.
  • The addicted smoker also lit up the cigarette to deal with the craving to use.
  • The morbidly obese person ate those extra calories against their better judgment.

Q 2. If they get a positive drug screen they need more than a tap on the wrist and “treatment that is all unicorns and rainbows.” (Said one workshop participant with disgust).

Yes, using substances when you resolved not to use; or are in treatment to achieve abstinence and sobriety needs more than a tap on the wrist. It requires the participant to take responsibility to learn from what went wrong and change their treatment plan in a positive direction. If they aren’t willing to do that, then they aren’t in treatment and should be counseled about the apparent need for some kind of sanction:

  • Not for having used, which is a natural vulnerability for people with addiction
  • But for not doing treatment in good faith and being out of compliance with court orders or agreements to do treatment.

Q 3. I’m OK with cutting them some slack early on in treatment if they use and get a positive drug screen. But if they are further along their phases and haven’t used for months, then shouldn’t they be sanctioned for any use?

People with addiction can establish abstinence for short or long periods of time depending on a variety of factors. But just like any other chronic illness, flare-ups and reactivation of the disease process can occur at any time, regardless of the length of stability.
For example:

  • The person may be triggered by a sudden loss of a relationship by death or divorce and use even if they have months and years of sobriety.
  • A flare-up of co-occurring chronic pain or depression and suicidality or trauma could trigger substance use.
  • The participant may have started to get overconfident after many months of abstinence and sobriety and even start thinking that maybe they don’t even have addiction. They start attending support groups less; or try having “just one drink” that then blossoms into full relapse mode.

It doesn’t mean substance use is excusable early on in treatment phases, but later use is willful misconduct needing punishment. Any substance use in addiction treatment is not a good outcome. But the approach is the same for early or later use:

  • What went wrong that you picked up a drink or drug again?
  • What can you learn from this bad experience and do something differently in a positive direction?
  • What people, places and things can you address to decrease the chance of a future flare-up?
  • Choosing to not do treatment will show up as disinterest in changing your treatment plan in a positive direction; and/or lack of follow through in active, adherent services. Then a sanction is needed.

References and Resources:

  1. “A Technical Assistance Guide For Drug Court Judges on Drug Court Treatment Services” – Bureau of

Justice Assistance Drug Court Technical Assistance Project. American University, School of Public Affairs, Justice Programs Office. Lead Authors: Jeffrey N. Kushner, MHRA, State Drug Court Coordinator, Montana Supreme Court; Roger H. Peters, Ph.D., University of South Florida; Caroline S. Cooper BJA Drug Court Technical Assistance Project. School of Public Affairs, American University. May 1, 2014.

  1. Critical Treatment Issues Webinar Series, Bureau of Justice (BJA) Drug Court Technical Assistance Project at American University Feb. 10, 2016 – May 3, 2016 https://www.youtube.com/watch?v=AuUEP52z1Xk
  1. Mee-Lee D, Shulman GD, Fishman MJ, Gastfriend DR, Miller MM, eds. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. 3rd ed. Carson City, NV: The Change Companies®, 2013. Application to Special Populations – People in Criminal Justice Settings

SOUL

On May 22, 2017, Ford Motor changed its CEO. Mark Fields, who had been with Ford for 28 years was replaced by Jim Hackett, an outsider who had only been at Ford for about a year. (Sometimes, just because you’ve have been in the business for decades doesn’t mean you have the most innovative ideas.)
Ford Executive Chairman, Bill Ford, said the “switch” was aimed at remaking Ford’s:

  • Legendary hierarchical culture
  • Expediting decision-making
  • Pursuing a cohesive vision for the future
  • Improving day-to-day operations

(USA Today, May 23, 2017 Money section page 2B)

What could justice teams and treatment providers take from these aims as they create more effective partnerships for public safety and lasting positive change?

  • Facilitating accountable pro-social thinking and behavior can’t be a top down, hierarchical court mandate or a provider’s push for treatment compliance.
  • When a flare-up of drug use destabilizes a participant’s treatment progress, good treatment and court decision-making must rise above a knee jerk sanction or suspension from treatment.
  • All stakeholders must come together to pursue a cohesive vision for the future of criminal justice reform and improved treatment outcomes that serve public safety and recovery oriented systems of care.
  • Communication between court teams and treatment teams must improve beyond cookie-cutter treatment compliance reports to meaningful progress reports on whether the participant is actually changing and growing.

The article quoted AutoPacific analyst Dave Sullivan: “Any time you go to a company like this, the culture is not gonna change overnight. It’s been set in stone for a hundred years.

It hasn’t been 100 years since Drug Courts started. But it feels like there is still a lot of stone. However if you resonate with any of the thoughts for a new direction, the stone is breaking down and the culture is already changing.

STUMP THE SHRINK

Here is a question from a Mental Health Specialist at the Department of Corrections in Oregon:

Q: “I am assessing an individual who is non-compliant with their probation/parole and has missed UAs (drug urinalysis) in addition to many other noncompliance issues, but has not admitted to using substances. I have always been taught that we do not consider a missed UA to be a positive UA when diagnosing and/or determining appropriate level of care (LOC). Would the American Society of Addiction Medicine (ASAM) agree with this?”


My response
:

The issue is less about the technicality of designating a missed UA to be coded as a “positive” UA result. Rather, the focus should be on assessing the individual’s Dimension 4, Readiness to Change. If the client is missing urine testing and other treatment meetings and strategies, the first consideration is to determine whether the client is even interested in treatment and whether s/he thinks there is an addiction problem needing treatment.

If s/he is ambivalent or not interested in attending, and there are no unstable problems needing containment and structure, then any treatment should focus on motivational enhancement that could be done in an outpatient Level 1 setting.

If there is instability threatening safety or their ability to access services, then the assessment and placement would be based on the needs of those issues, not just on missing drug testing.

In summary, the level of care placement depends on what issues, in which dimensions need services, the dose and intensity of which can only safely be delivered in which level of care? In that sense missing drug testing is indicative of broader issues rather than just legalistically considering that miss as a “positive” UA.

New publications on Drug Court Graduations and Discharge Categories; rethinking policies and practices; Customer service

Vol. #15, No. 3

Welcome to the June edition of Tips and Topics and to all the new and longtime subscribers.

David Mee-Lee M.D.

SAVVY

This is the fifteenth year of publishing Tips and Topics (TNT). It is always gratifying and meaningful when people tell me how much they appreciate receiving it. About three years ago, one of TNT’s readers introduced himself to me and has gone way beyond just being a reader of TNT. I introduced Izaak Williams to you in the November 2014 edition of TNT.  In there, he summarized a paper he had written which was prompted by my writing on graduation ceremonies, which had appeared in a 2011 TNT edition.

If you missed his paper entitled “Drug Treatment Graduation Ceremonies: It’s Time to Put This Long-Cherished Tradition to Rest,” here is a link to that paper:

November 2014 Tips & Topics

This June, Izaak published another paper as principal author.  I was a co-author, along with two others. This new one built on Izaak’s previous paper and expanded into graduations in Drug Courts. I will get to that in a minute.

Before that, here is some backdrop. Below is part of an exchange between Izaak and myself about: * how he came to be on the TNT mailing list in the first place and what resonated with him to read them so extensively?

Izaak Williams: “Years ago I was working on the frontlines of an outpatient addiction service, when my well-regarded Interim supervisor and colleague forwarded me their edition of Tips & Topics (If I may digress into a brief aside, I do not believe it coincidence that my professional relationship with these two former colleagues, who were both eager and avid readers of Tips and Topics at the time, would years later blossom into a personal friendship). As an addiction counselor, I was gradually becoming aware that there were areas of addiction treatment that needed improvement. Tips & Topics seemed to articulate a set of values and beliefs that really resonated with me. Since then I have used Tips & Topics as a bedrock to form a foundation upon which to build addiction services. Tips & Topics has become a prevailing medium to both highlight and inspire changes in treatment programs and to help fundamentally shift anachronistic paradigms. With Tips & Topics, I have drawn on the 14 years of Archives to address a variety of core initiatives that could very well make addiction treatment a better quality system in terms of its integrity, efficacy and effectiveness.”

Izaak L. Williams, Hawaii State Certified Substance Abuse Counselor (CSAC), was selected in the 2014 cohort of emerging leaders by the Center for Substance Abuse Treatment’s(CSAT’s) Behavioral Health Leadership Development Program. He can be reached at: izaakw@hawaii.edu.

 

TIP 1

Rethink Drug Court graduation ceremonies; consider a possible alternative approach

“Rethinking Court-Sanctioned Reintegration Processes: Redemption Rituals as an Alternative to the Drug Court Graduation” was published this month in the Howard Journal of Crime and Justice.

Here are some highlights:

  1. On Drug Court (DC) graduation day, participants receive a certificate signifying completion of treatment for their substance use disorders and compliance with DC requirements. Having satisfied the conditions of DC by staying drug free and not engaging in criminal behavior, graduation signifies successful compliance.

 

  1. Graduation ceremonies can, however, create the perception among DC participants and families that graduation represents the end of treatment, and that little, or no further support will be necessary to prepare DC participants for their future.

 

  1. This article offers an alternative perspective. It explores what it means to graduate from DC, and how DC graduation might be reconfigured and reoriented to preserve validation and accomplishment, while guarding against the impression of a cure.

 

  1. Our conceptual framework is grounded in both re-integrative shaming theory, as well as the idea of redemption rituals. The latter is a form of ceremony to facilitate the offender re-entry process. In this approach, the offender is “shamed” by their community by being held accountable for their actions, but also provided with the support to enable them to make the changes necessary for successful reintegration.

 

  1. Redemption ceremonies feature reward and celebration, evoke positive emotion, and involve the public. However, in contrast with conventional graduation ceremonies, redemption rituals are intended to be restorative in their outcomes.

 

  1. Redemption ceremonies offer alternative meanings and symbolism for graduation from DC. These represent much more than just a participant’s compliance with court orders, treatment programming, and drug testing expectations.

 

  1. Redemption ceremonies emphasize a number of key factors: achievement, coordination of care, status elevation, and moral inclusion.
  • Achievement“: refers to long-term positive changes in the behavior of DC graduates rather than just compliance with program requirements of abstinence; promotes sustainable change and treatment matching.
  • Coordination of care“: ensures that the overall care provided is sufficiently comprehensive and coordinated to address the diverse and specific needs of individuals pre/post-graduation. Major differences in the characteristics and needs of DC participants means that there needs to be coordinated, integrated services from a variety of providers.
  • Status elevation“: involves effectively elevating the status of DC graduates so they can be fully accepted by, and integrated into, the social community without ongoing stigma and discrimination.
  • Moral inclusion“: addresses the process of welcoming the DC participant as a full member of a moral community rather than as a stigmatized person; it highlights the role of community acceptance in promoting sustainable change among DC graduates.

“Redemption entails identifying clients who are doing time versus doing treatment and change, and ensuring that adequate treatment resources are made available to successfully engage the former category of participants in an ongoing process that requires more than the DC phase from which they have now graduated.” (Page 263)

How to access the full article:

I am not permitted to post the full paper, but here’s the link to the Abstract: http://onlinelibrary.wiley.com/doi/10.1111/hojo.12203/full

If you want to read the whole paper you can contact me at dmeelee@changecompanies.net. I can “transmit individual copies of this PDF to colleagues upon their specific request provided no fee is charged, and further-provided that there is no systematic distribution of the Contribution, e.g. posting on a listserv, website or automated delivery.”

 

TIP 2

Consider the underlying assumptions, attitudes and practices driving the structure and naming of Discharge Categories.

Back in 2005 (February and March editions of TNT), I wrote about Discharge categories and the hidden philosophy, values and attitudes underlying many agencies’ categories.

February 2005 Tips & Topics

March 2005 Tips & Topics 

Now 12 years later, Izaak and I formalized an article named:
“Co-participative Adherence: The Reconstruction of Discharge Categories in the Treatment of Substance Use Disorders”. It was just published this month online in Alcoholism Treatment Quarterly (ATQ).

Here are some highlights:

  1. Every program and agency has a variety of discharge categories classifying whether a client was successfully discharged or not.

 

  1. We suggested that a “moral-choice-compliance” (MCC) model of addiction and treatment underpins current discharge categories.

 

  1. Many providers advocate a “disease model of addiction”, but actually practice from the perspective of an MCC model. That model embraces practices and policies that sees substance use as willful misconduct, a moral problem where clients choose to pick up a drink or drug and therefore:
  • Should have “consequences” for their use
  • Be suspended from treatment for the day until sober
  • Be discharged from residential care and sometimes banned from reapplying for treatment until 30 days have passed
  • Be removed from mixing with other clients lest they trigger use for others.
  1. Rather than conducting treatment in recovery-oriented systems of care that values client empowerment, each client is expected to comply with treatment recommendations. Treatment progress is then measured by the client’s quality of compliance with program rules and counselor recommendations. Non-compliance can be met with “loss of privileges”, set back a level in a phase-based program; and even Administrative Discharge or Discharged for Non-compliance.

 

  1. To contrast a compliance, program-driven philosophy implied in the MCC model,we suggested a “coparticipative adherence” model to drive discharge terminology.

 

  1. Such a model values client autonomy in the administrative and clinical program systems. Clients participate and collaborate on goals and treatment plans, and participate in self-fueled adherence and committed effort in treatment. Coparticipative adherence thus facilitates a self change process rather than program-driven change.

 

  1. We offered contrasting and alternative discharge categories based on a “coparticipative adherence” model.

 

Here’s link to the Abstract:

http://www.tandfonline.com/doi/full/10.1080/07347324.2017.1322432

How to download the full article:

  • There are a limited number of free downloads at these two links to see the full paper:

http://www.tandfonline.com/eprint/eq3aFhfwTzK5BXaS7U8p/full              

http://www.tandfonline.com/eprint/yzyTQFmjskwUVeR3ZrKx/full

  • Check the Addiction Professional website around the middle of July to read Gary Enos’ online cover story of a Williams – Mee-Lee interview about this paper. For 30 days once that Addiction Professional article is posted, you can access the link for a free copy of the article https://www.addictionpro.com

 

References

Williams IL, Mee-Lee D, Gallagher JR, Irwin K (2017): “Rethinking Court-Sanctioned Reintegration Processes: Redemption Rituals as an Alternative to the Drug Court Graduation” The Howard Journal of Crime and Justice. Volume 56, Issue 2 June 2017 Pages 244-267.

Williams IL, Mee-Lee D (2017): “Co-participative Adherence: The Reconstruction of Discharge Categories in the Treatment of Substance Use Disorders” Alcoholism Treatment Quarterly. Vol. 35, Issue 3, June 2017 Pages: 279-297. Published online: 16 Jun 2017, Pages 1-19

http://dx.doi.org/10.1080/07347324.2017.1322432

 

SKILLS

Here are a few Skills tips to help rethink graduation ceremonies and promote sustainable self-change in the people we serve.

TIP 1

How to move from graduation to commencement ceremonies. 

  1. In the March 2011 edition of TNT, I suggested we develop RCA – the Reflection, Celebration and Anticipation ceremony.

March 2011 Tips & Topics

 

  1. Some drug courts and treatment courts have literally shifted terminology from “graduation” to “commencement” ceremonies. This encourages viewing recovery as a process just started, not completed.

 

  1. Talk to clients and participants in terms of having done an important “piece of work” in their treatment process, which is to be appreciated and honored. However, it is just a “piece” of the process of recovery, if sustainable change is to be achieved.

 

  1. Pay attention to clients who are just going through the motions of treatment.  Make sure you don’t give the impression that just complying with rules and regulations will bring lasting results. I was reviewing with a care manager about her client who was eager to know what his drug court graduation date was going to be.

Why was it important to him to know the exact date?

He wanted to plan his wedding date after graduation. That way he could drink alcohol at his wedding without fear of consequences from drug court. His drug court graduation date was pushed back, so he promptly changed his wedding date to a later date. You can see where his priorities were.

TIP 2

How to enhance “coparticipative adherence” 

What was the rationale behind coining the term “coparticipative adherence”?
The term emphasizes the true meaning of “adherence”; this encompasses collaboration, client empowerment for shared decision-making, and client choice in treatment decisions affecting their life. It isn’t an exercise in political correctness to replace “compliance” with “adherence”.

 

  1. Is the client actually a co-partner in defining overall and specific goals in their treatment? If you feel like you are doing more work than the client, then something has gone wrong with the co-partnering process.

 

  1. Are they actively participating in treatment or passively going along with treatment? If you feel like you are doing all the talking and making all the arguments (e.g. why attending self/mutual help groups is important; why medication adherence is necessary; why staying away from those friends is advisable) then your client is watching treatment, not doing it.

 

  1. Is your client adhering to the treatment plan – clinging to, steadfast, sticking to it – with the same energy and commitment they had in their active addiction days.  If they knew they could have whatever drugs, whatever quantity, so long as they met their dealer promptly at 4 PM, how many of your clients would say “I don’t think I can make it at 4 PM.  How about 5 PM?  Or feel a little flu coming on, can I go next week?”  However when it comes to treatment, if your client can’t seem to make it to appointments until 15 minutes late or not even show up or call, their adherence quotient is low.

Finally, if your client is not adhering, don’t look at the pathology of the client and think about Discharging them for Non-Compliance. Take a look first at the treatment plan and how well -or not- you have engaged the client.  It may well be your treatment plan not a coparticipative plan.

SOUL

Because I travel so much, I notice the hospitality and travel industries continually innovating to be more and more customer-friendly.

For example, renting a car?

  • If you are enrolled in a loyalty program, you can bypass the lines at the rental counter and go straight to your car in space A9.
  • How can you be sure A9 is your car? Either you receive a text or email telling you what car to look for in what space, or, their TV monitor lists your name and car space.
  • What if you don’t like the assigned car and want to choose yourself? Some companies allow you to choose any car in your rental rate category. Since we are a Toyota RAV-4, Prius family, it’s nice to select a car with familiar dials and settings.

How about hotels?

  • Many hotels now have phone apps. This enables you to check in ahead of time. When you arrive at the hotel, you simply pick up your key and go to your room.
  • In a few hotels it is possible to even bypass the key-pickup-process and use your smartphone to enter your room. I haven’t tried that yet.
  • Checking out is just as easy. Before leaving the room, just review your emailed bill, check out on your phone or laptop. You can now bypass the front desk.

Then there’s Uber

  • As soon as I type in my destination in the Uber app I love seeing the price, how many minutes my ride is away, the driver’s name, car brand and license plate number. Now I know what to look out for.
  • How great is it to be able to track the car’s path on the map and exactly how many minutes s/he is away, so there is no confusion who and where your ride is?
  • Have you tried Uber (or Lyft)? When you do, I think you’ll see, like me, that you’d never choose to use a taxicab again.

Healthcare and addiction and mental health treatment all serve people too. Yet, I have to think hard to churn out m/any bullet points of innovation:

  • I do like the easy access to my medical record online where I can make an appointment, ask my doctor a question, check my lab test results all without being placed on a phone hold.

However there are a lot of “unfriendly” practices which come to mind:

  • When I visit the doctor’s office, I am handed a clipboard with a request to update any changes to my medical history.  However the form is a brand new form as if I am a brand new patient.

Why not offer me a printout of my current history, then I can indicate any updates or changes on that ‘existing information’ form?

  • Often an anxious person or family member is given an intake appointment in 2 days, 2 weeks and even 2 months.

Why not establish and offer an orientation, service-overview group available in 2 hours? If no one turns up, the leader can do paperwork. If 10 people show up, engagement and support can start that day.

  • We still offer care and treatment services only in face to face appointments.

Why not provide phone apps, online education, treatment sessions, disease management, chat groups and support networks in the privacy of the person’s own home by phone or online?

Of course, innovations are already happening in healthcare.  Practices and policies are indeed becoming “friendlier”.  But maybe we could pick up the pace!  Surely people’s health and well-being are just as important as renting a car, booking a hotel room or catching a ride.

Until next time

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

Vol. #15, No. 4

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

David Mee-Lee M.D.

SAVVY, SKILLS & STUMP THE SHRINK

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

 

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

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

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

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

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

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

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

All my best and thanks again for your extraordinary service on behalf of clients everywhere.
TD
Therapist in a Drug Court
My response to TD
Before I respond to TD’s important questions, here is some information on creatinine levels. Since I am not expert on urine drug screening tests and interpretation, I turned to Dr. Google. If you are an expert and I got it wrong, please let me know.
  • Creatinine is a waste product of creatine, an amino acid contained in muscle tissue and found in urine in relatively constant quantities over a 24-hour period with “normal” liquid intake. It is filtered out of the blood by the kidneys and some amounts are normally secreted into the urine.
  • Therefore, urine creatinine can be used as an indicator of urine water content or as a marker identifying a specimen as urine.
  • A normal result is 20-300 mg/dL in urine.
  • Creatinine level varies based on a person’s size and muscle mass. Below normal creatinine levels indicate that a person has been drinking excess fluids. Such a reading is a red flag in drug tests because it signifies that the person tested has attempted to tamper with the results by disguising other active by-products that would have otherwise been detected.
  • In other words, the creatinine levels determine whether or not a person is trying to cheat on a urine drug test. Most laboratories now perform advanced screening procedures that verify whether there has been adulteration or dilution. In the case of the latter, when the urine sample is too diluted, the results are normally labeled as “inconclusive.”
  • Why Is Creatinine Being Analyzed in Urine Drug Tests? The accuracy and reliability of urine drug test results depend heavily on the validity of the urine specimen.
  • When the specimen is pure and free from adulteration or substitution, those who rely on the results of the analysis can be assured the reported outcome is precise.
  • Adulteration or tampering with the specimen in order to alter the drug test results to produce a false negative is a known practice among drug users. A common way to do is by adding some products such as bleaching agents or detergents to the urine sample.
  • Another method is to conceal the metabolites or by-products of the ingested drugs by consuming excessive amounts of fluids or taking diuretics in an attempt to “flush” out the metabolites and “dilute” the urine.
  • The best way to check for “dilution” is to analyze some urinary characteristics such as creatinine levels.
Another resource:
ASAM has developed the “Appropriate Use of Drug Testing in Clinical Addiction Medicine” document to provide guidance about the effective use of drug testing in the identification, diagnosis, treatment and promotion of recovery for patients with, or at risk for, addiction.
 
TD, here are some thoughts and suggestions:
1. Urine drug screens and creatinine levels are laboratory tests for addiction, like any other lab test in assessing the severity and treatment for any health condition.
2. Lab test results have to be interpreted in the context of the participant’s history, gender, current health conditions and signs and symptoms. Lab test results do not stand alone, and should not be the final answer on a person’s health and well being.
3. Creating sanctions based solely on a lab test result is against good clinical practice in tracking the progress in any disease and health condition.
4. When you say “I have many clients who appear to be really working a recovery program who are terrified about getting highs or lows.” This is a good example of what happens when the focus is on compliance, rule breaking and sanctions rather than on demonstrating positive, sustainable and lasting change (recovery).
5. Even if a client does attempt to tamper with a drug test, the treatment provider should look as much at themselves as the client.
  • What type of culture and treatment atmosphere have we created such that clients feel the need to play games and cheat, rather than be honest about any flare-up or relapse?
  • Do we offer this explanation? While substance use in treatment is never good, if it does happen, it is important to raise that and get help. This is exactly like a depressed person who becomes suicidal. We teach them to reach out rather than hide the depression flare-up.
  • Have we created a ‘gotcha’ attitude to urine drug testing and a ‘police state of affairs’, rather than a treatment healing environment where we expect progress in treatment rather than perfect abstinence?
6. For a toxicologist with expertise about lab tests and addiction recovery, I suggest you contact the American Society of Addiction Medicine and contact any of the members of the Expert Panel who developed the “Appropriate Use of Drug Testing in Clinical Addiction Medicine”.
7. As regards Vivitrol – “Sometimes the judge orders the client to take it-for a year-when the client doesn’t want to.”
  • This is an example of a judge or any court personnel working outside their scope of practice.
  • In addition, the best predictor of good outcomes is the quality of the therapeutic relationship. This means agreement on goals and agreement on strategies and methods, within the context of a safe, trusting working relationship.
  • What if the participant doesn’t agree with the goal of abstinence or the method (medication)? You do not have an alliance. The likelihood of a good outcome is very low.
  • Thus the problem is not only the wrong treatment strategy for the wrong participant, but it is assessed and prescribed by the wrong person working outside their scope of practice. Good intentions don’t produce good outcomes if the alliance and treatment are out of alignment.
References
Adherence. (n. d.). In Merriam-Webster online. Retrieved from https://www.merriam-
American Society of Addiction Medicine (ASAM) “Appropriate Use of Drug Testing in Clinical Addiction Medicine” https://www.asam.org/quality-practice/guidelines-and-consensus-documents/drug-testing
Compliance. (n. d.). In Merriam-Webster online. Retrieved from https://www.merriam-
Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies.
Ogden, J. (1999). Compliance versus adherence: just a matter of language? The politics and poetics of public health. In J. D. Porter & J. M. Grange (Eds.), Tuberculosis: An interdisciplinary perspective (pp. 213-234). London: Imperial College Press.
Williams IL, Mee-Lee D (2017): “Coparticipative Adherence: The Reconstruction of Discharge Categories in the Treatment of Substance Use Disorders” Alcoholism Treatment Quarterly. Vol. 35, Issue 3, June 2017 Pages: 279-297. Published online: 16 Jun 2017, Pages 1-19 http://dx.doi.org/10.1080/07347324.2017.1322432

SOUL

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

Until next time

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

Lessons from “American Sniper”; citizen of the world; trauma journals

Vol. #15, No. 5

Welcome to the August edition of Tips & Topics (TNT).  If you are in the Northern Hemisphere, I hope you are enjoying summer. If you are Down Under, may your winter be not too cold. 

David Mee-Lee M.D.

SAVVY

When President Trump declared the opioid crisis a national emergency earlier this month, I planned to write about that in this month’s Tips & Topics. However I am commencing this edition on a 13-hour plane ride back from Australia. That may sound like a long trip you wouldn’t want to make. Yet I’ve done it so many times- a couple of movies, a couple of meals, a few hours’ sleep and presto! You’ve arrived in San Francisco, non-stop from Sydney.
 
One inflight film I watched changed my whole plan for Tips & Topics. I am in awe of the impact a well-written, well-directed and acted movie can have to raise awareness, educate and catalyze empathy and understanding….in just over 2 hours. Not a brand new movie; just hadn’t yet gotten around to seeing it despite its excellent reviews.
 
TIP 1
Insights, information and inspiration I gained from the 2014 film “American Sniper”
 
Bradley Cooper’s portrayal of US Navy SEAL Chris Kyle in “American Sniper” is praised as one of his best performances. That is fitting since the life of Chris Kyle, if the movie accurately portrayed him, was also outstanding. Even if there were Holly wood inaccuracies, the messages and impact remain authentic for me.
 
Here, in no specific order, is a list of what touched me:
 
1. The total barbarity of war – the wars in the Middle East (and elsewhere) have been going on for so long, that news of another serviceperson’s death barely raises a flicker emotionally, I am sad to say.
 
2. “People are dying and we’re going to the mall” – It was words to that effect in the movie that reminded me how untouched most of us are by the wars. Fortunately now we treat the courage of all who serve in the military with great respect, unlike what happened in the Vietnam War; or as those in Vietnam call it “the American War”. But is it enough to let service people board the plane first ahead of even the most frequent flyers, honor them at the beginning of ballgames, and say “Thank-you for your service”? I know I am really am grateful for their service, but is that just because I’m glad it’s not me?
 
3. Posttraumatic Stress Syndrome  I thought I knew PTSD and what active duty and returning military personnel go through. But this movie ‘hit me in the gut’- what it’s really like for the person, spouse, partner, children plus friends and extended family:   
  • To be emotionally present: how incredibly hard is for the service person returning from a tour of duty, to try to live a regular life after the terror and trauma of war.
  • To simply hear ordinary sounds and experiences: These can so easily trigger rage, fear, and automatic aggressive reactions – e.g. the sound of the car mechanic’s drill triggering the memory of the terrorist’s drill torturing a child; a convoy of commercial trucks sounds like the beginning of a military operation; playful wrestling between the family dog with a child at a barbeque looks like the child is under attack.
  • The pain for loved ones to understand what is going on: It is so hard for the serviceperson to talk about what has happened to them and what is changing in their thoughts, feelings and behavior.
  • The partner’s pain: How painful it can be to love and be with the person who is not now the one you loved and married.
4. Trauma of the victims of war – Seeing what the citizens of the war-ravaged countries experience at the hands of both our military and the terrorists is heartbreaking. Both sides in the conflict believe they are doing “God’s work”. The civilians caught in the middle have no say, are at the mercy of their inability to flee and escape the unthinkable conditions I doubt I could survive.
 
5. Camaraderie and the mission – When there is a sense the mission is noble and worth dying for to protect home and country, the bonds formed in the military sustain the courage and grit needed to face the physical, mental and emotional demands of war. When the belief in any mission fades, only fear, tiredness and disillusionment is present.
 
6. Emergency services in the battle and healing support on return
The courage and sheer will it takes to be on the frontline is remarkable. In addition, there are so many others giving so much to save the lives of the wounded. For returning veterans, especially those with PTSD, they need easy access to all the services necessary to reintegrate back to “normal” life – housing, jobs, mental health services, physical health care and rehabilitation. Veterans Health and the Veterans Administration (VA) have such an important role.
 
7. Restoring hope – When Chris Kyle thought the only way to save more lives was to return to a fifth tour of duty in Iraq and kill the enemy, an astute clinician offered an alternative. He walked Chris through the halls of the VA to meet those who’d lost limbs, self-confidence, hope and health. There, he found a different, but equally effective, way to ‘save lives’ in service to returning vets. This not only restored hope for those he served, but also restored himself. His wife and family got back the one they loved.
 
8. War at home – I still believe there has to be a way for people to come together……come together not just in the big wars of the Middle East and North Korea and the many other hotspots of the world. But come together in the battles between:
  • White and black; white supremacists and multiculturalists
  • The different colors of race, religion and ideology
  • Climate change deniers and believers
  • Republicans and Democrats
  • Factions in Congress
  • The President and many of the citizens he serves
And the wars at home between:
  • Spouses and intimate partners in daily physical, mental and emotional battles
  • Siblings who don’t talk
  • Parents and estranged children
  • Grandparents separated from their grandchildren
  • The lonely, isolated and abandoned people at war with their depression and pain.

SKILLS

I am also in awe of the actors’ skills to make fact or fiction come alive on the Big Screen. They make us think, laugh, cry, horrify or inspire us. We work in the behavioral health field; here’s a few thoughts on our skills important to our mission and what we do.
 
TIP 1
Consider: what can you think, feel and do to help people thrive in the battles with addiction and mental illness?
 
Here, in no specific order, is a list of what comes to mind:
 
1. Nonviolent Communication
I have written before about understanding that behind violent words, behaviors and thoughts are universal feelings and needs to be recognized addressed and satisfied.
Tips & Topics, February 2007
Tips & Topics, March 2010
 
2. Keep an open mind to other methods, theories and practices
How aware are you of other treatment models and strategies different from your own training and experience? Do you fervently defend your approach out of ignorance, fear of feeling incompetent in other methods, or because this is what worked for you in recovery? In addiction and mental health, we have the battles between:
  • Medication in addiction treatment and abstinence-based treatment:
    “We don’t believe in medications here – it is just substituting one drug for the other.”
  • Harm reduction and abstinence-mandated services:
    “Harm reduction is a last resort for people who fail abstinence.” Do you think harm reduction is a good thing or bad?
  • 12 Step approaches and Moderation Management or behavioral therapy to teach controlled use.
  • A focus on psychotropic medication versus psychosocial and community-based interventions:
    Why is Pharma called “Big Pharma”?
  • Treatment and prevention:
    Where do the majority of funds go to: treatment or prevention? How much does lifestyle affect chronic disease development and healing?
3. Posttraumatic Stress Syndrome  Fortunately there is an increased awareness, education and skills in building trauma-informed services and systems. Films like “American Sniper” and talking with those suffering with PTSD and their families connect us to the full impact of the human experience.
 
4. Trauma of the victims of war
I have not personally worked with refugees of war-torn countries and immigrants settling into the United States. We have so much to learn from those who work in this arena. In the current political climate, it is disturbing to me how little empathy we have for these victims of war. What can our country, rich in resources and opportunities, do for so many people whose lives have been devastated by the guns, bullets and bombs of us and the terrorists?
 
5. Restore hope and a sense of mission  Many we serve have lost hope and any optimism they can recover. They doubt they can change and overcome their loss of control of substances, gambling, depression or mood swings. Having a sense of hope has more positive impact in treatment than even the evidence-based practice used. Guiding people to take even ‘baby steps’ of success can build hope for recovery.
 
Holding onto hope and retaining a sense of mission can be challenging for clinicians themselves faced with:
  • Increasing case-loads
  • Decreasing funding
  • A rapidly changing healthcare system with performance measures, electronic health records, strict managed care, productivity expectations and population management
  • Compassion fatigue and burnout
Who helps the helper? Who supports and nurtures the carer? What can you do to stay centered, empowered and hopeful? What are you doing to handle and resolve the battles and conflicts at home with your loved ones, estranged friends or family and at work with supervisors, colleagues and administration?
 
6. Holistic whole person care
Treatment isn’t just about abstinence, faithful support group attendance, medication adherence, psychosis stabilization and staying out of the hospital. Just as important is paying attention to the following:
  • Does your client have a safe place to live? – maybe a Housing First service takes priority over getting abstinent and sober first.
  • Do they have transportation, money to buy food, a drop-in center to feel a sense of community?
  • Can they access physical health care for their blood pressure which hasn’t been checked for years or for teeth unattended to in decades?
  • Will the person be bounced between addiction, mental and physical health systems when they need integrated co-occurring or complexity capable services?

SOUL

In many ways, I consider myself a citizen of the world. Growing up as an Australian-born Chinese kid in a then predominantly white Australia (they even had an explicit “White Australia” policy from 1901 which officially ended 1973), I had to learn my place in that world. I love foreign travel and the stimulation of experiencing different cultures and customs.
However I also have two countries I call “home” and two passports to prove it – an Australian passport for my country of birth; and a US passport for my adopted country where I have lived almost twice as many years as Australia. As I return now from Australia, I smile at the little things I always look forward to experience nostalgically when I return home:
  • Eating an Aussie meat pie – so much better than an American pot pie
  • Eating a lamington – even a lot of bakeries in Australia have stopped making them: sponge cake covered in cocoa or chocolate topped off with desiccated coconut, cut up into little rectangles or squares of about 3 by 4 inches. But the size varies, so that’s also part of the fun.
  • Aussie hamburgers – Of course McDonalds and Burger King’s equivalent called Hungry Jacks are everywhere. But a real old-time hamburger has handmade hamburger with lettuce, tomato, beetroot and a fried egg between a mouth-widening bun.
  • Vegemite in both my “home” countries – we always bring back some jars so we can have toast spread with Vegemite and avocado in both Australia and the USA.
Lorikeets
There’s more eating memories, but onto a few other animal experiences you could relate to as a tourist: the huge variety of birds from colorful lorikeets, flocks of white cockatoos, laughing kookaburras and many more birds; cuddly sleepy koalas on our hikes. You have to watch out for kangaroos at sundown just like avoiding deer on the highways.

 

  • Aussie beaches – wide, long expanses of sparsely trafficked, fine
    Brunswick Heads, New South Wales

    sandy beaches. No pebbly, rocky, narrow, coarse sand beaches for me!

  • Australian currency – besides an exchange rate with the US dollar favorable to the US visitor, the actual notes and coins are both attractive and practical. There’s a one and two dollar coin – no $1 or

$2 dollar notes. All the Aussie notes are brightly colorful, easy to distinguish. Somehow they’re manufactured with material that’s always so smooth, durable and new-looking. They don’t crinkle up as they get old; they stay flat and compact in your wallet. Take a look at your US dollars and see if they meet the same criteria.

Well that is surely enough of what I look forward to. Thanks for indulging my nostalgic experiences. They are certainly not enough for me to up and leave all the stimulating and gratifying experiences of my adopted home.

In this world of ours, so torn by conflicts and wars and pain and suffering, how could we all become citizens of the world? What would it take to be proud of our country while also shunning intolerance, isolationism, hate and bigotry? How might we embrace empathy, inclusion, community and the fulfillment of universal human feelings and needs?

I know I am naïve and idealistic.

SHARING SOLUTIONS

Here are some relevant Interactive Journals from The Change Companies:
 
Trauma In Life – (Women’s Specific version) Developed with the Federal Bureau of Prisons for their 16 hour workshop offered through their Resolve Programming. It is focused on risk and resiliency.
 
Traumatic Stress & Resilience – (Men’s Specific version)- Developed with the Federal Bureau of Prisons for their 16 hour workshop offered through their Resolve Programming. It is focused on risk and resiliency.
 
Coming Home Series – It is transition-focused but also explores PTSD and has some great self-management resources in it for those dealing with Trauma.
 
Self-Management Journals– although not ‘specific’ to trauma have great resources in there for individuals with Trauma
 

Until next time

Thanks for joining us this month. See you in late September. 
                                                                                                                                               
David

Open Notes, Progress Notes, race relations

Vol. #15, No. 6

Welcome to the September edition of Tips & Topics (TNT) and to all the new subscribers and our longtime readers.

David Mee-Lee M.D.

SAVVY

In many previous editions of Tips & Topics I’ve written on treatment planning in the hopes of focusing less on paperwork and more on “people-work”.  How can we meet standards and get the documentation done to meet medical necessity payment requirements?  Obtain quality audits and accreditation, and yet have the paperwork be meaningful to help people – meaningful to both the client and the counselor and clinician?

 

So when I noticed an article by John Torous, M.D. and Pamela Peck, Psy.D. in Psychiatric News it caught my eye.
TIP 1
Your clinical and progress notes can be much more than paperwork documentation.

The article was titled: “Sharing Clinical Notes With Patients Improves Treatment Effectiveness”

and was published online: September 12, 2017 Psychiatric News – Sharing Clinical Notes
Here are some excepts from the article:
“The American Journal of Psychiatry published a paper in May 1980 titled “Patient Access to Records: Tonic or Toxin,” which discussed the controversial topic of sharing psychiatry clinical notes with patients. An international movement known as OpenNotes has gained considerable momentum in the last several years and reignited interest within psychiatry.”
“OpenNotes allows patients to independently read their clinicians’ visit notes. Research on the impact of OpenNotes in primary care settings suggests”:
  • Improved communication between patients and clinicians
  • Greater patient engagement and adherence with care plans
  • Improvement in the quality of care.
The authors go on to to say that “the impact of sharing notes around psychiatric care had not been looked at specifically in a psychiatric outpatient setting.” They are coauthors of a study published in the September ScienceDirect. It “offers pilot evidence, as well as clinician and patients’ perspectives, on implementing OpenNotes in a busy outpatient psychiatry clinic.”
The Study
  • 15 mental health clinicians, including psychiatrists, a nurse practitioner, and social workers participated in the study.
  • They offered 568 of their patients immediate access to clinical notes through the hospital online patient portal over a 20-month period.
  • 30%, or 117, of the study patients read their notes.
  • 52 patients completed an exit survey about their experience with OpenNotes.
Survey Results
1. Patients found access to their visit notes helped them:
  • Better remember their care plans
  • Adhere to their medication regimens
  • Make the most of clinical appointments.
2. Clinicians reported that:
  • OpenNotes did not significantly increase their workload.
  • OpenNotes did not lead to complications in the treatment relationship.
  • These positive results may have been a function of patient selection for the study, which excluded many with psychotic illnesses and severe personality disorders.
3. The authors’ discussion:
  • “While it is a mistake to over-interpret the results of this pilot study, the results do suggest that offering select patients easy access to psychiatry notes is not “toxic.”
  • May improve treatment in an outpatient setting in an academic medical center.
  • It is hoped that the results will spur more interest and research in OpenNotes for psychiatry.”
More information about OpenNotes: Open Notes
John Torous, M.D., is co-director of the Digital Psychiatry Program at Harvard-affiliated Beth Israel Deaconess Medical Center in Boston and a member of the American Psychiatric Association’s Committee on Mental Health Information Technology. Pamela Peck, Psy.D., is clinical director in the Department of Psychiatry at Beth Israel Deaconess Medical Center.
In collaborative, person-centered services and documentation:
  • Who should know their treatment plan best?
  • Who should know clearly what they are working on, to get what they want out of treatment?
  • Who should have input and a significant say in what goes into their Progress Notes?

SKILLS

If you go to the Tips & Topics Archives at www.tipsntopics.com, you can see previous editions on aspects of treatment planning:

July 2015 See July 2015
February 2015 See February 2015
July-August 2005 See July-August 2005
February 2005 See February 2005
June 2003 See June 2003
 
TIP 1
Choose five of your client charts at random, gather the treatment team and play “Name that Client” by reading the treatment plan one problem/priority at a time.
If the treatment plan is individualized based on an assessment of the participant’s specific needs, then after reading a few of the problem statements in the treatment plan, you should know which person we are talking about. So let’s try it:
Name that client: Problem #1 “In denial”
Name that client: Problem #2 “Low self esteem”
Name that client: Problem #3 “Lacks positive support system”
Name that client: Problem #4 “Legal problems”
Name that client: Problem #5 “Depression”
Name that client: Problem #6 “Poor impulse control”
 
You could read 10 problems and it could apply to so many clients. This shows this is a generic problem list more for documentation, than a person-centered care
 
See if this is better:
Name that client: Problem #1 “I was just in the wrong place at the wrong time to get that second DUI. I don’t have a drinking problem”
Name that client: Problem #2 “I don’t think anyone would want to sponsor me so I’m afraid to ask.”
Name that client: Problem #3 “All my friends drink or drug, but I don’t see anything wrong with that.”
Name that client: Problem #4 “I want to get off probation.”
Name that client: Problem #5 “I feel like crying all the time, can’t sleep properly and even feel suicidal sometimes.”
Name that client: Problem #6 “When someone ticks me off like that, they deserve a beating.”
When you look at the problem statement, ask yourself What made me say that?”  If you can answer with something more specific which makes sense to the client, then document that answer, not something abstracted back one or two levels.
So for Problem #1 above, “What made me say “In denial”? Well the client said “I was just in the wrong place at the wrong time to get that second DUI. I don’t have a drinking problem” Then that more specific “problem statement” is what to document.
For more suggestions on Problems, Goals and Strategies:
March 2006   See March 2006
March 2005 See March 2005
 
 
TIP 2
If all of the Progress Notes sound generic, check if you are really providing individualized, outcomes-driven treatment.
 
There is a problem if you read a progress note and it says something like:
Client attended group, gave positive feedback to others; is gaining insight and more in touch with her feelings. Continue current treatment objectives.”
 
Such a Progress Note:
  • Is just noting that the person attended group.
  • While it sounds like it is documenting progress, it is not clear what insights are being gained, what feelings are better understood, and what specific treatment strategies are to be continued.
  • It meets the letter of the law in doing a Progress Note, but doesn’t note what progress is being made on what issue.
How does this sound for a more meaningful Progress Note?
“Joe told Jane that she was quite confident in the role-play when she practiced asking for a sponsor. Seeing her do it helped him feel less intimidated about getting a sponsor for himself. Will try asking someone at the next AA meeting and report back to the next group session.
Actually, Joe could have written his own progress note if he was fully empowered in his treatment planning and ongoing progress.
For more suggestions on Progress Notes:
February 2006 See February 2006

SOUL

I just returned from a conference in Roanoke, Virginia. The other trainers were having lunch at the same table and I was curious about a workshop being held at the same time as mine. The topic was race relations, co-led by a white man and a black woman. (I wished I had the opportunity to attend, however my workshop participants would have been quite upset if I had actually done what I joked: “You go ahead and read the handout while I attend the other workshop.”)
There was lots of interesting discussion but I asked the black woman trainer what was the best term to use: “African American” or “black”? I knew enough that the “n” word was totally unacceptable. I learnt some points I had not thought of before:
  • She said that for her, both terms were acceptable, but she preferred “black” because it has positive connotations linked to the civil rights movement of black power, Martin Luther King, and the fight for equality.
  • “African American” was more familiar and perhaps acceptable to younger people more removed from the history of the civil rights movement.
  • “Colored” was definitely a dated word with strong negative emotions and connotations harking back to the time when there were separate drinking fountains, toilets, seating on the bus etc.
  • Some black Americans object to “African American” because “I’m from the USA, not Africa.”
Other pearls I picked up were that “millennials” * are a delight to have in a workshop, as they are so much more willing to talk open-mindedly about race relations and tackle the tough questions. Older white participants often don’t know what they don’t know for example, disputing that there is any such thing as “white privilege”. Being white in a historically predominantly white society easily blinds you to the automatic privileges of being white.
(* “Millennials (also known as Generation Y) are the demographic cohort following Generation X. There are no precise dates for when this cohort starts or ends; demographers and researchers typically use the early 1980s as starting birth years and the mid-1990s to early 2000s as ending birth years.” https://en.wikipedia.org/wiki/Millennials)
Like religion and politics, race relations is one of those topics which stirs a lot of feelings and discussion, best avoided in polite gatherings. However, we live in an era, globally and in the USA, where a tweet, a political rally, a slew of policies on immigration and citizenship are so intertwined with race, religion and politics. One would have to avoid all news media and stop thinking to find conversations that don’t eventually turn to these politely avoided topics.
It is inevitable we all harbor certain prejudices, biases and dark thoughts and attitudes about race relations. Maybe you believe you are evolved and enlightened enough that this is not true in your case.
I know I became a little more enlightened this week over lunch.

Until next time

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

David

Why risky teenage behavior? Prevention and the 5S’s; Power

Vol. #15, No. 7

Welcome to the October edition of Tips & Topics (TNT). Thanks for joining us this month.

David Mee-Lee M.D.

SAVVY

On the August 25, 2017 edition of Science Friday, I was introduced to some different thinking and research on dangerous teenage behavior.  Ira Flatow, the host, introduced the segment with this: “Not long ago, the most popular explanation for any dangerous teenage behavior was what? Remember? Raging hormones. Fast-forward a few years and the explanation changed – the teenage brain is actually biologically different. Teens’ prefrontal cortex is less developed than in adults… that’s kind of current.”
What caught my attention in that broadcast was the work of Dr. Dan Romer from the University of Pennsylvania. This suggests that the risky behavior of youth is driven by something else entirely different from the current theory that the teenage brain is still developing.
If you want to listen to Science Friday August 25, 2017
 
TIP 1
Consider a different explanation for risky teenage behavior: “experience-seeking” rather than an “imbalance” in brain maturation.
Current theories on Adolescent Brain Development
* Sensation-seeking increases in adolescence. Recent findings from developmental neuroscience suggest the adolescent brain is biologically too immature to control impulsive drives and risky behavior.
* The decision-making center of the brain is the prefrontal cortex. This center is still developing up until age 25 or so. It’s the last area of the brain to fully develop, so the adolescent prefrontal cortex is less developed than an adult one.
* The time-lag in brain maturation creates an imbalance between the decision-making center and those regions in charge of motivation and reward, which have already matured.
* Researchers use this to explain why teens have poor impulse control or why they take risks adults probably wouldn’t. The reward center is motivating the teen, however the prefrontal cortex just isn’t prepared to put the brakes on that.
* Dr. Dan Romer and colleagues looked at the research literature and they didn’t see evidence for immature brain development being the cause of bad decision-making.
What was the evidence they saw?
(a) Most teens are not impulsive. They’re somewhat hyper-rational. Teens choose risky behavior because they are trying to gain experience. This ‘gaining of experience’ provides teens with a learning opportunity to gather information that helps in future decision-making.
(b) If it is biology (brain maturation imbalance) which explains risky behavior, many more teens would demonstrate that problem.  But only a handful of teens, relatively, makes impulsive decisions to drink and drive, have unprotected sex or drive at high speeds.  There should be a much higher prevalence if it was due to biology.
(c) If the cause of risky behavior is imbalance in decision-making versus reward center, then you’d expect teens to have difficulty controlling their urges for a quick reward, but that is not actually the case.
Example:

Give a teen the choice between $2 now or a 50/50 chance that they can get $4 later or could get nothing. If the problem is that the decision-making prefrontal cortex is immature and cannot put the brakes on the urge for a quick reward, teens would take the $2. However they are better at weighing the choices in this case.
In studies where teens are given enough information to decide about their chances for a reward or a loss, they are able to use that information to make a successful decision.
(d) Teens are still going to be risky, even if it’s not because of the prefrontal cortex being underdeveloped. They’re still going to make risky decisions. This is especially the case when teens don’t have enough information available to them.  When they’re making decisions without all the information pertaining to a risky behavior, they’re going to choose to take the risk more than adults would, because they’re going to want that new experience (of driving fast, having sex, bungee jumping- whatever it is.)
Conclusion: A complete understanding of developing self-control over risky behaviors is not easily explained by the existence of the imbalance between decision-making and reward regions. Individual differences must be considered.
TIP 2
Understand the explanation for adolescent sensation-seeking and drug use.
 
Dr. Romer’s results are consistent with one explanation given for the rise in risk-taking that is characteristic of adolescence. Their results replicate findings from an earlier study showing that the peak in sensation-seeking during adolescence can explain a good deal of the variation in youth drug use.
  • It is the surge in dopamine activity in subcortical reward centers which explains the peak in sensation-seeking during adolescence.
  • Increased drug use in adolescence is related to a rise in sensation-seeking.
  • Less drug use later on in life is related to the decline in sensation-seeking that occurs later in adolescence, as well as transition to adult roles. Neither of these may require greater frontal brain control as the explanation.
  • Experience gained during the adolescent period may help adults to recognize the hazards of some forms of risk-taking or to cultivate skills to limit such risky behavior.
  • Youth with greater sensation-seeking show that they are better in their ability to delay gratification. This idea may seem odd at first, but it suggests that experience with risk-taking is itself a promoter of self-control and helps them to think before acting impulsively.
  • This finding is also consistent with another apparently odd finding that adolescent criminal offenders are better at self-control as they age. Their repeated arrests provide the experience to weigh the odds and make a decision for self-control.
Conclusion:
When it comes to developing control over adolescent risk-taking, maturation of the prefrontal cortex and its executive functions and decision-making may indeed play a critical part. But Dr. Romer’s results suggest that at least some of this control develops as a consequence of experience.
Reference:
Romer, Daniel, Duckworth, Angela L., Sznitman, Sharon, Park, Sunhee (2010): “Can Adolescents Learn Self-control? Delay of Gratification in the Development of Control over Risk Taking” Prevention Science 2010 Sep; 11(3): 319-330.   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2964271/

SKILLS

These explanations of risky behavior and sensation-seeking in youth have implications for prevention and treatment.
TIP 1
How to find the balance between sensation-seeking and promoting life experiences.
Youth will try risky behaviors both because of the surge of dopamine in the reward centers, but also because they want to experience new situations and learn from them.
The Challenge
How to protect high sensation-seeking youth from negative outcomes while at the same time promoting life experiences to facilitate learning and the development of good decision-making and life skills?
The answer lies in providing adolescents with increasing experience with risky activities but under supervised conditions.
An example that works:
Graduated driver license programs have been shown to reduce dramatically the crash risk of teenage drivers. When such programs supervise the young driver’s experience with risky activities, this is one way to satisfy a teen’s high sensation-seeking needs as well as protecting youth from their own risky behavior.
  • An experienced driver knows that if the car wheels slide off the side of the shoulder of the road, reflexively jerking the steering wheel back could actually turn the car over.
  • Giving the teen the supervision needed to gradually and gently guide the wheels back to the road can prevent the more dangerous reflex to jerk the steering wheel.
  • Allowing the young driver to experience loss of traction of the car tires that starts the fishtailing sway of the back of the car can satisfy the need for a risky thrill. Showing the teen how to steer their way out of that dangerous situation can provide life-saving experience to prevent the car spinning and crashing.
Preventing the use, or negative consequences, of addictive drugs
  • Encouraging activities stimulating to the dopamine system (such as sports and physical activity) can be a way to safely channel sensation-seeking.
  • Direct your prevention efforts for high sensation-seeking youth to providing high-thrill, safe activities. The goal is to increase control over risk-taking impulses without experiencing adverse consequences. e.g. rock-climbing
Strong sensation-seeking tendencies lead adolescents into novel situations that may potentially hinder their adjustment. Nevertheless, this does teach them the importance of considering future benefits and consequences.
An example:
Our youngest daughter (now 31 and well-adjusted) was what you may describe as the “spirited child”. When she was an older teen, we were away one weekend and she had the house to herself. She decided that would be a great time to have a “little” party.
  • A “few” friends came over. Then the word got out to the teens of the town that it was party time at the Mee-Lee’s.
  • Uninvited “friends” were banging on the front door, climbing over the back fence, assembling in the backyard, smashing bottles in the street…you get picture.
  • Neighbors noticed the commotion!
  • She quickly realized things were getting out of hand and called the police to help.
That never happened again, not because we yelled at her or because of our harsh punishment, but because she learned from that experience.
Additionally, in retrospect, although we certainly talked about alcohol and other drug use with our children, we didn’t do well enough with further guidance/strategies:
  • “Whatever you decide to do about substance use, really do it with your eyes wide open about the dangers e.g., riding with others who are intoxicated; knowing how much could cause an overdose of alcohol”
  • “If you do use, call us anytime rather than ride with someone intoxicated or drive yourself home.”
  • “Talk to us about anything. There are no silly questions and you are not alone. If you don’t want to talk to us, we’ll find someone you are comfortable to talk with.”
TIP 2
Remember the Five Ss
When this same youngest left for college, I reiterated my parting and ongoing advice to her that we had shared with all three children: “Remember the five S’s.” These are the areas of life critical to have thought through ahead of time – to examine one’s values, practices and their consequences. It is too late to consider what to do in the heat and immediacy of the moment – the results can be irreversible and profoundly life-changing.
I first wrote about these in the SOUL section of the August 2004 edition of Tips & Topics
Here are the five Ss:
  1. Substances – Besides addiction which is treatable, there are consequences that can be irreversible: acute intoxication causing a fatal accident or overdose, or a head injury with permanent cognitive impairment.
  2. Sex – In the midst of making out, it is not the time to examine your values and practices about abstinence, safer sex, pregnancy and abortion.
  3. Speed – I don’t mean stimulants, I mean cars and driving fast. When the tire blows out and the car rolls, or the car upfront suddenly stops, or the road is wet and the brakes don’t work well – that is too late to think about speeding.
  4. Seat belts – When the car is rolling or you are heading for the windshield, it is too late to buckle up.
  5. Sleepiness – A sleepy driver is as dangerous to self and others as a drunk driver.  When my son sideswiped the median barrier dozing off for a split second after a late date, sleepiness was added to the list.
It is our family’s joke to mention the five S’s.  But hopefully it will prevent some pain with your family or loved ones and save lives and that’s no joke.

SOUL

I imagine any man who has knowingly committed sexual harassment is feeling quite nervous right now. With the current empowerment (correctly so) of women to speak up and speak out that it has happened to “me too”, men who have abused their power and position are on notice.
I can’t imagine that I have every sexually harassed a woman. But then the 41st President George H.W. Bush age 93, wheelchair bound and with his wife right there next to him probably didn’t imagine he could be accused of sexual harassment either….and twice at that! Read about it:
 
At least 45th President Trump is open and honest about how he sees nothing wrong with abusing his power as a celebrity to kiss, grope and try to have sex with women he finds attractive. At one point in the 2005 Access Hollywood video with host Billy Bush, Donald Trump says, “Grab them by the p—y” and “when you’re a star, they let you do it.” Washington Post article on President Trump
 
Of course abuse of power, especially sexual abuse of any kind, is so damaging and wrong. But then I got to thinking how regular people like you and me can also abuse the power we have in relationships.
Do you have any of these attributes or privileges that give you power over another?
  • Age
  • Education or high intelligence
  • Race
  • Sexual orientation
  • Skin color
  • Social class or socio-economic status
And then what about these relationship dyads with inherent opportunities for abuse of power?
  • Parent – child
  • Counselor/therapist – client
  • Doctor – patient
  • Supervisor – supervisee
  • Older sibling – younger sibling
  • Rich – poor
  • Housed – homeless
  • Landlord – renter
  • Husband – wife
  • Expensive fast-car owner – modest low horsepower, slow car owner
I bet that everyone one of us has something where we have power over another… and either have or are tempted to abuse that power.

But it is also true that the Biblical “to whom much is given, much will be required” or “with great power comes great responsibility.”
“There but for the grace of God go I.”

Until next time

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

David

Asian Americans – contrasting cultures; the KKK and a black man

Vol. #15, No. 9

Welcome to the December edition of Tips & Topics (TNT). I hope 2017 has been a good year for you.   But if not, may 2018 be the chance to learn and grow from the challenges you faced.

David Mee-Lee M.D.

SAVVY

In October, I had the opportunity to present at the 23rd Annual Asian American Mental Health Training Conference in the Los Angeles area. Although I am an Australian-born Chinese psychiatrist with 43 years in the USA, I haven’t specialized or focused my training on Asian-American issues. So this was a learning experience for me, as much as it was for the participants of the conference.
The first plenary session presented by Tazuko Shibusawa, PhD, LCSW, Associate Professor, Silver School of Social Work at New York University was particularly illuminating.  Dr. Shibusawa pointed me to a different perspective by contrasting Western cultural beliefs and norms with those of Asian culture.  Even though I was familiar with aspects of what Dr. Shibusawa presented, she did such a clear job of contrasting the cultural differences that I wanted to share these pearls with you.
TIP 1
Compare and contrast the beliefs and norms we take for granted in Western culture with those of Asian culture.
I was reminded how blindly, unspoken and ingrained in our total being are the cultural beliefs and norms we often don’t even realize we hold so dearly.
Western Culture
Asian Culture
1. Problems can be solved.
1. Problems may just need to be accepted e.g., Karma, fate.
2. Problems can be solved by talking about them.
2. Problems don’t have to be verbalized and talked about.
3. Problems can be solved by finding their cause.
3. It is OK to leave things unquestioned.
4. Secrets are dysfunctional and we should be honest and transparent.
4. Secrets can serve a function.
5. Emotions should be understood and expressed.
5. Expressing emotions can be too exposing and unsafe.
6. Communication style is visible, as in public displays of affection.
6. Communication style is invisible – ‘like the air”.
7. Mind-reading is wrong; verbalizing is necessary and important.
7. Understanding can come without verbalizing – understanding through the context of the culture, not necessarily verbalizing everything.
8. Processing and verbalizing are therapeutic.
8. Digesting things can lead to resolution without having to verbalize all the issues.
9. Freedom of speech.
9. Freedom of silence.
10. Straightforward communication is valued e.g., conflict resolution policies; “Let’s talk this through to resolution”; “Let’s have a heart to heart talk”; “I” statements.
10. Indirect communication is valued e.g., a 100 ways to say “no” without exactly saying “no” so as to avoid confrontational interactions – “I’ll get back to you on that”; silent non-response; “I’ll think about it”.
There were so many beliefs on the left hand side of the table above that just seemed self-evident truth.  However I’ve experienced and observed enough Asian culture to appreciate there are billions of people for whom the right hand side of the table is obvious truth.
(We would do well to talk to the “other side of the fence” to create such a table of contrasting world views with the columns being “Republicans” and “Democrats”; “Conservatives” and “Liberals”; “Christians” and “Muslims”; “American citizens” and “Immigrants” – you get the picture.)

SKILLS

You don’t have to be an expert to see how a culturally-informed approach should be quite different when working with Asian-Americans. Having said that, it is equally true because you might now be sensitized to how Asians as a whole culture may view the world differently, you probably still won’t know every Asian or Asian-American person.
TIP 1
Remember that each client and family is unique in their own right. This sharpens our skills to stay person-centered even when you think you know how they view the world.
Being culturally-informed is important; it gives us the knowledge to see through the fog of our own cultural blinders. Even though an individual may be of Asian origin, this doesn’t necessarily mean they think and live like an Asian person.  I have referred to myself as a “banana” – yellow on the outside and white on the inside – because I grew up in a predominantly white society with no close Chinese friends or Asian cultural immersion.  So you wouldn’t know how this Asian person is if I was your client.

In the June 2013 edition Dr. David Powell guest wrote for Tips & Topics to share some of his wealth of knowledge about Asian cultures.  You can read more detail on understanding and working with those from Asian cultures here:

Little did I know that five months after he wrote that for me, he would be gone.  November 2013

 

TIP 2
Check your personal inventory of stereotypical thinking and attitudes about Asian-Americans.
In 2016, Asian American New York Times Deputy Metro editor, Michael Luo, was out walking with his family.  A well-dressed woman on the Upper East Side, annoyed by his stroller, yelled: “Go back to China. Go back to your f…king country.”   Luo wrote an open letter to the woman and placed it on the front page of the Times, asking other Asian-Americans to share their experiences with racial prejudice.
Many Asian Americans shared their brief brushes with the predominant culture – some surprising, some amusing and some sad. It is worth a look at the Times Video: #This is 2016

SOUL

As 2017 draws to an end and our thoughts drift to peace on earth and goodwill to all people, I can’t help but feel sad that we seem more polarized, factionalized, fragmented and disunified as ever.  Historians would probably differ with that and remind me of the American Civil War (what could be more polarized than an actual killing war versus a war of words); and the first and second World Wars.
I know I am guilty of watching certain news channels almost exclusively and don’t spend much time listening to the other divergent views on a competing channel.   I know I self-righteously condemn those who are comfortable with dooming millions of US citizens to little or no healthcare coverage when we are one of the richest countries in the world.  I don’t take the time to really try to understand and empathize with the other side of the argument.
So when I saw this headline: “What happened when a Klansman met a black man in Charlottesville“, I had to read on.  In a December 15, 2017 article Mallory Simon and Sara Sidner wrote about Daryl Davis and how his home is filled with memories of the days he has spent with the Ku Klux Klan.
He is not a member of the white supremacist organization. He can’t be. Davis is the descendant of slaves. He’s a blues musician who has learned how to lift hate out of hearts, even from those who in other times might have been hell-bent on killing him or anyone who looked like him.”
Daryl Davis, a 59-year-old African American, has spent decades talking to Imperial Wizards, Grand Dragons and rank-and-file Klansmen.  He has a collection of about 48-50 KKK robes, given up by Klansmen he has befriended.  “His questions started as a 10-year-old in the 1960s, when he was confronted by racism in the Belmont suburb of Boston and wondered “How can you hate me? You don’t even know me.”  As a man, Davis took that question directly to Klansmen, and some women, too.”
  • Sometimes, it can get ugly.
  • He has been kicked and attacked.
  • “But mostly he listens. Even as some people spew hate. He listens. Thinks. And responds.
  • Occasionally, Davis is the first black person they’ve ever spoken to.”
“Thirty years of these meetings has left him hopeful, not hateful. His closet is filled with dozens of KKK robes and memorabilia given to him by those whom he has inspired to leave the Klan. Not because he demanded it, cajoled or threatened them, but, he says, because they learned from him.”
“They’re done, they’re done,” he says of the men who’ve given up the robes they used to wear so proudly. “As a result of meeting me and having these conversations, not overnight, but over time.”
You can view the rest of the story about when he went to Charlottesville at:
“He listens. Thinks. And responds.”  May we all do more listening and learning and thoughtfully respond in 2018.

Until next time

Thanks for joining us this month. See you next year in late January. Happy New Year!
David

November 2017

Vol. #15, No. 8

Welcome to the November edition of Tips & Topics (TNT). To all of you in North America, I hope you had a great Happy Thanksgiving. Wikipedia says that Thanksgiving is also celebrated by some of the Caribbean islands, and Liberia. But I don’t have any Tips & Topics readers there.

David Mee-Lee M.D.

SAVVY, SKILLS & STUMP THE SHRINK

I frequently receive questions from readers that I answer under a section we call “Stump the Shrink”. Of course I only put in the questions I know the answers to. This month I’m combining Savvy, Skills and Stump the Shrink to include some of the recent questions you may be interested in.
TIP 1
Address client complaints in a person-centered, not counselor-centered manner
Question:
Dr. Mee-Lee, I have a question regarding changing counselors in a residential treatment setting. A person receiving services has stated that she feels that her counselor hates her. She talked with the supervisor and requested another counselor. It was denied. The counselor then gave the person receiving services a book regarding resistant clients in treatment. How would you suggest that a situation like this be handled in a more person-centered manner? Thank you for your time in this matter.
Jan, Minnesota
My response:
Hi Jan:
Thanks for your question. Here are some thoughts:
1. You said the person spoke to the supervisor, but did the person first speak directly to the counselor to share their concern? In any conflict between clients and counselor or staff member to staff member, it is best to have the person talk first at the lowest level of involvement. Then pull in the next level up of authority if the conflict is not resolved. So the client would be encouraged to first talk to the counselor before the supervisor gets involved.
2. If the person said, “I already tried talking to the counselor and it didn’t go well, which is why I am coming you”, the supervisor, then the next step is for the client, counselor and supervisor to meet together so the supervisor can observe how the counselor responds. The supervisor may see that the request for a change is appropriate or if not, they can all discuss why a change would not be helpful and how to work on the conflict in future sessions.
3. If the counselor gave the person a book regarding “resistant clients”, as in this case, that signals to me that the counselor puts all the blame on the client, which would concern me about the counselor’s competence (and maybe even that of the supervisor) though I would need to hear all sides of the decision-making. The 2013 edition of Motivational Interviewing doesn’t even use “resistance” any more because clinicians should be looking as much at their contribution to so-called “resistance” as blaming the client.
Here’s a quote from page 197: “…our discomfort with the concept of resistance has continued to grow, particularly because it seems to place the locus and responsibility for the phenomenon within the client. It is as though one were blaming the client for “being difficult.” Even if it is not seen as intentional, but rather as arising from unconscious defenses, the concept of resistance nevertheless focuses on client pathology, under-emphasizing interpersonal determinants.”
(Miller, William R; Rollnick, Stephen (2013): “Motivational Interviewing – Helping People Change” Third Edition, New York, NY. Guilford Press.)
Hope this helps, but let me know if not.
Thanks.
David
In the February 2007 edition of Tips & Topics, I wrote about conflict and a conflict resolution policy. If you don’t have such a policy where you work, here is one to consider:
 
 
TIP 2
Engaging youth in treatment and using ASAM Criteria levels of care
Question:
Good Morning!
I took a refresher course in ASAM Criteria this past weekend. I was compelled to reach out. Strange how my 10 years in the field has added a “reality” lens to my use of the Criteria. Dealing with insurance companies and limited availability of resources has surely effected my clinical impressions.
 
Working in Portland, Oregon you would think we have great resources, we do – for adults. However, for insured adolescents there is almost nothing. I work with these families. I have a few clients in my outpatient practice who could use Level I (ASAM Criteria Outpatient Services) or Level 2.1 (ASAM Criteria Intensive Outpatient Services) levels of care. It turns out, I am their ONLY source of treatment. I carry my CADCII as well as an LCSW, but I CANNOT meet the needs for clients who need a higher level of care.
 
Any thoughts?
 
Also, what is my responsibility (ethically) working with teens who have no interest in decreasing their use? I am engaging in Motivational Enhancement Therapy (MET) with these folks but I feel a bit stuck.
 
Thanks for your guidance,
Beth Rossi, LCSW, CADCII
Hillsboro, Oregon
My response:
Hi Beth:
Thanks for staying up on The ASAM Criteria and sounds like you are doing some good work with adolescents and their families. While you may not have a lot of access to residential levels, from an ASAM Criteria perspective, clients only need 24 hour treatment in residential if they are in imminent danger* and life threatening risk to self or others or of running behavior with severe consequences like fire setting or prostitution etc. Unless a client is in imminent danger, residential levels should not be used to “break through denial” or just get them away from their environment. Such treatment ends up focusing on behavior control for a young person not interested in learning about prosocial behavior change and recovery. The focus of behavior control treatment is on adolescent rule breaking and loss of privileges and setbacks in the phases of the program rather than on treatment and recovery.
So one question I would have for you is what are the clinical reasons you think your adolescent clients need a more intensive level of care than you can provide?
As regards working with teens not interested in decreasing their use, that is normal for most clients who are motivated more for getting people off their back or avoiding some consequence they don’t like e.g., limiting their curfew, being sent to a foster home or juvenile hall. So the focus of treatment you do is “discovery, dropout prevention” not “recovery, relapse prevention”** using as you are doing MET and Motivational Interviewing. You help the teen discover, at a pace that makes sense to them, a connection between drug use and the consequences they don’t want. Also you want to keep them engaged to not drop out. It is hard to help someone if they are not there!
Here is an example of “discovery” motivational work for a teen who doesn’t think he has a drug problem because “I can stop any time I want”; and certainly doesn’t see anything wrong with hanging with his drug using friends:
Treatment Plan Strategies:
1. Jordan will gather all the data he can from school, family, legal history to prove he doesn’t have an addiction problem.
2. Jordan will demonstrate he doesn’t have a substance use problem by just stopping all use; and continue hanging with his friends to see how well he does with abstinence as measured by random urine drug screens.
So long as the teen is willing to try these “discovery plans” and is adhering to them, you keep working with them. If a client doesn’t show up or doesn’t follow through on a treatment plan you collaboratively agreed upon, then you could be “enabling” the client. By that I mean, that if outcomes are not going well, and the teen keeps getting into trouble with their substance use or behaviors, the next step is to assess what is not working and change the treatment plan in a positive direction. It is “enabling” If the client is not held accountable to change the treatment plan in a positive direction and you just continue to see the client. The client gets the message that there is no real expectation to change or take responsibility for treatment.
Any changes to the treatment plan can be a small incremental step e.g., “OK I will stay away from Harry who is the hardest person I have trouble saying “no” to. But I’m not giving up all my friends.” That is a change in the client’s treatment plan in a positive direction so treatment should continue. That is progress and you keep going. But if the client does not see anything s/he will do in a positive direction, then just keeping the person in treatment is enabling. The client has the right to choose no further treatment and then you let the consequence happen.
Hope this helps, but let me know if not.
Thanks.
David
* Imminent Danger (The ASAM Criteria 2013, pp. 65-58) – Three components:
1. A strong probability that certain behaviors (such as continued alcohol or other drug use or addictive behavior relapse) will occur.
2. The likelihood that such behaviors will present a significant risk of serious adverse consequences to the individual and/or others (as in reckless driving while intoxicated, or neglect of a child).
3. The likelihood that such adverse events will occur in the very near future, within hours and days, rather than weeks or months.
  

** I first wrote about “discovery, dropout prevention” and “recovery, relapse prevention” plans in just the third edition of the first year of publication of Tips & Topics – June 2003. If you’d like to read more on that, here’s the link:

Beth’s response:
Dr. Mee-Lee:
I really appreciate your feedback. You have given me numerous points to consider. What is my role for these clients? Therapist or addiction counselor, usually BOTH roles apply.
 
I guess for some reason I am fearful that parents/guardians will have expectations that I can decrease/prevent substance abuse in their teen. Having worked in residential facilities in the past and knowing that parents sometimes think treatment = abstinence. Now that I am processing it, I realize I am placing some high expectations on MYSELF!
 
I am currently working with a family whose daughter was in imminent danger and I could not get her treatment until she made a suicide attempt (after running away with drug use and prostitution). Now she is in treatment in another state and we are engaging in weekly sessions via telephone. Her progress is limited.
 
I feel that some of my adolescent clients need 2.1 level of care and I do not have the time in my schedule to provide this amount of client contact/treatment.
 
Maybe I am looking at the ASAM Criteria too literally? I do not need to place someone AT a facility just to place them using the Criteria. I need to be more flexible in my thinking! ?
 
Thanks again!
Beth
 
 
My second response:
Yes, Beth, with your training you are actually able to do integrated co-occurring disorders work, which is what a lot of clients need but can’t obtain very well.  For most youth, motivational work is going to be where to start- once any imminent danger situations have been stabilized.  I wonder if your client ,who is in residential treatment, is actually receiving motivational work; or whether she is expected to be interested in sobriety and recovery when she might not be.  That might be contributing to what you said is happening: “progress is limited.”
You are in a good position to do that motivational work once any imminent danger activities are stable.
All the best,
David
 
References:
1. 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.
2. Miller, William R; Rollnick, Stephen (2013): “Motivational Interviewing – Helping People Change” Third Edition, New York, NY. Guilford Press.

SOUL

As I write this, I am on a plane en route to India to conduct three days of ASAM Criteria training. Making this training happen has been a labor of love for both the organization in Pune, (not far from Mumbai or previously, Bombay) and for me as well. They have very limited resources, yet the Executive Director has been passionate and single-minded about introducing The ASAM Criteria to India.  I couldn’t let her commitment over the past two years go unsupported.

When they finally found enough resources to conduct the training, it was a rush to match my limited availability with their window of dates too. That made getting an Indian entry visa a time-pressured, tense process: completing a complicated visa application (three times to get errors correct); photos; several approval processes, some requiring

more documentation, explanatory phone calls, waiting…….more waiting, more documents and explanation – all of this to just enter the country for a week to do an ASAM Criteria training to physicians.

Once all the documents were declared accurate and the complete, the tension shifted to the Embassy’s processing the application. Would the visa come on time to make the trip? Why did the tracking update information on their website stay stuck for days on “Under Process at Embassy”? All I want is to do a 3-day training in India, I am not wanting to immigrate; or steal any resources; or terrorize the country.
In the process, I expanded my empathy for the millions applying for a visa to enter the USA. Getting an Indian visa was not life and death. The worst that could happen is the training got postponed.  However for many seeking asylum and safety in the USA, it is literally life and death. And they are not waiting just for a few days or weeks. The wait is often years, maybe decades!
I am so grateful to hold a passport to two wonderful countries – my country of birth, Australia; and my country of choice, the USA.  Coming and going so freely with passports many would die for trying to get them, is easy to take for granted.
My Indian visa experience reminds me that freedom to come and go is to be treasured.

Until next time

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

David