Vol. 14, No. 10
In this issue
Enduring principles as healthcare changes
Customer & team values
David Mee-Lee M.D.
Vol. 14, No. 10
In this issue
David Mee-Lee M.D.
Vol. #14, No. 11
In this issue
David Mee-Lee M.D.
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)
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.
What is stigma; and why it is important to know about stigma when working with gambling disordered individuals.
Why it is important to know about stigma:
Be mindful of stigma and words. Here are some examples of stigma in Gambling and Substance Use Disorders.
Stigma and Words
Examples of Gambling and Substance Use Disorder Stigma
Combat stigma by changing our language to recovery terminology.
Combating Stigma – Watch our language!
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)
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)
How to create “Gambling Stigma Reduction Initiatives”
Here’s what it takes to create “Gambling Stigma Reduction Initiatives”:
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.
Daniel echoes the theme for this year’s Problem Gambling Awareness Month for having the conversation about gambling.
Because gambling is considered an invisible addiction, addiction and mental health counselors are encouraged to screen for gambling disorder.
Why an “invisible” addiction?
When clinicians and counselors screen for gambling disorder, this leads them to “have the conversation” with their clients; otherwise, it may go undetected.
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:
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.
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.
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To order: The Change Companies at 888-889-8866; www.changecompanies.net
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.
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.
Welcome to May edition of Tips and Topics. We’re glad you could join us.
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.
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.”
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.
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.
“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:
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:
In the September 2014 edition of Tips and Topics, we covered in more detail problem- solving courts. Tips & Topics September 2014
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:
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:
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.
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:
References and Resources:
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.
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:
(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?
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.
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?”
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.
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:
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: firstname.lastname@example.org.
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:
“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 email@example.com. 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.”
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.
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:
Here’s link to the Abstract:
How to download the full article:
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
Here are a few Skills tips to help rethink graduation ceremonies and promote sustainable self-change in the people we serve.
How to move from graduation to commencement ceremonies.
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.
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”.
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.
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?
How about hotels?
Then there’s Uber
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:
However there are a lot of “unfriendly” practices which come to mind:
Why not offer me a printout of my current history, then I can indicate any updates or changes on that ‘existing information’ form?
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.
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.
Welcome everyone to the July edition of Tips & Topics (TNT). Glad you could join us.
Thanks for joining us this month. See you in late August.
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.
|Brunswick Heads, New South Wales|
sandy beaches. No pebbly, rocky, narrow, coarse sand beaches for me!
$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.
Welcome to the September edition of Tips & Topics (TNT) and to all the new subscribers and our longtime readers.
The article was titled: “Sharing Clinical Notes With Patients Improves Treatment Effectiveness”
If you go to the Tips & Topics Archives at www.tipsntopics.com, you can see previous editions on aspects of treatment planning:
I’m glad you could join us this month. See you in late October.
Welcome to the October edition of Tips & Topics (TNT). Thanks for joining us this month.
I’m glad you could join us this month. See you in late November.
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.
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”.
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
Thanks for joining us this month. See you next year in late January. Happy New Year!
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.
** 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:
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.