Vol. 9, No. 10
In This Issue
SAVVY – What do you do when a severely mentally ill person keeps using substances?
SKILLS – Clinical and systems questions, suggestions and solutions
Politics of personal destruction
STUMP the SHRINK
Addiction relapse and confidentiality and the courts
David Mee-Lee M.D.
For many years, I have been doing case consultations with clinicians and Assertive Community Treatment (ACT) teams who work with severely mentally ill people.
One consultation question continues to come up year after year. The question is this:
What do you do with a client who is ambivalent about, or even outright uninterested in, stopping or cutting back on their alcohol and other drug use?
In addiction treatment, counselors can try Cognitive Behavioral Therapy (CBT), Motivational Interviewing and other methods to try attracting a person into recovery. If these strategies fail to engage the client, it is not unusual for clients to drop out of treatment or even be discharged as “non-compliant”.
For mental health programs and clinicians…. When working with these clients (those with severe mental illness and co-occurring substance use problems) it becomes very difficult to discharge the client- even if they wanted to. The goal of treatment is to attract people into recovery and to make real change, not getting rid of clients when outcomes are poor.
SAVVY this month is not about imparting some nifty tips on this particular topic. There are many clinicians, consumer advocates and peers more expert than me on working with severely mentally ill people. I am opening up this topic to harness that expertise out there. How do we improve clinical and systems approaches to people with co-occurring severe mental and addiction illness?
Consider the clinical and systems dilemmas in working with severely mentally ill people who are not interested in treatment for their substance use problems.
Here is a clinical vignette to set the scene:
A client diagnosed with a schizophrenic disorder repeatedly and firmly declines any addiction education or treatment.
- Diagnostically, the mental health team identifies a clear Substance Use Disorder; the client even acknowledges his alcohol and drug use, but declares no interest in changing his substance use.
- The mental health team has very little leverage to create incentives for treatment.
- They have already implemented strict representative payee management of funds by paying for his housing directly with the landlord. They accompany the client food shopping so they can pay the supermarket directly. They give him very little spare cash to discourage using his disability income for drugs or from his being mugged and robbed while intoxicated.
- Despite such tight care management, the client is able to make enough money (by panhandling and odd jobs in addition to his disability payments) to use those funds to buy and use alcohol and other drugs.
- The client’s addiction and his mental illness interact creating crises to which the ACT team is compelled to respond. For example—- They transport him to detox if he has run out of money and can’t buy any more drugs for now. They have frequent care management visits to ensure the client is safe and has not overdosed, as has happened several times before. There are other interventions directly related to the client’s refusal to moderate his substance use and get any treatment.
Dilemmas I hear from the clinicians about the clinical and systems implications:
1. We want to be responsive to consumers in crisis. But we spend so much time and energy “picking up the pieces” of the clients’ drinking binges and substance-induced psychiatric emergencies, that it seems more like babysitting an out-of- control adolescent.
2. It seems like we waste a lot of treatment and care management resources watching the revolving door of frequent detox admissions and acute psychiatric crises in the emergency room. Clients are not held accountable for their behavior. Then we use expensive treatment and wrap-around resources to deal with the aftermath of their refusal of addiction and/or mental health treatment.
3. I feel like I am “enabling” the client – giving the explicit and implicit message that you can do whatever you want and we will keep “bailing you out”, literally and figuratively. For example, the consumer is evicted from housing because of noisy partying with intoxicated friends, and we scurry around to find a new apartment or hotel room. The client loses his/her disability money due to being robbed while intoxicated, and we make sure the client gets food and shelter.
4. I know about harm reduction, and “Housing First” initiatives which provide housing regardless of a consumer’s commitment to treatment. (See SAVVY, Example D. June 2009 http://www.changecompanies.net/tipsntopics/?p=807)
I see the value of meeting the client where they are and attracting them into recovery. But where do we draw the line? We clinicians feel frustrated and disempowered by what seems to be:
Giving clients the wrong message about personal responsibility and the consequences of a person’s choices.
Inefficient and ineffective use of treatment and care management resources, especially with tight budgets which already means many consumers are unable to access services.
Systems’ mandates that we do ‘whatever it takes’ to keep people in the community, but then staff feel like glorified servants responding to every demand or crisis. Some clients are so used to being transported to appointments, provided food and shelter whenever they have mismanaged their resources, that they have now been trained to say whatever it takes: “I’m in withdrawal and need to go to detox” or “I’m suicidal or hearing voices telling me to kill myself”.
5. I know the importance of establishing a therapeutic alliance and adopting a recovery-oriented, strength-based approach. But how do you attract a person into recovery and help them to see and experience their own strengths and skills, when there is no agreement on a treatment goal of abstinence or cutting back; no agreement on interventions (“I don’t want medication or addiction treatment”) and the working relationship with the client is based on the care manager’s task to fix every housing, transportation or behavioral health crisis?
There you have it!
–> Do you resonate with these dilemmas? Or work with people who do?
–> Do you have solutions you can share?
–> Are there hidden attitudes, biases or values in the way these dilemmas are expressed?
–> Is there a need to change anything we are doing with ACT teams, care management, housing and community reintegration for the severely mentally ill?
As I said, I don’t have all the answers to these clinical and systems dilemmas. But here are some tips to get us started. Actually they are more questions and suggestions than tried and true solutions.
Balance care with confrontation; support with accountability.
Mental health systems have a long tradition of caring and supporting people. Some state hospitals still have patients who have lived there for years and even decades. In some private psychiatric hospitals, some treatment models were designed to create the community in the hospital, where patients stayed for months and years.
Addiction treatment has had a long tradition of confrontation and accountability. If a client has alcohol on his breath, he is confronted and may be told to leave. Or if she is late to a group session, the door might be locked. If there is a positive drug screen result for cocaine or opiates, the outcome may be discharge or a legal sanction.
When mental illness and addiction come together, finding the right balance is especially difficult with those with severe mental illness.
How do you find the right balance?
- The balance between: Empowering consumers to make their own choices, recognizing the strengths and skills they have for recovery and overcoming institutionalization; while at the same time taking care of their housing, transportation, food, income and treatment regardless of what choices they make?
- The balance between: Having them be accountable for their choices (with the natural and logical consequences of those choices); while at the same time- recognizing their mental and addiction illness may severely compromise their ability to choose effectively?
Assemble all stakeholders to brainstorm about these clinical and systems issues.
We need ALL people at the table to find the right balance: consumers and consumer advocates; behavioral health administrators and funders; clinicians, care managers, treatment personnel of all disciplines and credentials; providers of housing, board and care homes, shelters; mental health and drug courts; criminal justice personnel. Even politicians need to be part of the conversation as they frequently have to face the community outcry about mentally ill, intoxicated homeless people roaming the streets.
What could be some innovative clinical and systems solutions which would have the following goals?
Efficient and effective use of treatment and care management resources.
Design and develop a more flexible continuum of treatment and care management services than the current one, which is funded more narrowly with Intensive Case Management (ICM) and ACT teams.
Pilot different clinical approaches to minimize “enabling”. Find approaches successful at holding clients accountable for their outcomes, balanced with their level of severity, recovery potential, skills and strengths.
The Farm – Design a pilot project which promotes recovery, accountability, dignity and success experiences.
There are about 15 therapeutic farms in the United States where residents are offered “a tranquil place to learn the value of work and community.” (Behavioral Healthcare, 2009). For a long time I have wondered if a State or County would try a pilot project for the kinds of clients described in SAVVY above. Instead of repeated crises (plus the revolving doors of detox, psychiatric emergency visits, hospitalizations, an array of board and care, hotel rooms, group living and 24 hour supervised living) ……..imagine The Farm!
“The Farm” would model itself on the experience of therapeutic farms having their roots in the 18th century, combined with using strategies and successes of present day therapeutic farms. Naturally much more dialogue is needed to sort out the clinical and financial aspects. The therapeutic farms in the 2009 article are treatment settings that require a daily cost of $150-$250/day. The Farm, as I envision it, would be more a longer-term, supportive, therapeutic community at a lower cost.
Here is the vision:
1. Every day, care managers are taking control of repeated failure experiences with clients. Instead… The Farm would provide daily success experiences “enjoying the calming surroundings…..daily interactions with pigs, sheep, horses, cattle, and other animals, as well as work in flower and vegetable gardens.”
2. Every day now, consumers get the message reinforced that they can do whatever they want and the treatment team will pick up the pieces. Instead….The Farm would be “a tranquil place to learn the value of work and community.”
3. Every day, resources are spent, inefficiently and ineffectively, providing acute care detox and psychiatric services. In addition, social services and criminal justice costs are incurred. Instead…..The Farm would provide 24-hour support and services at a fraction of the costs now spent too reactively on acute care, care management, social and criminal justice services.
For clients with severe mental illness refusing to consider cutting back or stopping their substance use, the time would come to stop “enabling”:
“You are either unable or unwilling to function stably in the community. Instead of repeatedly trying to make you function in the community with the ACT team reacting to crises, the plan is to have you live at The Farm. There, you will be supported on a 24-hour basis, because right now we are reacting to your crises rather than being proactive promoting recovery for you. Because The Farm is in the country, you will not be able to come and go, so you might find this more restrictive than you are used to. However we want to give you a chance to be safe, supported and successful.”
We can anticipate some clients’ reactions to hearing of this pending change in their living situation. Many clients might object, emphatically stating they don’t want to go to The Farm. They want to roam free, able to do whatever they want, when they want, with whom they want, as they have been doing. Clinicians are frustrated as they have the goal of recovery and sobriety for their clients. Such clients have not agreed on this recovery goal. Now we have a better chance to create agreement on the treatment goal: to avoid going to The Farm. Now we have a chance to focus on improving mental health and substance use functioning.
“I understand why you want to roam free, do what you want to do, when you want and we want that for you too. It’s just that when you keep acting as if you can’t function well yourself in the open community and we have to keep picking up the pieces, that we think about The Farm. Would you like to work on not having to go to The Farm? If so, we can then work on what methods and strategies will improve your functioning in the community so you can stay independent and not need The Farm. However if the outcomes don’t change and we continue to have to “bail you out” as often as we are now, then we have no alternative but to have you be safe at The Farm.”
Such a pilot project would achieve the balance of care with confrontation, of support with accountability. This means ALL stakeholders would come to the table to fashion this project. The aim would be: to promote recovery, personal and fiscal responsibility, dignity, success experiences, choice and empowerment.
I believe it is high time to examine the unintended negative consequences of the safety net, ACT and ICM wrap-around services we have created.
Douglas J Edwards: “Planting Recovery”- Behavioral Healthcare, February 2009
“Health Care and Public Service Use and Costs Before and After Provision of Housing for Chronically Homeless Persons with Severe Alcohol Problems”, 2009
Here is one reason I know I will never run for political office…the Politics of Personal Destruction.
You may remember that President Bill Clinton used that phrase in 1998 when under fire for his relationship with Monica Lewinsky. Go back—more than 200 years ago in 1808, Massachusetts Governor Sullivan told Thomas Jefferson that the “principal object” of the Federalists appeared to be “the political, and even the personal destruction of John Quincy Adams.”
I’m no historian, I just Googled it.
I know that when people run for political office, especially Presidential political office, they are not naïve about the Politics of Personal Destruction. Or if they were naïve, they soon wake up. How many times have you seen a candidate say: I am going to take the high road…propose positive solutions not negative attacks against my opponents…uplift and inspire people, not drag opponents through the gutter.
Either…you don’t hear much from them anymore because they drop out of the race, because they have not responded and countered with negative attacks of their own which they know can take them “off message”, Or…. quickly they fight back and start their own negative attacks (or their proxies do). It is just a fact that in politics part of the process of winning the prize requires you to beat the other person down to stand on their shoulders to get to the top.
I have no illusions this will ever change because conventional human nature likes conflict, a good fight, winners and losers, a good debate with clever, cutting sound bites. Imagine if the Super Bowl was played just for the fun of it and no one kept score. There would be no “Super” in the name. Instead of a prime Sunday afternoon time slot, the game would air at 1 AM on your local town cable network- if it aired at all. In political debates, your poll numbers go up if you show you can fight back and defend yourself, and they go down if you are too nice and accepting.
This all seems so opposite to what we value when trying to help people recover and have hope for an empowered life.
We tell clients: Succeed by harnessing what is good and effective in your life, not tearing yourself or others down. Focus on what can be, not on your past failures and shortcomings. Learn from your mistakes, however your mistakes are not the essence of who you are, or how you have to act in the future.
Oh well, I’d much rather live in a democracy than an autocracy or theocracy. So the Politics of Personal Destruction comes with the territory. No political candidate will be beating down my door for consultation on how to run their campaign.
Just so long as the politics of personal destruction doesn’t come anywhere near the business of helping people change and grow.
STUMP the SHRINK
“Please direct me toward an answer to this question. I understand the CFR 42 (Federal regulations on confidentiality of alcohol and drug abuse patient records) to say that information about a person’s drug use cannot be used legally, punitively against them. Yet, frequently when we report a relapse to a client’s probation agent, the client is violated or taken back to court. Do we as a treatment program hold any liability for actions taken by corrections or the court after we report chemical use?”
Resa Walker, MS LADC, CCDP-D
Neighborhood Counseling Center Dual Disorders Program
Thank-you for your question, which is a tricky one. I don’t think you are liable legally if you give a progress report and the court uses it to violate the person, though I understand your dilemma. You would probably be more liable if you refused to give the information of a relapse. The solution, which is worth working on (I have written about this before in Tips and Topics and elsewhere) is to work on your relationship with probation officers and the court to have the court mandate assessment and treatment adherence.
Thus, if someone uses or relapses while in treatment, and the client is willing to change their treatment plan in a positive direction, then you can report that even though the person used, they are still in treatment and complying with the court order. Explain that the person has agreed to change their treatment in a positive direction and therefore should continue treatment rather than interrupt the treatment with re-incarceration or something else that breaks the therapeutic alliance.
If the client is not willing to change their treatment plan in a positive direction, then they are not doing treatment. They can be violated as non-compliant with the court order to do treatment. They are not being sanctioned because of relapsing or using, but because they are not doing treatment.
“Thank-you for the response. It was helpful, but an ongoing dilemma due to our philosophy of harm reduction with the goal of abstinence and recovery.”
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Thanks for reading. Join us in late February.