Volume 3, No.8
In this issue
SAVVY | SKILLS | SOUL
David Mee-Lee M.D.
Last month I attended the Second Annual Joint Commission National Conference on Behavioral Health Care: Focusing on Outcomes Research and Using Data. It got me thinking again about what is quality care that results in positive outcomes in addiction and mental health. Vijay Ganju, Ph.D., is the Director of the Center on Mental Health Quality and Accountability at the National Association of State Mental Health Program Directors Research Institute. In his keynote address he said something that caught my ear. He suggested that we must think beyond “person-centered care” to now focus more on “person-directed” care – emphasizing an even more active, stronger collaboration with clients, patients and consumers.
A second presentation by John Norcross, Ph.D., Professor of Psychology and Distinguished University Fellow at the University of Scranton, put into perspective the effective elements of a therapy relationship. He emphasized the alliance over the specific technique; goal consensus and collaboration over treatment method and model.
- Review the rules on patient-centered care that are considered central to improving the quality of care for mental and substance-use conditions.
In November 2005, the Institute of Medicine released a new report. This built upon a 2001 report titled “Crossing the Quality Chasm: A New Health System for the 21st Century” which puts forth a strategy for improving health care overall. The new 2005 report was titled “Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series.” The Quality Chasm framework is applicable to health care for mental and substance-use conditions, and describes a multifaceted and comprehensive strategy to do so.
Ten rules originally published as a guide to the redesign of health care in general were reiterated in the 2005 report on mental and substance use conditions. Of the 10, at least five are rules for “patient-centered care”:
–> Customization based on patient needs and values
The system of care should be designed to meet the most common types of needs, but have the capability to respond to individual patient choices and preferences.
–>The patient as the source of control
Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them. The health system should be able to accommodate differences in patient preferences and encourage shared decision- making.
–>Shared knowledge and the free-flow of information
Patients should have unfettered access to their own medical information and to clinical knowledge. Clinicians and patients should communicate effectively and share information.
–>The need for transparency
The health care system should make information available to patients and their families, information which allows them to make informed decisions when selecting a health plan, hospital, or clinical practice, or choosing among alternative treatments. This should include information describing the system’s performance on safety, evidence-based practice, and patient satisfaction.
–>Anticipation of needs
The health system should anticipate patient needs, rather than simply reacting to events.
As you read each of these rules it may sound like you’ve heard it all before in Joint Commission and CARF accreditation standards etc. The clinical, administrative and programmatic implications of each rule are wide ranging and would indeed be a redesign challenge worth exploring.
Crossing the Quality Chasm: A New Health System for the 21st Century (2001) Institute of Medicine, National Academy of Sciences. http ://www.iom.edu/CMS/8089/5432.aspx
Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series (2005) Institute of Medicine, National Academy of Sciences. http://www.iom.edu/CMS/3809/19405/30836.aspx
- Developing the alliance is the highest priority in the opening phases of therapy.
In the last 30 years there have been over 2,000 research publications and papers on the concept of the alliance. Here are some of the conclusions about developing the alliance which may help in your therapeutic practice with clients:
–> Develop a strong alliance early in treatment.
“Early” is relative to the length of therapy. But there is a convergence of evidence that points to sessions 3 to 5 as a critical window. In some ways this is not surprising if you have ever gone to therapy yourself. Would you likely go back to a therapist who you didn’t feel was helping, and whose methods and ‘fit’ with your style seemed ineffective? Would you really be interested in hanging in for five or more sessions? Of course if you have excellent retention rates, then you can ignore this point. You must be doing this well already.
–> A client’s experience of being understood, supported, and provided with a sense of hope is linked with the strength of the alliance in early stages of therapy.
Clinicians need to be curious about the client’s perception of what you are doing to generate empathy, support and hope. Their interpretation of what you do, especially early on in treatment, can be quite different from what you intended. Message sent may not be the same as message received. Simply because you think you are great at engaging people does not mean the client experiences it that way, at this point in time, with you. Restated: you may be a great clinician, but not necessarily for this particular individual at this time, doing the kind of work you do. This leads to the next concept.
–> Continue to improve and negotiate the quality of the relationship as an important and urgent challenge.
You can assume your initial assessment of the client’s relational capacities, style, preferences and quality of the alliance will probably differ from the client’s. It is the client’s perception of the alliance that is most influential, not yours. If they feel no hope or confidence in what you have to offer, they are the ones who stop coming to treatment – either physically and/or energetically (particularly if mandated or incarcerated). So it is important to specifically check out their perceptions on whether the relationship in treatment is working for them or not.
–> Techniques and models contribute less to outcome in early stages of treatment than the quality of the alliance.
The alliance should be forged first. This includes a collaborative agreement about the goals and strategies of treatment. Only then can various models and techniques be usefully implemented.
The bottom line:
Developing a good working alliance with the client is not just a nebulous, generic, nice thing to work on over weeks and months. It is a specific, early, clinical priority to evaluate and measure.
“Psychotherapy Relationships That Work – Therapist Contributions and Responsiveness to Patients” (2002) Ed. John C. Norcross. Oxford University Press, New York. pp 11-14.
Horvath AO, Bedi RP (2002): “The Alliance” in “Psychotherapy Relationships That Work – Therapist Contributions and Responsiveness to Patients” (2002) Ed. John C. Norcross. Oxford University Press, New York. pp 37-69.
Words and terminology we use are often so ingrained, the meaning and implications so unconscious that it can be a surprise when someone actually raises your awareness. That’s what occurred as I was reading “Improving the Quality of Health Care for Mental and Substance-Use Conditions.” It happened a second time as I listened to this presentation: ” A White Paper by People who are New York State Consumers, Survivors, Patients and Ex-Patients” (NYS Office of Mental Health Bureau of Recipient Affairs).
- Notice and consider the terms we use and take for granted. You may want to change any that reinforce stigma and other unintended implications.
Not to make you a PC (politically-correct) freak, but chapter 3 of the Institute of Medicine’s 2005 report entitled “Supporting Patient’s Decision-Making Abilities and Preferences” raised some terminology points I had not considered before.
–> “Mental illness” often is used as a singular noun instead of plural “mental illnesses”. A one-size-fits-all label of “mental illness” could contribute to a perception that all mental illnesses have equal consequences, disabilities and handicaps. We do not typically refer to individuals as having “cancer” as if it is a single disease. Our more accurate terminology says an individual has leukemia, breast cancer, melanoma, or lung cancer. Similarly we don’t say an individual has “infectious disease”. We use specific terms – HIV, measles, or TB etc.
–> “Disorders” and emotional “disturbances” are used to describe mental illnesses, problems and symptoms. In non-mental illnesses, the terms “disorders”, “disordered” and “disturbance” are used less frequently. In general health care terms like “diseases,” “conditions,” “symptoms,” “problems,” and “complaints” are used for most health conditions. If these terms were also applied to mental illnesses, individuals might have an illness, condition, symptoms, or a problem that is amenable to a short-term intervention. Mental illnesses and problems ought to be regarded no differently from most general health illnesses, problems, and symptoms.
–> “Serious and persistent” has no counterpart in General Medicine. General illnesses use terms such as “severe,” “chronic,” “mild,” and “acute.” It is not common for example, to talk about “serious” cancers. The term “persistent” could connote a lack of belief in the ability to improve and recover. There is a less pejorative and clinically useful way to categorize individuals with mental illnesses where there are chronic, functional limitations. A way to refer to them could be: someone who has a mild, moderate, or severe disability associated with a mental illness symptom or diagnosis, rather than referring to them as the “seriously” mentally ill.
- Shift to terms which promote collaboration, empowerment and recovery.
Amy Colesante, Deputy Director of the NYS Office of Mental Health Bureau of Recipient Affairs, reminded us that “labels belong on jars, not people”. Here are terms she called “spirit-breaking” language:
What attitudes and emotional reactions bubble up for you when you say this person is “non- compliant”? I would bet very few positive reactions come to mind. In the January 2004 edition of TIPS and TOPICS here’s what I stated about Treatment compliance versus treatment adherence: In the literature, much of healthcare has been using “adherence” long before the mental health and addiction treatment field became aware of the implications of using “compliance” versus “adherence” terminology. In this age of empowerment and collaborative service planning, it is not for the expert counselor and professional to develop a plan with which the client must comply. It isn’t for the physician to prescribe the medication with which the patient must demonstrate medication compliance.
Webster’s Dictionary defines “comply” as follows: to act in accordance with another’s wishes, or with rules and regulations. It defines “adhere”: to cling, cleave (to be steadfast, hold fast), stick fast. Do we really want people to “comply” with treatment? Or do we want them to be so invested in a collaborative endeavor together that they want to be steadfast and hang in with treatment – to “adhere”?
If your client, patient, consumer or family is “non- compliant” don’t look at the pathology of the individual. Look at the lousiness of your alliance and treatment plan. It is probably your treatment plan that you want them to comply with, rather than their treatment plan in which they are invested and desire to adhere to.
If you want to see more about terminology, read Volume 1, No. 9 January 2004 issue of Tips & Topics.
When you use this term, do you face the person with optimism and confidence that much will be achieved? Is it easy to assume a more passive stance when you hold very low expectations for recovery or improved function? Wouldn’t it be more useful to identify a person’s struggles, and then develop a collaborative plan to address those areas most important to the client? For example with the use of money: Would your client like to have more control themselves rather than have a representative payee in charge of their money? With a living situation: Would your client like to live wherever they want, rather than remain homeless, be told where to live, what to do, and with whom to associate?
If “chronic” is misused to mean a sense of hopelessness about poor outcomes, serious and persistent illness, repeated treatment failures, a non- compliant and low-functioning relapser, I suspect both your spirit and your client’s spirit will be broken. “He’s a chronic” or “She’s just chronic” do not exactly inspire hopeful recovery work. When used in contrast to “acute” illness in general healthcare, “chronic” is a more neutral term to denote the long-term nature of an illness needing committed treatment and continuous support.
An argument can probably be made for all these terms. It is not my intention to make us so self- conscious and PC-obsessed that we can hardly converse without offending someone. Let’s remember that behavioral health people are generally people of good will, trying to do the best we can with limited resources and huge challenges. See what you think of these suggestions/ perspectives. If there’s a way to use our terminology better so it positively reduces stigma, impacts recovery and increases resources, perhaps it’s worth tweaking our language.
Recently I heard about the “Slow Cities” movement – whole towns deliberately committed to a slower pace of living in work, play and all activities. (If you want to read more about this, click Here)
That intrigued me, especially as I was driving at 70 miles per hour on the freeway to San Francisco on a conference call with a committee across three time zones. My cell phone (hands-free of course) communicated with their speaker phone and another committee member who was conferenced in on his cell phone. I was rushing to make it in time to register for a conference, trying to weave in and out of long traffic lines waiting to pay the toll across San Francisco Bay. Doing that, I might even gain ten feet and one minute!
What’s wrong with this picture?
Yet I don’t think I am the only crazy person who too often lives and works like this. You probably have your own pet story that captures our collective busy- ness.
As I paid the exorbitant speeding fine (after rushing to get home from another conference in San Francisco on another occasion) I felt a rekindling of my annoyance (almost incense) at the highway patrol woman who had stopped me. Didn’t she know I was a law-abiding citizen who hadn’t had a speeding ticket in years? Hadn’t I just helped the community by conducting a workshop on helping people with co- occurring mental and substance use problems? Didn’t she see I was just keeping up with the flow of traffic etc. etc.? You are not interested in my several other rationalizations, minimizations and projections of blame.
In case you haven’t had a speeding ticket lately, you can do traffic school over the Internet now and avoid getting bad driver points. I didn’t know that. My 20 year old, “spirited” daughter did know that—-from personal experience. She even offered to do the test for me – for a fee of course. Being the law-abiding citizen I am, I did the course myself. Did you know you should leave a three second space of time between you and the next car in front of you? Do you even know how to judge a three second lag time anyway?
Want to join me in the “slow living” recovery path?
Gotta run. I’m late getting TIPS and TOPICS published this month again, and I’ve got to hurry to get ready for a long training day. I’ll start tomorrow.
Until Next Time
Thanks for joining us this month. See you in February.