January 2012

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
SOUL
Politics of personal destruction
STUMP the SHRINK
Addiction relapse and confidentiality and the courts

 

David Mee-Lee M.D.


SAVVY

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?

TIP 1

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?

SKILLS

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.

TIP 1

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?

TIP 2

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.

TIP 3

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.

References:

 

Douglas J Edwards: “Planting Recovery”- Behavioral Healthcare, February 2009
http://www.behavioral.net/article/planting-recovery

 

“Health Care and Public Service Use and Costs Before and After Provision of Housing for Chronically Homeless Persons with Severe Alcohol Problems”, 2009

 

SOUL

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

 

Question

Dr. Mee-Lee:

“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
Program Director
Neighborhood Counseling Center Dual Disorders Program

My response

Resa:

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.

Thanks,
David

Resa

“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.”

SHARING SOLUTIONS

In December, I alerted you to watch for some new ASAM products to be released in January 2012.

I am very happy to announce that these 2 brand-new products are now here and available for purchase!

** An E-Learning Training Module**

ASAM Multidimensional Assessment Course

This course is an interactive online training to help participants understand, assess and implement the six dimensions of the ASAM Criteria. Each section has information interspersed with video clips where I explain various aspects of the assessment dimensions. There are Knowledge checks and case application exercises to reinforce the information.

Continuing Ed Credits?

Five hours of NAADAC, CAADAC & NBCC Continuing Education (CE) have already been approved. And now Employee Assistance Professionals can earn PDHs as well. Physician, psychologist, social work and nursing CE is pending.


** A Participant Interactive Journal**

Understanding the Dimensions of Change

Your clients and patients will be able to assist your multidimensional assessment as they work through exploring their needs and strengths and skills in each of the six ASAM Criteria dimensions.

Here is the first customer comment on this newly released journal:

 

One word: Outstanding!!!! We received the first shipment today and the presentation of the information is exceptional! This booklet can be used in all types of addiction counseling. Great work.” JW.

 

Examine for yourself these products in more detail at The Change Companies’ website. Look for the ASAM logo and click to see more detail.

http://www.changecompanies.net/asamsystem.php

Until next time

Thanks for reading. Join us in late February.

David

January 2010

Volume 7, No. 9 | January 2010
In this issue


SAVVY
Senior Vice President and what it means for you
SKILLS
Impaired Driving Article and a Mini -Video
SOUL
Conan O’Brien and Cynicism
SHAMELESS SELLING
Get to know The Change Companies

David Mee-Lee M.D.


(more…)

January 2007

Volume 4, No.8 | January 2007
In this issue


SAVVY | SKILLS | SOUL

David Mee-Lee M.D.


Welcome to all the new readers who are joining TNT for the first time. Thanks to all the “old-timers” too as we start 2007.

 

SAVVY

A psychiatric disorder that is often associated with substance-related disorders is Attention-Deficit/ Hyperactivity Disorder (ADHD). There are certainly children, adolescents and adults for whom ADHD is concurrent with a substance disorder. However, it is also easy to get “trigger happy” with the diagnostic gun and see any impulsivity, distractibility or restlessness as ADHD. So here are a few facts, figures and philosophical issues about ADHD.

Tips

  • Attention-Deficit/ Hyperactivity Disorder (ADHD)

FACTS

-ADHD dates back to 1902 when Still, a British pediatrician, first describe symptoms of ADHD in children. (1, 2); modern psychopharmacology started in 1937 with a study of benzedrine in a mixed population of children with ADHD symptoms; methylphenidate was subsequently synthesized in 1955 with its formulations being the most commonly prescribed agents for ADHD (2)

FIGURES

-In the USA, ADHD is the most common psychiatric disorder afflicting children and adolescents with approximately 5% (3, 4) or 6%-9% of juveniles affected; and 4%-5% of adults or about 7 million adults. (5)

-ADHD can be a life-long disorder with 60% – 70% of children who have ADHD age into adulthood with impairing symptoms of the disorder, if not full- syndrome criteria of ADHD (2, 6)

-Up to 71% of adult alcoholics had childhood-onset ADHD that was persistent; and 15%-25% of adult alcoholics and drug addicted people meet criteria for ADHD (7, 8, 4)

-About one third of ADHD patients have co- occurring alcohol and other drug dependence; 60% of people with untreated ADHD have co-occurring substance use disorders. (9 )

WHAT ADHD LOOKS LIKE

-Current diagnostic criteria for ADHD describe three subtypes: hyperactive-impulsive; inattentive; and combined. (10)

-In adults, the hyperactivity can manifest adaptively as working long hours with two jobs; or in a very active job. May avoid situations requiring low activity e.g. going to the ballet. Constant activity can lead to family tension and often feel like they cannot play or work quietly. (2)

-Impulsivity may manifest as low frustration tolerance – quitting a job; ending a relationship; losing temper; driving behaviors. Makes quick decisions; interrupts. (2)

-Inattention may manifest as poor time management. Difficulty initiating or completing tasks or changing to another task when required; or difficulty with multitasking. Avoids tasks that demand attention; proscrastination. (2)

WHAT IS HAPPENING IN THE BRAIN (5)

-Neuroimaging shows structural brain abnormalities – smaller volumes in the frontal cortex, cerebellum and subcortical structures.

-Brain imaging to look at what areas are functioning normally or are too active or low activity, point to problems in the subcortical systems in the frontal area; and in the anterior cingulate activation. There is too low a level of activity in the Anterior Cingulate Cortex.

-Three subcortical structures – the caudate, putamen, and globus pallidus – are part of the neural circuitry underlying motor control, executive function, inhibition of behavior, and modulation of reward pathways – these are all critical in substance use disorders too.

-Executive functions are:

-Planning: foresight in devising multi-step strategies.
-Flexibility: capacity for quickly switching to the appropriate mental mode.
-Inhibition: the ability to withstand distraction, and internal urges.
-Anticipation: prediction based on pattern recognition.
-Critical evaluation: logical analysis.
-Working memory: capacity to hold and manipulate information in our minds in real time.
-Fuzzy logic: capacity to choose with incomplete information.
-Divided attention: ability to pay attention to more than one thing at a time.
-Decision-making: both quality and speed.

-The subcortical circuits provide feedback to the cortex to regulate behavior. ADHD is thought to use neural systems involving neurotransmitters norepinephrine and dopamine. Dopamine is also involved in the reward pathway for substance use disorders.

-Bottom line: In ADHD there is too low activity (hypoactivation) in the areas responsible for regulating behaviors and cognitive functioning like motor control, executive function, inhibition of behavior, and modulation of reward pathways.

WHAT TO DO ABOUT ADHD – Nonpharmacologic approaches (9)

-ADHD coaches who help clients identify deficits and organize and prioritize their time; identify strengths and exploit them and identify weaknesses and avoid them. A qualified ADHD coach can be found through the ADD Coach Academy’s website.

-Time management

-Patient education and advocacy groups like Children and Adults with ADHD (CHADD, www.chadd.org); the Attention Deficit Disorders Association (ADDA, www.add.org). College students with ADHD can have accommodations such as un- timed tests in noise-free rooms.

-Cognitive-behavioral therapy

-Anger-control skills

-Individual, group and family therapy

-Coaching versus counseling

WHAT TO DO ABOUT ADHD – Pharmacologic approaches (9)

Stimulant medication has been used for over 70 years but should be used carefully in the presence of preexisting structural heart defects.

-Short-acting (4-6 hours); moderate-acting (6-8 hours); long-acting (8-12 hours)

-Amphetamines (Adderall, Adderall XR= extended release, dexedrine); methylphenidate (Ritalin, Concerta, Metadate CD, Ritalin LA=long acting); D- methylphenidate (Focalin XR)

-Stimulants act on the brain’s dopamine and norepinephrine neurotransmitter systems by enhancing the release of these neurotransmitters from storage vesicles in the presynaptic neurons. Stimulants also block the reuptake of the neurotransmitters which thus increases the available amount of dopamine and norepinephrine.(4) This increase in the available quantity of neurotransmitter makes up for the hypoactivity in the relevant areas of the brain. It is thought that this then restores the low activity to more normal levels. This corrects the signs and symptoms of ADHD.

-Treating ADHD pharmacologically does not appear to exacerbate a substance use disorder e.g., stimulants have not been found to increase subjective or objective measures of cocaine use or cravings in ADHD or cocaine-substitution studies (11, 5)

-Treatment of ADHD appears to protect against the development of substance use disorders.

Nonstimulant medications are more recent. (5, 9)

-Atomoxetine (Strattera) – noradrenergic agent; two reports of liver toxicity in over 2 million exposures; and slight increase of suicidal ideation in children, but not adults.

-Buproprion (Wellbutrin) – atypical antidepressant

-Modafinil – arousal agent

-Tricyclic antidepressants – desipramine, nortriptylineAntihypertensives for adolescents – clonidine, guanfacine

Medications for co-occurring ADHD and Substance Use Disorders (5)

-Untreated ADHD worsens the ADHD and the SUD

-Atomoxetine, buproprion and extended-release stimulants are recommended for ADHD patients with very recent SUD i.e. within 3 months.

-Alpha agonists and tricyclic antidepressants are often reserved as alternate agents for ADHD with SUD – lower potential for drug-drug interactions with substances of abuse.

-Avoid amphetamines in patients with a history of amphetamine-related psychosis.

REFERENCES
1. Still GF (1902). Lancet 1:1008-1012, 1077-1082, 1163-1168.

2. Donnelly CL (2006): “History and Pathophysiology of ADHD” in “Differential Diagnosis and Treatment of Adult ADHA and Neighboring Disorders” Authors Donnelly C, Reimherr, FW, Young, JL. CNS Spectr 11:10 (Suppl 11) October 2006.

3. Faraone SV, Sergeant J, Gillberg C, Biederman J (2003): “The worldwide prevalence of ADHD: Is it an American condition?” World Psychiatry 2:104-113.

4. Donnelly CL (2006): “Treating Patients with ADHD and Coexisting Conditions”. Behavioral Healthcare Vol. 26, No. 9. pp. 40-44. September 2006.

5. Wilens TE (2006): “Attention Deficit Hyperactivity Disorder and Substance Use Disorders”. Am J Psychiatry 163(12): 2059-2063. December 2006.

6. Biederman J (2005): “Attention- deficit/hyperactivity disorder: a selective overview”. Biol Psychiatry 57(11):1215-1220.

7. Goodwin DW, Schulsinger F, Hermansen L, et al (1975): “Alcoholism and the hyperactive child syndrome”. JNerv Ment Dis 160:349-353.

8. Wilens TE (1998): “AOD use and Attention Deficit Hyperactivity Disorder” Alcohol Health Res World 22:127-130.

9. Young JL (2006): “Treatment of Adult ADHD and Comorbid Disorders” in “Differential Diagnosis and Treatment of Adult ADHA and Neighboring Disorders” Authors Donnelly C, Reimherr, FW, Young, JL. CNS Spectr 11:10 (Suppl 11) October 2006.

10. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) Washington, DC, American Psychiatric Association.

11. Grabowski J, Shearer J, Merrill J, Negus SS (2004): “Agonist-like, replacement pharmacotherapy for stimulant abuse and dependence”. Addictive Behaviors 29:1439-1464.

SKILLS

Last November I chaired a panel discussing how to improve services for teens in West Virginia. Phil Washington was telling us all about how he engages adolescents in educational but fun ways. He shared some of the tools he uses. With his permission, I am sharing a couple of exercises he uses which provokes good discussion within the group. Some are best used just with adolescents. Others can be used with any age group.

Tips

  • “Sounds Like Fun” are some thought- provoking questions to check whether using really is all fun.

Sounds Like Fun
These questions are to be asked in light of the fact that young people call getting high or drunk a good time. If it’s such a good time why do we not share it with everyone? Remind them of the times that they stuck their head in a toilet bowl to throw up. Remind them of promising God, “If you get me out of this I will never do it again.”

1. Do you ever call the police to let them know that you will be drunk and they can come pick you up at wherever?

2. Do you arrange for special lodgings at the jail in anticipation of being picked up for public intoxication?

3. Do you arrange for a special hairdo and clothing so you don’t get vomit on your good stuff?

4. Do you call your friends and family and tell them to watch the news to see you get into an altercation with the police on those special evenings?

5. Do you video yourself when you are drunk or high so you can show those special moments to your future children and grandchildren?

6. Do you let your potential boyfriend/girlfriend know that you sometimes have had unprotected sex while under the influence of drugs/alcohol?

7. Has anyone ever taken a picture of you while you were drunk or high, and you were so proud you made copies and sent them to the whole family?

8. Have you ever been with your boyfriend/girlfriend and offered them a big, wet, sloppy kiss after throwing up?

9. Have you ever checked your breath after drinking and smoking and thought, “Wow, my breath is enchanting. I think I’ll kiss someone”?

10. If not, why not? Isn’t this what we call a good time? Shouldn’t good times be shared by all?

Reference for “Sounds Like Fun” and “Would You?”
Phil Washington – Daymark Inc.
1598 C Washington St., East
Charleston, WV 25311
(304) 340-3690
phil@daymark.org

  • “Would You” helps young people and adults think through the situation and examine their values.

Would You?

1. Would you give the keys to your car to someone who was drunk or high?

2. Would you give the keys to your apartment to that same person?

3. Would you allow someone under the influence to baby-sit your children?

4. Would you allow a person who drinks and drives to take your children to an outing in their car?

5. Would you hand a person under the influence your check book?

6. Would you invite someone under the influence to fix your pipes, or electrical appliances, or your roof?

7. Would you take someone under the influence on vacation with you and your children, or family?

8. Would you take someone under the influence to meet your parents and family?

9. Would you take someone who you know will get drunk to your company picnic where there will be beer and liquor?

10. Would you recommend someone who gets high for a job at your company?

SOUL

My New Year’s resolution was about achieving balance between work, love and play. Since you will get this month’s TNT while I am playing Down Under, here are a few lighthearted quotes and tidbits to help you play a little too. Most come from the vast cyberspace:

Zen for those who take life too seriously:
–> Change is inevitable, except from vending machines
–> Plan to be spontaneous tomorrow
–> If you think nobody cares, try missing a couple of payments
–> When everything’s coming your way, you’re in the wrong lane
–> Depression is merely anger without the enthusiasm
–> Just remember – If the world did not suck, we would all fall off.

Quotes from George Carlin:
–> “Ever notice that anyone going slower than you is an idiot, but anyone going faster than you is a maniac?”
–> “Isn’t making a smoking section in a restaurant like making a peeing section in the swimming pool?”

And to end with an Aussie flavor:

-“What do you call a boomerang that doesn’t work?”
-“A stick.”

G’day mate!

Until Next Time

Thanks for joining us. See you in February.
David

October/November 2005

Volume 3, No.6
In this issue


SAVVY- SKILLS | SOUL

David Mee-Lee M.D.


 

Welcome to the October/November edition of TIPS and TOPICS. Summer vacation time usually means a combined edition of TIPS and TOPICS. So what’s the excuse for skipping a month now? Well around our place we have been in summer mode again. With extended family visiting from Australia, we’ve taken time to hike in Yosemite, show off California sights and sounds, and generally enjoy family conversation.

Therefore I have tried to practice what I always preach about striking the right balance between work, love and play. I set aside my sense of duty to produce a monthly newsletter, and put family first. (It also helped me to remember that this is a free publication anyway, so you have to put up with my time schedule—sorry, but you get what you pay for!)

 

SAVVY

It is now a cliché to say: “The only thing that will not change is that there will always be change.” Whether that is adjusting to budget cuts, layoffs, a new boss, new job or a new policy, most everyone it seems is in survival mode. So when I was asked to do a workshop on “How to Survive Integration Implementation” (a workshop about coping with implementing county-wide integration of mental health and addiction services) that resonated with what many people are experiencing—just trying to survive.

I subsequently received another message from the training committee. They asked me to modify the title to “How to Survive and Thrive During Integration Implementation“. That got me thinking. Yes, it isn’t just about surviving. Could people actually thrive while adjusting to change? Could change, crisis and turmoil actually be an opportunity to grow and thrive versus staying stuck in victim-role, trying to keep one’s head above water?

Here are some tips that might inspire you (here’s another cliché) to turn lemons into lemonade.

Tips:

  • Turn frustrations into systems solutions.

Michael Gerber has had 30 years of experience working with thousands of small business owners. He has studied how technologies and people work best together to produce optimum results; how to create an organization/ business/agency which can do great things, and achieve better results than any other organization/ business/agency.

Everybody has frustrations.

Here is Gerber’s definition of frustration:

A frustrating condition is a series of specific recurring events in the business/organization/agency over which you feel you have little or no control. It is an undesirable pattern of specific events which can be eliminated by the installation of a system.

We know that frustrations happen at home as well as at work. The following suggestions can also help you thrive at home too.

There are 3 types of frustrations:

(a) A technological frustration: This is where your concern is clearly and undeniably a matter of ‘systematology.’ You are simply needing information or a system to install in order to eliminate a particular condition. This is systemic thinking. For example:

-> Problem: “I don’t know what questions to ask in an interview”

System Solution: You could create a laminated sheet containing the questions to be asked. A system is then in place.

-> Problem: “I don’t know what our census is at any given moment”

System Solution: All three programs in the agency could agree to call in each day at 9 AM to a central administrative assistant or voice mail box to report their current census. The census system is then in place.

-> Problem: “The photocopy machine keeps breaking down”

System Solution: A preventive maintenance contract can be established with a company that checks the machine monthly. A system is then in place to eliminate or minimize the technological frustration.

(b) A self-directed frustration: This is the kind of frustration that results from myself being the source of the problem at work or the frustration at home. Compare (a) & (b). A technological frustration is a reflection of “I don’t know how,” whereas a self- directed frustration reflects, “I can’t”, “I won’t” , or “I’m stuck.” For example:

Problem: I find it hard to balance the importance of client needs with my needs.”

Perhaps you planned an hour to catch up on paperwork and then a client knocks on your door. You respond to the client’s need to talk and feel frustrated that you are now behind on your paperwork.

Problem: “I’m too nice when it comes to conflict or disciplinary measures, sometimes contributing to the continuation of problems. I wonder whether people feel as though they got away with something.”

As a supervisor, you feel frustrated that you too readily buy peoples’ performance excuses.

Problem: “I allow myself to get distracted too easily when it comes to sticking to a schedule or getting my paperwork done. It’s easy to find excuses and put work off.”

Paperwork is no fun. It is frustrating to see the hour you set aside disappear with a much more interesting lunchtime discussion.

When you see yourself as the problem, all your energy is focusing on YOUR need to change. Gerber believes that this self-focus is basically a waste of time. It chews up your thinking and energies which are best spent on analyzing what is getting messed up. Phrased another way- how does this self- directed frustration prevent getting the results needed at your agency/organization? You can make it impossible for yourself to ask the questions necessary to create the right system when you are waiting for yourself to change. (Self-analysis has its time and place, but not here.) Deciding on action steps and taking those steps is a much more productive use of your personal resources and energy. When you get yourself out of the way, you can begin to ask productive questions such as:

Systemic Thinking: “What kind of appointment or scheduling system would allow me to be responsive to clients and also protect time for me as well?”

Systemic Thinking: “What kind of disciplinary or termination system would both give me what I need as well as be fair to my supervisees?”

Systemic Thinking: “What kind of time management or scheduling system would provide me with the least distractions, and assist me in getting my paperwork and other duties completed?”

Once you are able to ask the result-oriented questions, this directs your attention to changing the business instead of yourself. You will begin to identify options, possibilites and solutions previously obscured because of your self-directed focus.

(c) An outer-directed frustration: This occurs when you largely hold someone else or something else as accountable for an undesirable condition at work or home – i.e. “he/she/they/it can’t- -” or “he/she/they/it won’t—.” For example:

Problem: “Other professionals have unrealistic expectations of what we do at our program.”

You are frustrated when referral sources send you dual diagnosis clients your agency is not fully set up to manage yet.

Problem: “She has a negative attitude and it infects others.”

It is frustrating to have “bad apples” in the team which affects staff morale.

Problem: “The pool of counselors out there is so limited that we can’t hire qualified people.”

It is frustrating to have so few candidates from which to choose. Why aren’t more people committed to this field like in the old days?

A similar problem exists in the case of outer-directed frustrations. When you view someone or something outside as the cause of your frustration, there is the need to change something you cannot control. You cannot change people, time, the pool of counselors, the economy or when a person gets sick. You can only change those things you do have control over, namely your business. Thus while there certainly are outer-directed frustrations, it will not service your efforts to define problems or solutions in outer- directed terms. Success depends on the creation of a system designed to produce a specific result. Whenever your focus is on people, you are forever searching for extraordinary ones. When you focus on the system, you need only find people who are willing to help you build and use it.

Look at the problems stated above from Gerber’s viewpoint. The frustration we experience around others’ unrealistic expectations about our program above is viewed not as a referral source problem, but rather a management problem, a technological problem requiring a technological solution.

Systemic Thinking:

Do not ask yourself the question- “How can I get referral sources to be realistic about what clients they send to us?

Ask yourself this question- “What’s missing in the structure of our business that is permitting referral sources to send us clients with whom we do not do well? What system do we need to establish that will encourage appropriate referrals, so we are not consumed with placing clients we cannot manage well?”

If you find technological solutions to people problems, you will move forward and minimize frustrations. Redefine your ‘people’ problems in technological terms, and reframe problems first as technological frustrations. Then translate your self-directed or outer-directed frustrations into a specific condition in the business you want to address. Remember these 2 important points in this process:

-> You can only change those things over which you have control – you only have control over your business. Changing the structure of your business is the only way to get what you want from it.

-> Determining what to change demands that you be willing to look very specifically at what it is about your business that is not working. What is it about your business (not your people) that generated your original self-directed or other-directed frustration? Get specific/ concrete in naming your frustration. This then will tell you how to eliminate it by transforming the frustration from a thought or feeling to a condition in the business that you can do something about.

Reference:
The material above has been adapted from Gerber Business Development Corporation’s Key Frustration Process. Mailing Address: Michael Gerber, E-Myth Worldwide, 2235 Mercury Way, Suite 200, Santa Rosa, CA 95407/Corporate Offices: Phone: 800-300- 3531 or 707-569-5600 Fax: 707-569-5700
Web: http://www.e-myth.com

  • When you find yourself clashing with another person or feeling like a victim of circumstances, turn that into an opportunity to grow – emotionally and spiritually.

Eckhart Tolle’s book “The Power of Now – A Guide to Spiritual Enlightenment” has sold over 2 million copies. Oprah Magazine stated: “It can transform your thinking—the result? More joy, right now!” Sounds like advertising hype and it is. But I found it also to be true for me. Here are a couple of quotes that may help you thrive when faced with that team member who you feel just doesn’t get it. (Or your spouse or partner too.)

*** Relationship as spiritual practice

“So whenever your relationship is not working, whenever it brings out the “madness” in you and in your partner (or team member, or client, consumer, family member etc), be glad. What was unconscious is being brought up to the light. It is an opportunity for salvation. Every moment, hold the knowing of that moment, particularly of your inner state. If there is anger, know there is anger. If there is jealousy, defensiveness, the urge to argue, the need to be right, an inner child demanding love and attention, or emotional pain of any kind – whatever it is, know the reality of that moment and hold the knowing. The relationship then becomes your sadhana, your spiritual practice. If you observe unconscious behavior in your partner, hold it in the loving embrace of your knowing so that you won’t react. Unconscious and knowing cannot coexist for long – even if the knowing is only in the other person and not in the one who is acting out the unconscious. The energy form that lies behind hostility and attack finds the presence of love absolutely intolerable. If you react at all to your partner’s unconsciousness, you become unconscious yourself. But if you then remember to know your reaction, nothing is lost.” pp. 131-132

*** Here is another another nugget when you feel you are a victim of circumstances beyond your control:

“As an alternative to dropping a negative reaction, you can make it disappear by imagining yourself becoming transparent to the external cause of the reaction. I recommend that you practice it with little, even trivial, things first. Let’s say that you are sitting quietly at home. Suddenly, there is the penetrating sound of a car alarm from across the street. Irritation arises. What is the purpose of the irritation? None whatsoever. Why did you create it? You didn’t. The mind did. It was totally automatic, totally unconscious. Why did the mind create it? Because it holds the unconscious belief that its resistance, which you experience as negativity or unhappiness in some form, will somehow dissolve the undesirable condition. This, of course, is s delusion. The resistance that it creates, the irritation or anger in this case, is far more disturbing than the original cause that it is attempting to dissolve.
All this can be transformed into spiritual practice. Feel yourself becoming transparent, as it were, without the solidity of a material body. Now allow the noise, or whatever causes a negative reaction, to pass right through you. It is no longer hitting a solid “wall” inside you. As I said, practice with little things first. The car alarm, the dog barking, the children screaming, the traffic jam. Instead of having a wall of resistance inside you that gets constantly and painfully hit by things that “should not be happening,” let everything pass through you.”
– pp. 159-160

Reference:
Tolle, Eckhart (1999): “The Power of Now – A Guide to Spiritual Enlightenment” New World Library, Novato, California.

SKILLS

To thrive, not just survive, in the midst of change takes commitment to actually try some different solutions. Sometimes it’s easier to complain and blame. But if you would like to move from that position, here are some ideas to try.

Tips:

  • To translate the Self-Directed or Other- Directed Frustrating Condition into a System Solution requires careful assessment and quantification.

What follows may seem a bit obsessive compulsive, however it is a necessary process if you are serious about not being frustrated all the time. You could skip this TIP, but don’t blame me if you and your team keeps feeling frustrated.

STEP 1. Identify how a self-directed or outer- directed frustration impacts your agency, organization or business.

Ask these 3 questions of any frustration you might experience.

Q1: What does not work well in our organization because of this frustration?
Q2: What are some specific, detailed examples on what is not working well?
Q3: What are the concrete results and effects of this on our agency/organization?

Follow our example below with this sequence of 3 questions. Then insert your example.

Frustration Example:I find it hard to balance the importance of client needs with my needs.”

Q1: “What does not work well in our organization because of this frustration?”
A1: “Things don’t work well when I am not meeting my commitments on time.”

Get more specific. Dig more deeply about what is not working well. Be explicit and detailed.

Q2: “How do I not meet my commitments on time?”
A2: “I don’t keep my paperwork up to date in a timely fashion.”

Become progressively more specific, and identify the results and effects this has on your agency.

Q3: “What is the concrete result in my agency/business when I do not get paperwork done in a timely fashion?”
A3: “I am not getting my treatment plan reviews done on time.”

Summary:
Not getting treatment plan reviews on time is the frustrating condition in your organization, but you can deal with this ‘condition’ far more effectively than the original self-directed frustration because:

-> It can be eliminated by the installation of a system
-> It is specific and when solved, it moves you closer to being able to get your work done. It enhances the whole health of the agency/business.

STEP 2. Quantify the specific, technological frustrating condition, wherever possible.
This adds clarity as you ultimately determine the most appropriate solution. This makes the frustrating condition very precise.

Ask these 3 questions around quantification of any frustration you might experience.

Q1: What percentage of the time does this frustrating condition occur?
Q2: How many times does this frustrating condition occur each (day/week/month) on average?
Q3: What are the usual expectations of your agency so you can identify how big or small a problem you are dealing with?

Follow our example again with respect to quantification. Then apply your example.

Q1: What percentage of the time does this frustrating condition occur?
A1: In the case of “late treatment plan reviews” it is 75% of the time or more.

Specify and quantify further.

Q2: “How many times does this frustrating condition occur each (day/week/month) on average?”
A2: “Usually each month I am four days late in turning in my treatment plan reviews.”

Specify and quantify even more. You will be looking to find how big or small a problem you have.

Q3: “How many treatment plan reviews are expected?”
A3: Nine are expected per month. I thus turn in six (75%) of my treatment plan reviews on an average of 4 days late each month.

Each answer to a previous question should be progressively questioned. If you do, this will lead you to the most appropriate solution.

Question even the solution further: “If I can’t eliminate every late treatment plan review, can I cut them down to less than 25% or two per month?” Or “If my late treatment plans are as high as 75% late, is administration making unrealistic demands on my time and duties?”

Summary:

Quantifying with “real” numbers is far more valuable than approximating. Approximations can often simply reinforce an inaccurate perception. If you actually quantify, you might discover you have a very different condition than you thought existed in the first place.

STEP 3. Seek system solutions

Ask this question.

Q:What system can I set up that will achieve the results I want in the organization or agency?

Follow our example again with respect to the systems solution. Then apply your example.

System Question: “What system could I set up that would allow me to get my late treatment plans under 25%?”
System Answer: Perhaps all paperwork could be done in an office away from easy client contact. When treatment plan reviews are approaching the due date, the chart has a yellow sticker on it to alert the counselor.

Obviously your exact system will be based on an analysis of your specific frustration, plus quantification of what are the most recurring conditions in the frustration. The solution is not a random stab at quick fixes.

Or another System Question: “What system would monitor and quantify what consumes counselors’ time to help develop realistic expectations?
System Answer: A time management monitoring system would track all clinical and administrative duties for 1 month to gather data to allow the development of realistic expectations.

It takes commitment to develop a systems solution— or you could just complain and feel like a victim.

Reference:
The material above has been adapted from Gerber Business Development Corporation’s Key Frustration Process. Mailing Address: Michael Gerber, E-Myth Worldwide, 2235 Mercury Way, Suite 200, Santa Rosa, CA 95407/Corporate Offices: Phone: 800-300- 3531 or 707-569-5600 Fax: 707-569-5700 Web: http://www.e-myth.com

  • Choose to Thrive as a Conscious Choice and Process.

Whatever you are doing now in your career and daily work has probably evolved dramatically over the years. That may be good, and you may have engineered all those adjustments. On the other hand, it might be that where you work and what you do no longer fits with the original job and mission you signed up for. The agency/program has changed under budget, policy, and political priorities etc. You find yourself working in an environment with quite a different mission from what you chose initially. For example, perhaps you did not plan on working with people with co-occurring disorders.

-> If you want to thrive, it is a conscious choice to move away from victim-survival mode.
-> You decide if “who you are” and “what you want” fits with “where you work”- the agency’s current mission.
-> Develop your own primary aim or personal mission statement and values to alert you when you are “off track.”

For example, I frequently get job offers and interesting opportunities presented to me. By now, I am clear which opportunities do or do not fit my personal mission.

Here is my mission statement and values:

I am actively creating a unique forum using my talents of bridging the gap for people between disparate fields and concepts, in a very persuasive, challenging and inspiring manner; simultaneously influencing systems in a global way for the greater good, with rich personal satisfaction and financial reward.

Mindfulness – awareness of body and feelings
Spaciousness – expansiveness and open mind
Seeing Through – not reactive
Spiritual Nourishment – non-egocentric; gain nourishment from others’ success
Loving Presence – being there without resentment

-> Check to see if there is a good fit between your primary aim or personal mission and where you now work.

SOUL

Today I mowed the lawn. I think mowing the lawn is the most satisfying of all household chores. You start with a straggly, messy expanse of green. In less than an hour, you have almost a golf course green in front and back of your house. Of course this assumes you have a house and a lawn to mow; and that if you do, that you are like us, and don’t keep it manicured every week.
Even though we have weeds, it still looks good immediately after mowing. In fact I often go out a couple of times in the next 12 hours and the next morning to admire my handiwork. In a few days, it will not look so great. Then I often wait until I see the neighbors doing their mowing for the guilt to rise sufficiently to get out the mower again. I get to experience the satisfaction of a job well done, yet again.

Mowing the lawn may not do it for you. Maybe it is cleaning your car, washing the dishes, doing your laundry, shortening the guilt pile of unread journals, or clearing your desk of all those papers.

For a lot of us, we have worked for many years with people, programs and projects which bear fruit, and have their great satisfactions. Results are often long- term, and you need to exercise a great deal of delayed gratification to keep the vision alive and stay focused. (I have been working with the ASAM Patient Placement Criteria for over 15 years now). The impatient side of me likes faster results. That’s one of the reasons I was drawn to addiction treatment— people can actually get back on track, turn their lives around faster than many other behavioral health problems. It is a pity that so many in the mental health field who have not witnessed recovery in others still feel hopeless about people with substance use disorders.

When the going gets tough, it’s nice to know you can always mow the lawn. Satisfaction is immediate. Rewards are concrete. The experience is grounding in all ways. It is easy to be tempted to long for those other fields where the grass appears greener on the other side. But a friend reminded me: the grass may be greener, but you still have to pull the weeds and fertilize!

Happy mowing.

Until Next Time

Next month it will be one edition of TIPS and TOPICS for one month—-I promise. Thanks for reading. See you in December.
David

December 2004

Volume 2, No. 8
In this issue


SAVVY | SKILLS | SOUL | SUCCESS STORIES

David Mee-Lee M.D.


SAVVY

This month it was nice to be able to be in my home state of California for a couple of days focusing on the what and hows of integrating services for people with co-occurring substance use and mental disorders. When a large city and county like San Francisco, and a large State like California, starts to get serious about co-occurring disorders and dual diagnosis (or whatever your region calls it – MICA, CAMI, MISA, SAMI, MICD, dual disorders) that is something to celebrate. As I participated in those two days, I was reminded of a few concepts and resources that I want to share.

Tips:

  • Integrated treatment for co-occurring disorders is about services, not organizational charts.

The debate goes on from county to county, state to state, Federal agency to Federal agency: Should substance abuse agencies be organizationally integrated with mental health into one behavioral health agency? The arguments for organizational and financial coordination and efficiencies seem rational and timely. Equally compelling are fears that the much larger and longer established mental health bureaucracy and budget will swamp and drown out the hard won gains and priorities for addiction treatment.

I’ve trained and consulted in systems that have either organizationally merged, or remained separate entities. It is clear that the real focus needs to be on how to integrate services so that the consumer, client, patient, customer gets what they need. Attitudes, knowledge and skills will not blossom to serve dual diagnosis clients well just because the organizational chart changes one way or the other.

“Integrated treatment is the interaction between the mental health and/or substance abuse clinician(s) and the individual, which addresses the substance and mental health needs of the individual.”

(From page vi in “A Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders” 2002, from the Substance Abuse and Mental Health Services Administration (SAMHSA). Resource: www.samhsa.gov/reports/congress2002/foreword.htm )

So in whatever system you find yourself – combined behavioral health division, or separate addiction and mental health departments – check to see if at the consumer level, there really is integrated treatment or not.

Question checks:

1. To what degree do consumers experience their care as One Team, One Plan for One Person? Or do they fall through the cracks, bounced around from one clinician or case manager to the next with everyone, including the client, being clueless on what the integrated treatment plan might be?

2. Do you really mean, “Every door is the right door,” so that wherever clients call, they receive knowledgeable and welcoming assessment and service of their needs? Or are they greeted with confusing voice mail prompts, directives to call the other number as “we don’t take suicidal people or anyone on Xanax or Klonopin?”

3. Can people with substance use problems only get a psychiatric consultation and medication evaluation if they have a major mental illness by DSM-IV codes? Can a heroin-addicted consumer only get inpatient detoxification and medication support by exaggerating depressive and suicidal thoughts to the level of imminent danger?

  • The Co-Occurring Center for Excellence (COCE) is an up and coming resource for Co- Occurring Disorders.

In September 2003, the Substance Abuse and Mental Health Services Administration (SAMHSA) launched the Co-Occurring Center for Excellence (COCE). Its vision was to become a leading national resource for the field of co-occurring mental health and substance use disorder treatment. The mission of COCE is threefold: (1) to transmit advances in treatment at all levels of severity, (2) to guide enhancements in the infrastructure and clinical capacities of service systems, and (3) to foster the infusion and adoption of evidence- and consensus-based treatment and program innovation into clinical practice. COCE consists of national and regional experts who serve to shape COCE’s mission, guiding principles, and approach. I am pleased to be one of the Senior Fellows assisting in the development of the COCE.

In the near future look for the COCE Overview Papers (OPs). These will be short, concise, and easy-to- read introductions to state-of-the-art knowledge in co-occurring disorders (COD). The intended audiences for these OPs are policymakers at the State and local levels, their counterparts in American Indian tribes, administrators of substance abuse and mental health agencies, and providers of wrap-around services. Sixteen topics have been selected for OPs based on input from SAMHSA, States, the COCE Steering Committee, and Senior Fellows.

These topics include:
Definitions, Terminology, and Nosology;
Overarching Principles;
Screening, Assessment, and Treatment Planning;
Epidemiology of Co-Occurring Disorders;
Services Integration;
Workforce Development and Training;
Financing Mechanisms;
Systems Integration and more.

Resource: For more information on the COCE, see: http://alt.samhsa.gov/samhsa_news/VolumeXII_5/arti cle4_4.htm. A technical assistance Web site is forthcoming. You can contact the COCE at (301) 951-3369, or e-mail: samhsacoce@cdmgroup.com.

SKILLS

Usually the Skills section focuses on individual clinician skills. But this time, I will highlight some staff, program and systems issues related to Co- Occurring Disorders.

Tips:

  • Normalize conflict in the team. If there aren’t disagreements, someone is wimping out and not advocating for their beliefs.

It is highly unlikely that you can assemble a team of mental health and addiction treatment professionals, (some of whom are in their own personal recovery) without there being conflict over when, what ,and if to use medication. Or on how to deal with substance use while in treatment.. Or on whether to immediately detox a long time alcohol-dependent, Klonopin user who believes it is absolutely necessary for his anxiety disorder.. The problem isn’t the fact of disagreements or conflict. The problem is if you don’t have a functioning conflict resolution policy. Practice disagreeing without being disagreeable:

Doctor, would you be willing to share with me your evaluation and history data you got, so I can understand the information I got from the client? I am concerned that the addictive sleeping medication you have prescribed clashes with my sense of the evaluation, being that the client has a severe addiction illness. I want to be sure I am clear on our work together with this client.”

If the physician responds that he/ she was unaware the patient was using substances to any great extent, let alone substance-dependent, then your questions have provided more comprehensive information. The physician may be aware of the substance use problem, but is using the potentially addicting sleeping medication only during the initial detox phase as an engagement strategy. You might feel more comfortable leaving things alone, and seeing what happens.

Question Checks:

1. Check if you have a conflict resolution policy.
2. Do you know where it is and what it says?
3. Do all team members know how to use the policy?

  • Everybody has a territory, but nobody has a kingdom.

When I was part of Parkside Medical Services (a large multi-program, multi-state addiction treatment system that has now largely disintegrated) this was one of the many meaningful values of the company’s Mission, Vision and Values. Programs need the gut, intuitive wisdom of the recovering staff members with their spiritual commitment to recovery. To complement that, they also need the objective skepticism of the mental health professional skilled in living with diagnostic ambiguity. It may be quite a while before further evaluation and time make it clear what the best course of treatment should be.

Integrated treatment needs programs that provide a “kingdom” of diverse services, levels of care, wet, damp and dry living supports, engagement and motivational services, medications, case management, mutual help groups, community resources and the list goes on. Each of our territories are critical, but only as they function in harmony with the whole.

Question Checks:

1. What is your territory?
2. Can you advocate for it without competitiveness and ill will?
3. How can all the territories in your region work together to create the kingdom co-occurring disorders deserve?

SOUL

In a few weeks I will travel to Sydney, Australia to celebrate my mother’s 90th birthday. She is gathering a hundred or so friends and relatives at a restaurant to mark this important milestone for a woman in incredible health and mental well-being. I hope I have half her energy and cognitive ability, when I am 90.

A close relative was also planning to attend the celebration, but she cannot now make it. A mother of three young boys, she was oblivious to the fact that she had a rare form of malignant fat cell cancer. She had removed what appeared to be a simple lipoma on her chest wall. She has done remarkably well with her positive attitude both before and after the subsequent, extensive surgery to remove all cancer cells. I hope I have half her positive attitude if I ever am ill.

In this season of giving and receiving, this year has reinforced what all of us who are in the second half of our life have come to appreciate. The gift that has the most attraction for me is the gift of good health. This year, my loved ones have reminded me through their example, that in sickness or in health, an attitude of gratitude speaks volumes.

I wish you good health for 2005- in every aspect of your life and your loved ones.

SUCCESS STORIES

It is gratifying to know that sometimes training events actually end up helping the people we serve, as well as the participants. This is a positive experience- a nice way to end 2004.

Dr. Mee-Lee,
I attended the trainings you held on September 22 and 23 in Ann Arbor, Michigan. I was the guy who performed “Jimmy” in the second day’s role-play. I want to thank you again for an inspiring and genuinely helpful training, and share with you a small success story.

I went to see a client (whom I’ll call Bill) the day after the training. This was my first time meeting the client after his discharge from a state psychiatric hospital, where he’d been treated for three months. My goal was simply to get to know him and his family a bit better, and also to get some sense of what he wanted to accomplish in his work with the ACT team I’m part of.

When I asked what he wanted his treatment to accomplish, his response was, in a sense, what we might call delusional and grandiose. “I would like to have greater influence over lawmakers,” he said, “to get stricter penalties against pedophiles”. Before his recent hospitalization, Bill had gone on a hunger strike in the aim of winning this sort of influence. Moreover, he believed that he could identify pedophiles by a certain “pattern” on their faces, leading to some heated verbal altercations when he accused such people.

Before taking your training, I think my response would have been something like, “Well, that’s a pretty high-level issue. How about we talk about something a little smaller and easier to accomplish?.” In other words: Let’s ignore that what you just said is kind of crazy and therefore invalid, and that I really don’t know how to work with that, and let’s get back to the things that are important to my program, like you taking your meds and staying out of the hospital.”

Instead I said, “How do you think we could help you with that?”

Bill responded, “I don’t know, I think I need to be more presentable.”

AH-HA! So there we were. Instead of deflecting him, I ask one question, and we’re back in the territory of what ACT can actually help with. “What would it mean to be more presentable?” I asked. And from there we got into a conversation about the importance of being clear-minded, of how going in and out of a psychiatric hospital would reduce his credibility on social issues (not fair, sure, but true), and how “being pushy” in the past made people believe he was out of control and landed him in the hospital.

The result: Bill sees taking his medications and working closely with us as a way of working on being presentable, stable, and credible.

The rest of the meeting went much the same. He identified two more goals, all of them “problematic” from a treater’s viewpoint (he wants to drive, and he wants to return to a clubhouse that has a trespassing order against him). In each case, by listening and asking questions, we were able to find some common ground that motivated him *and* satisfied the safety aims of my program.

I look forward to practicing motivational techniques and improving my skills. It’s very exciting stuff. I’ve prided myself on being quite skilled at interacting with acutely and chronically psychotic clients, and I’ve done a lot of good work at forming treatment relationships in a general way and handling crises, but these techniques show great promise at making a client’s treatment plan relevant and getting them more viscerally involved.

Thanks again,

John Gonzalez
Washtenaw Community Health Organization
Ypsilanti, Michigan

Until Next Time

Happy Holidays and I’ll talk to you next year.

David

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…)

Vol. 11, No. 1

In This Issue
  • SAVVY : Words of appreciation
  • SKILLS : Ten years of anniversary SKILLS Tips
  • SOUL : What a difference in these two 19 year olds
  • SHARING SOLUTIONS : The Anniversary Deal – Tips and Topics book for $10 total

Welcome to the 10th anniversary of Tips and Topics (TNT). Perhaps this is your first edition as a new reader or your 100 edition as a longtime reader. Either way, enjoy this anniversary edition……and my party hat!

David Mee-Lee M.D.

SAVVY

When I turned 30 years old, my wife threw me a surprise birthday party.  It was very thoughtful of her, but I enjoy_ other_ people’s birthday parties. It’s not so comfortable when I’m the center of attention, especially when it’s a surprise.  Now, I’ve gotten a little more comfortable with attention (doing fulltime training and consulting for decades gives you lots of practice.)This month, for our 10-year anniversary of Tips and Topics, I actually _asked_ for readers’ attention!I thought it would be fun (and informative to me) to hear what you appreciate about Tips and Topics.  So here are some of your “appreciation gifts” to me to celebrate 10 years together.  I excerpted from your “gifts” so as not to be too voluminously boring.

Welcome to our Tips and Topics birthday party! (and check out SHARING SOLUTIONS for a special anniversary deal)

TIP 1

See if you resonate with any of the themes of these “anniversary gifts.”

I grouped readers’ comments in like categories….sort of……

Challenging our thinking and sharing TNT with others

What an honor to be asked to share how your efforts with Tips and Topics have impacted us over the years as an anniversary gift to you.

Since first becoming aware of your work and meeting you 6 years ago, I have been a faithful reader of Tips and Topics…….Over the years, I have used Tips and Topics to share with the clinical staff a deeper understanding of how they could assess a caller…  Your ability to bring so many different service delivery providers together and weave the experiences in a meaningful way that makes one stop, think and yes, sometimes even challenge how we think of providing services continued to contribute not only to our development as professionals but also to the benefit of the clients.

I have no doubt that I contributed to adding to your email list because I often encouraged people to make sure they took advantage of having such a powerful resource at their finger tips; especially the interns that I supervised. …I have entered the arena of private practice and the skills I have learned over the years from Tips and Topics come in handy with almost every client.  When I think of the ripple effect of your life works and how many it impacts I stand amazed.

I do have to say one of my favorite aspects is when you share details of your life — from your journeys home to Australia, to your kids and their accomplishments…..And just know that I am looking forward to at least another 10 years of Tips and Topics!

Happy Anniversary!

Theresa Buzek, MS, LPC-S
4009 Banister Lane, Ste 356
Austin, Texas

***

Thank you for the work you do and the newsletter.  I just wanted to let you know I really appreciate it, and pass it along to our staff and my peers in the field

Yvonne Jones, LCSW
Senior Psychiatric Social Worker
CONREP
San Leandro, California

***

Your last e-mail has finally motivated me to write my appreciation to you and your monthly newsletter.  If I receive the e-mail during a particularly busy time at work, I leave it unread until I can make the time to bring my full attention to the tips and topics and have time to contemplate how to apply it to my work and life.  I not only read it myself, but share it with my colleagues and have also forwarded it on to my boss on occasion.  Your thoughts push me to think about how to approach my work differently, to question my current techniques, and how to be an effective clinician (and sometimes parent!).

Thank you very much for all you do.

Stephanie R. Steinman, LPC CSAC
UW Health Gateway Recovery
Madison, WI

***

I am reflecting on your upcoming ten year anniversary, and can hardly believe that you have been publishing this long!!  I recall conversations with you about my interest in searching the archives, long before you had that capability!  Guess that means I am getting old!

I read Tips and Topics fully, and can honestly say that every issue has caused me to pause and think; despite over 30 years in the addictions field, I learn something new each and every time.  I share access with everyone I can, and encourage others to sign up on-line in all of my trainings.    I imagine that this is just one of many competing priorities for you, but know it is thoroughly enjoyed, valued and appreciated!

Dotti Farr   LSW, LADC, CCDP-d
Director of Quality Management
Bucks County Behavioral Health System
Warminster, Pennsylvania

Useful learning and appreciating the TNT edition on Therapeutic Communities

David, we worked together briefly in Delaware and, even in a short time, I learned a great deal from you. I read every edition of your newsletter and wanted to compliment you on the Therapeutic Community article.  You handled the subject productively and ‘gingerly’.  There are probably some who would say you were too gentle but change usually requires persuasion not coercion.

Thanks for your efforts to inform and improve the field.

Colette Croze
Principal, Croze Consulting

Dr. Mee-Lee,

I certainly look forward to Tips and Topics each month, I have yet to read an edition and not get something useful from it. The edition on Therapeutic Community was especially interesting.  When I started working in the field in the late 80s …one of my first experiences was with a seasoned counselor conducting what he called “Gestalt empty chair technique”, but what actually seemed to have as its only goal to have the group make the person cry or storm out of the room…..Things have certainly changed for the better. Thank you for the publication each month.

Dan Adams, MBA, MARS
Assistant Director
Southeast Missouri Behavioral Health
Salem Center

***

Dear David:

My note of appreciation is simple. Somehow, you have a hidden camera in our program, in my office, and in my head. Lest you think that I fit the textbook definition of paranoia, let me say instead that you have, since I started in this position, managed to elegantly publish in your Tips and Topics exactly what I was trying to say just days before in a staff meeting, in a supervision, or in a training. I find myself EVERY month simply forwarding your email to someone else in the program or printing it out for everyone and putting it in mailboxes with a simple….”This is what I was trying to say—he says it so much better”!!!

The best example of this was in Nov 2012 with your response to Ray from Cape Cod.  Being from the “other” large substance abuse agency in Southeastern Mass, I recognized Ray Tomassi of Gosnold and his way of thinking immediately. I immediately copied that article on how we use words and how our words shape our actions and handed it out to everyone in our program—staff and clients alike. It lead to such interesting conversations-not only about those words and actions, but about the role of shame and coercion in treatment. Especially for us as a program that walks that tightrope between voluntary and “court ordered”, we look at issues like relapse and discharge daily—and struggle to be client-focused and evidence-based in our actions and approaches.

The other edition that was so helpful was your Tips and Topics that took on the sacred cow of “Therapeutic Communities”. Technically, we are by our RFR, a “modified therapeutic community”. Given our varied mandates and our population of 100% of our clients with co-occurring other mental health challenges, we find ourselves always searching for the balance between being “client centered and individualized” and “community-based” recovery. As we try to do that while following Motivational Interviewing practices across all levels of the program and integrating as many EBP’s as possible, the core of our model shifts and morphs. For some of us, that is comforting that we are always “making it up as we go along” to be as successful as possible. For others, it creates such panic that “no one is in charge and no one knows what is happening next”. This edition helped calm some of those fears and helped the “old-timers” see that there really is a method in the constantly shifting landscape and that parts of the tried and true will always be a part of what we do.

For the record, we are a pilot program in Mass—the ONE specifically funded year-long program (combination of residential(3 months or so)/community based(9 months)) jail diversion substance abuse treatment program for clients facing incarceration for crimes directly related to substance abuse issues. In year 3 of a 5 year pilot, we have such tremendous support and freedom to try to get it right….and such wise counsel both from our agency leadership and Bureau of Substance Abuse Services to help us be successful and create a program that can be replicated. Please know that I count you as one of our “distance mentors” as well.

Thank you for being part of the knowledge and wisdom that helps shape who we are and what we are doing!

Mary R. Bettley MSW, LICSW
Program Director
Reflections-Court Alternative Program
High Point Treatment Center
New Bedford, Massachusetts

Inspirational, informative and influential

I’ve been a subscriber to your newsletter for a while now….I look forward to its arrival every month. (I confess that I also hoard them.) I’ve been working with individuals who struggle with substance use disorders for over 40 years now and there are a few individuals, including yourself, who I consider to be inspirational. You are those people who I can count on one hand (with fingers left over) who seem to be able to bring “things” into focus for me. I don’t __always__ agree with “you guys” but I love to read everything that you write and I try to hear you speak whenever I can….. I’ve been blessed to consult with other organizations in many states. I try to share your newsletter with as many of these people as I possibly can. You are very inspirational and informative. Sometimes you even manage to interject some humor! Thank you for taking the time to make an investment in my life. I believe that you’re making a difference in our world.

Michael W. Bennett MBA CAP CPP ICADC CCCJS CCFC
8495 Bluestem Court
Jacksonville, Florida

***

Dr. Mee-Lee, I love reading the Tips and Topics even though I don’t counsel in substance abuse treatment. I still have contact with people in recovery as a case manager in a transitional housing program.  Knowledge is always great even if you don’t use it right away.

Michael McMullen

***

Mahalo Dr. Mee-Lee:

For 10 years of sharing your “mana” (interpersonal power, strength, authority, efficacy) with those of us attempting to follow your lead by reading your Tips & Topics newsletter each month.

Your generous offerings and influence have been a guiding light for a me, a substance abuse counselor in a rural, island community.

I’m looking forward to 10 more years of your influence.

In the mean time, I wish you a very fond……..

Aloha,

Lorrain Burgess, CSAC
Makakilo, HI

A couple of suggestions

Dear Dr. Mee-Lee:

I read your TNT with great interest every month. Over the years I have saved the ones that have been particularly helpful to me, as I work in a community mental health center.

I would like to see a new category added to TNT to trumpet new and innovative approaches to Co-Occurring Disorders (COD), or old approaches that are not well known…..

Another thought I have is soliciting a Guest Column each month on something directly related to COD treatment. Along these lines, you could identify a topic such as Guidelines for the First Session, and then invite your readers to solicit brief summaries for review…..

In any case, thank you for being on the cutting edge of treatment!

Harry Ayling, LCSW, ACS
Mental Health Supervisor
Fairfax County, Virginia

Thinking outside the box

***

David I truly appreciate your objectivity, open-mindedness and willingness to think outside the box. In helping addicts help themselves most often the instrument for change is that non-judging compassionate empathic therapeutic alliance that springboards the person to make that most important choice for a path on the road to recovery.

Chris Keeley, LICSW

***

Tips and Topics is always spot on! Thanks for keeping us at the head of the curve. Your ability to eloquently bridge theory with practice has been a real gift to the addictions field!

Bob Lynn Ed.D
Clinical Systems Development
Origins Recovery
C4 Recovery Solutions
Counseling Group and Family Institute

Favorite things

I read TNT pretty voraciously each month.  One of my favorite parts is the SOUL section.  Sometimes it ties into the content from the rest of the month, and sometimes not, but it is a helpful reminder to me of the toll and the wonderfulness of the work we do, and that we face the same challenges of families throughout the lifecycle that our clients do.  I especially like the SOUL about:

Jennifer Harrison, LMSW, CAADC, Western Michigan University, my co-author for the TNT book (see later for a special anniversary offer) wrote the above appreciation note.  When I asked her how she wanted to be identified she added “and awesomest co-author ever would be great.” Jennifer is indeed a great co-author but since I have several co-authors who might read this, I’ll let her say “awesomest co-author ever.”;

Helping clinicians help others

I appreciate that you keep the focus on the idea and reality that the “illness” I see is actually an accommodation my client has made to his or her world and makes sense to the person who holds it.  To assist in the change process, I must show how what I have to offer is a better accommodation to his or her world–otherwise I am not worth my pay.  (No one pays a bully.)  I have just found myself down at the end of that alley with one of my folks–resulting in his leaving the program.  I have to own that, at first, I was relieved.  He’s gone, MY WAY is reaffirmed by events.  Then, I read through this most recent post of yours and felt the underlying guilt based on “How could I have allowed myself to fall into that old trap again!?”

ARTICLE LINK

That was the question I needed to ask weeks back before events worked out the way my ego had ordained that they would.  I can and will look for a way to re-engage with this person so that I can feel better about payday.  Thank you again for holding our feet to principles of good behavior, ethical treatment, and service.  Peace!

Jim Recktenwald

***

While I have read and enjoyed your Tips & Topics, what I have appreciated most was your willingness to help us in our struggles as clinicians. Several years ago, the agency I was working for was moving toward a one-size-fits-all model trying to get everyone to do their Intensive Outpatient Program (IOP)…..I was the Intake Specialist and believed in meeting the client where he/she was and referring them to a level of care that matched their needs at that time.

THANK YOU for your hard work and dedication!

Carol Goulette LCPC, CCS

***

I just want to thank you for this regular piece of sanity in my mailbox. Some days it is hard to put one foot in front of the other in the midst of non-client/programmatic madness.  Seeing your words reminds me that I’m not alone and neither my clients nor I are crazy.

Staci Hirsch, Psy.D. – Program Supervisor
NEIGHBORHOOD SERVICES ORGANIZATION
Supportive Housing/Bridges
Detroit, Michigan

Subject: How Tips and Topics have helped me.


Dr. ML,

My brother, Bill, died on Feb. 4, 2013.  He was diagosed with schizophrenia in his twenties.  He was probably ill since his teens.  He was “hyper-religous”, “hyper-alcoholic”, and smoked as many cigarettes as he could get his hands on.  In retrospect, I think that he sought a community of accepting people (religion), an escape from psychic disturbance (alcohol), and probably an element of the first two conditions in socializing and rewarding himself with what relaxed him (cigarette smoking).  He was a very bright man. People questioned why he didn’t just “take his medications” and “fly right”.  I think, in his own way, that is precisely what he did.  I think of the John Nash story, “A Beautiful Mind”, where, under what might be considered more optimal conditions, people encouraged him to follow his treatment regimen. Why? What is a person giving up to trust another to do what is in their best interest?  I think the Tips and Topics literature has helped me to ask this question.  Why should a person who has many gifts give someone like me an opportunity to assist them in living in a way that others might consider “better”?  What stage of change am I in?  Keep up the good work.

Respectfully,

Peter Fuller, LCSW, LADC

And now for an appreciation note from me

  • Firstly, my heartfelt thanks to you all for signing up for TNT and for the many readers who through the years have taken the time to write notes of appreciation. Your telling me when a certain tip or topic spoke to you and helped you personally/professionally is very gratifying as a writer. Without readers and without knowing if ‘message sent’ is actually ‘message received’, all these words could just be traveling into outer cyberspace. So thank-you.
  • Secondly, if there have been some long and complicated sentences that left you scratching your head, I probably wrote those and they weren’t caught by my life partner and TNT editor, Marcia, my wife without whom none of the 10 years of TNT editions could have been successfully communicated to you in the straight forward and efficient sentences you usually receive and understand when you read TNT each month. (The long sentence is a joke, sort of, but the appreciation is real.)

Each month, I churn out the first draft. Then Marcia and I ‘fight’ over what I meant in some obscure paragraph and how to make it shorter, readable and comprehensible. She keeps me honest and keeps you reading. So thanks to my editor too.

SKILLS

Join me in a retrospective of April’s SKILLS Tips – from year 1 to year 10!TIP 1

See which TIPS take your fancy and click on the link to read more.

April 2003

When assessing the severity or level of function (LOF) for each ASAM dimension, it is useful to consider the three H’s:

History; Here and Now; and How Worried Now.

April 2004

The more the identified client is ambivalent or resistant to recovery, the more you focus on _who has the power_ in the client’s system…

April 2005

Ask “How much?” and “How often?” questions, rather than “Do you?” or “Have you?” questions…

April 2006

Every client who is talking to you in an assessment, treatment session or outreach visit is treatment-ready…

April 2007

Tune into what your clients are feeling on that first visit. Identify what methods you use to effectively engage a reluctant client. Here are what probation officers see and do (in no particular order)…

April 2008

For alcohol, the NIAAA one question is a good start: How many times in the past year have you had 5 or more drinks in a day (men); 4 or more drinks in a day (women)?

April 2009

When clients are ambivalent, don’t always argue for the healthy choice: “You can hangout with those friends if you want to. Why not continue going to parties with them?”

April 2010

Even if there was not the current political focus on healthcare reform, we would need to re-think how we do behavioral health care.

Identify one innovation you are willing to do in at least one of the following three C’s – even if you have to start small.

April 2011

Identify where to start on PEOPLE, PARTNERSHIPS and PERFORMANCE MEASURES

April 2012

Conflict is normal. Not resolving conflict is the problem.  See more SAVVY Tips.

SHARING SOLUTIONS

As a special anniversary celebration, I am offering the Tips and Topics book for a $1 for each year. So for $10 total (shipping and handling free), you can receive the TNT book if you purchase in April and May. After May 31, it will revert to regular pricing of $19.95 plus shipping.Get selected relevant clinical and systems tips from the years of Tips and Topics all in one place, “Tips and Topics: Opening the Toolbox for Transforming Services and Systems” by David Mee-Lee, MD with Jennifer E. Harrison, MSW. (158 pages; usually sells for $19.95 plus shipping but through May 31, $10 all-inclusive)

You can buy in two ways:

    1. Go to http://www.changecompanies.net/products/product.php?id=TNT and buy online; or
    2. call The Change Companies at (888) 889-8866 and ask for the anniversary deal for the Tips and Topics book.

SOUL

SOUL

On Friday, April 12, 2013, on National Pubic Radio’s Science Friday program, I was introduced to Zachary Sawyer (“Zack”) Kopplin.  Zack is 19 years of age and is an American science education activist from Louisiana.

http://www.sciencefriday.com/segment/04/12/2013/the-teenage-troublemaker-fighting-for-science.html

A week later on CNN, I was introduced to Dzhokhar Tsarnaev.  Dzhokhar is also 19 and is an alleged bomber, charged with using a weapon of mass destruction to kill in Boston, Massachusetts.  He was found hiding in a boat about three miles from where we lived for 17 years.

Both 19 year olds have been in the media quite a bit for just being 19.  Zack and his tireless campaign to elevate the importance of science education in the USA has been covered in hundreds of newspapers and radio and television interviews.  He has been interviewed in both national and international media, including Vogue Magazine, MSNBC, and the Washington Post.

Dzhokhar has been interviewed by a special team of federal investigators at Beth Israel Deaconess Hospital in Boston, and his radio and video presence now far outstrips Zack’s for many sad and tragic reasons.

What a contrast in two young men- one with focused energy to do good and the other to destroy.   One who channels his youthful idealistic fervor to build; the other who channels his to tear down and terrorize.  It is easy to deify or demonize and that is not what this is about.

What it is about is the important responsibility we all have to nurture our children and youth: to harness their idealism for good, to protest peacefully, to preserve and uphold life, not destroy and kill; and to speak up for what they believe while respecting the rights of others to differ.

Somehow Zack got that message and Dzhokhar didn’t. One has his life ahead of him to keep being a force for positive change. The other will languish incarcerated forever, or may even be killed as he allegedly did to others.

SHARING SOLUTIONS

As a special anniversary celebration, I am offering the Tips and Topics book for a $1 for each year. So for $10 total (shipping and handling free), you can receive the TNT book if you purchase in April and May. After May 31, it will revert to regular pricing of $19.95 plus shipping.Get selected relevant clinical and systems tips from the years of Tips and Topics all in one place, “Tips and Topics: Opening the Toolbox for Transforming Services and Systems” by David Mee-Lee, MD with Jennifer E. Harrison, MSW. (158 pages; usually sells for $19.95 plus shipping but through May 31, $10 all-inclusive)

You can buy in two ways:

    1. Go to http://www.changecompanies.net/products/product.php?id=TNT and buy online; or
    2. call The Change Companies at (888) 889-8866 and ask for the anniversary deal for the Tips and Topics book.

Until next time

Thanks for joining in the 10th anniversary celebration. I look forward to seeing you in late May.

David

Vol. 11, No. 2

In This Issue
  • SAVVY : Getting closer to payment for outcomes and preventing harm
  • SKILLS : Be prepared for healthcare reform, use The ASAM Criteria

Thank-you for celebrating with me the 10th anniversary of Tips and Topics (TNT) last month and to all of you who bought the Tips and Topics book. You still have until May 31 to keep celebrating with this special anniversary price.

David Mee-Lee M.D.

SAVVY

A small proportion of Tips and Topics readers receive the American Medical Association News. When reading some recent editions, two headlines caught my attention. I’ll share them with you and address the implications for addiction and mental health clinicians and services.

Our overseas readers will, I expect, find the first headline less relevant unless you are curious (amused?) by how the USA still struggles to provide universal health care to its citizens. Where you live, you likely have solved this years ago.

Despite the fact that we spend more per person on healthcare than you do, we have poorer quality results. The Institute of Medicine (IOM) reports that the “the panel analyzed US health conditions against 16 nations: Australia, Austria, Canada, Denmark, Finland, France, Germany, Italy, Japan, Norway, Portugal, Spain, Sweden, Switzerland, the Netherlands and the UK.” The report explains: the “disadvantage exists even though the US spends more per capita on health care than any other nation, partly because of a large uninsured population and inaccessible or unaffordable medical care.”)

TIP 1

“Volume, not quality, still decides most doctor pay”

This was a headline in the April 22, 2013 edition of American Medical News, page 5.

While this talks about how doctors get paid for their services, it’s also true for how just about every other counselor, clinician and behavioral health program and agency is paid – the more patients and clients you serve, the more money and funding you get.

–> The more services you provide – (individual and group sessions, family therapy, medications and recreational therapy etc.) – the more you can charge (unless you are funded with a fixed case rate.) That is why it has been said the USA has a sick-care system not a health-care system. The incentives are to fill beds or treatment slots with sick people. If the population is well and don’t need you, you’re out of business.

Why is this important if you live and work in the USA? The Affordable Care Act (ACA) is coming into full force in just over 7 months. The shift in how you will be paid for services will continue to change and pick up pace. It has already started. Hospitals are already being penalized for quality issues like readmission of patients within 30 days. For patients, it was bad if they were quickly released from hospital, became destabilized and then needed to return for readmission. But….it was not bad for hospitals. That kept hospitals’ censuses up, helped pay their bills, maybe even increased their profits.

–> Everyone says they are interested in quality outcomes and excellence. But you have to follow the money. Check with your institution’s budget and finance person. Ask how much your program spends on measuring and tracking outcomes. Then check how much is spent on marketing and expanding services to increase the volume of new clients and increase revenues. My guess is that the budget for the first is a fraction of the budget for the second.

–> I’m not saying marketing and expansion is “bad”. It’s just that the shift in healthcare has already started where quality outcomes will increasingly determine your funding, referrals and revenues than just volume.

TIP 2
“Top 10 ways to improve patient safety NOW!”
This was a headline in the April 22, 2013 edition of American Medical News, page 12.

The article talked about newly-released evidence on the best areas to prevent harm to patients – things hospitals should be doing to prevent harm. In that setting, this involved things like:

  • Improved hand hygiene compliance – to prevent health-care associated infections.
  • Use of barrier precautions to stop the spread of infections – by wearing gowns and gloves when providing care.
  • Employing pre-operative checklists to reduce surgical complications – the checklist prompts communication among members of the surgical team.

So I asked myself:
What are the equivalent areas to prevent harm in behavioral health treatment?

A few came to mind, drawing from the first 5 of 13 research-based Principles of Effective Addiction Treatment from the National Institute on Drug Abuse (NIDA):

Principle 1.
“Addiction is a complex but treatable disease that affects brain function and behavior.” – “Drugs of abuse alter the brain’s function, resulting in changes that persist long after drug use has ceased. This may explain why drug abusers are at risk for relapse even after long periods of abstinence…”

In relation to this principle, how do we prevent harm to our clients?

  • We design and deliver chronic disease management of addiction.
    When you “graduate” people from treatment and talk of “treatment completion,” it sounds like you don’t believe addiction is a chronic disease. It creates potential harm if the client and others believe they are “cured” and done with treatment altogether. Patients don’t complete treatment and “graduate” from diabetes, bipolar disorder or asthma care.

Principle 2.
“No single treatment is appropriate for everyone.” – “Matching treatment settings, interventions, and services to an individual’s particular problems and needs is critical…”

In relation to this principle, how do we prevent harm to our clients?

  • We “walk the talk” about true individualized and person-centered services.
    No longer will it make sense to answer, “How long do I have to be here?” with a number of weeks, months or sessions. Then perhaps we can avoid potential harm when the client spends more time focused on their treatment plan, rather than the calendar/ treatment time!

Principle 3.
“Treatment needs to be readily available.” – “Potential patients can be lost if treatment is not immediately available or readily accessible. As with other chronic diseases, the earlier treatment is offered in the disease process, the greater the likelihood of positive outcomes.”

In relation to this principle, how do we prevent harm to our clients?

  • We work to eliminate waiting lists and any barriers to access to care.
    Other areas of healthcare are streets ahead of behavioral health in screening, early intervention and immediate access to care. Certainly they do not have it all resolved; however we could learn from approaches like “no appointment necessary” experiments, telemedicine and in-home consultations etc. When clients are not moved flexibly through seamless continuums of care (often due to long fixed lengths of stay and lack of community resources for housing and care management), what happens? Waiting lists lengthen, access diminishes and harm increases.

Principle 4.
“Effective treatment attends to multiple needs of the individual, not just his or her drug abuse.” – “To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems….”

In relation to this principle, how do we prevent harm to our clients?

  • We provide assessment-driven services rather than program-driven care. Using the structure of multidimensional assessment like the 6 ASAM Criteria dimensions, the individualized service plan covers all client needs.
    (See January 2011 for more on the 6 ASAM dimensions)
    Treatment is not about compliance with a certain program model. It is the development of services to match each person’s unique multidimensional needs. It would be harmful for every patient to get the same medication dose for withdrawal management, diabetes treatment; the same type and intensity of therapy for trauma work; the same vocational counseling regardless of assessed needs. Worse still, outcomes are poorer if housing needs are unaddressed; family and significant other treatment is ignored; and trauma and co-occurring disorders are not detected. It is much more than “don’t drink or drug.”

Principle 5.
“Remaining in treatment for an adequate period of time is critical.” – “The appropriate duration for an individual depends on the type and degree of his or her problems and needs. Research indicates that most addicted individuals need at least 3 months in treatment to significantly reduce or stop their drug use and that the best outcomes occur with longer durations of treatment….As with other chronic illnesses, relapses to drug abuse can occur and should signal a need for treatment to be reinstated or adjusted. Because individuals often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment.”

In relation to this principle, how do we prevent harm to our clients?

  • We engage and attract people into recovery. We use the whole continuum of care to increase access to, and lengths of, treatment. Treat relapse, don’t discharge for relapse.
    People with addiction rarely seek treatment spontaneously without any external family, work, school or legal pressure. Typical readiness to change issues, slips and recurrences of addictive behavior will always show up. We need to assess them, not harmfully exclude and discharge from treatment. How can we call addiction a disease and then exclude people from treatment for recurrences of their signs and symptoms?
That’s my two cents’ worth. So it’s your turn now. What’s on your Top 10 list of ways to improve patient safety and behavioral health care NOW!? Send me one or two of
your Top 10, especially if you have any supporting evidence or data.

References:

  1. Institute of Medicine: U.S. Health in International Perspective- Shorter Live, Poorer Health. Report Brief, January 2013.(http://www.iom.edu/Reports/2013/US-Health-in-International-Perspective-Shorter-Lives-Poorer-Health/Report-Brief010913.aspx)
  2. National Institute on Drug Abuse: Principles of drug addiction treatment: a research-based guide (NIH Publ No 09-4180). Rockville, MD: National Institute on Drug Abuse, 2009

SKILLS

This month, two major publications will affect addiction and mental health treatment providers and programs:

  1. The Fifth edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, DSM-5. (DSM-5 is now released.)
  2. A new edition of The ASAM Criteria.(The ASAM Criteria will be released in October, 2013) (See SHARING SOLUTIONS for how to Preorder the new edition.)

For most clinicians and programs in the USA, you will need to use DSM-5 to get paid.

The ASAM Criteria will not only help you provide and manage care which prevents harm to your clients and patients, but also get you ready for healthcare reform, if you truly implement the spirit and content of The ASAM Criteria.

TIP 1
Compare how the new edition of The ASAM Criteria addresses all the issues in SAVVY above and more – the goal being to “do no harm”.

Ways to improve patient safety and care

How The ASAM Criteria helps design/deliver services

 

 Design and deliver chronic disease management of addiction.

Current & Continuing

New & Additional

The Criteria have always had multiple levels of care to promote a seamless continuum. The new edition expands Level 1

  • It emphasizes outpatient services for ongoing disease management and recovery monitoring.
  • Level 1 isn’t just a treatment level at the beginning of recovery.
“Walk the talk” about true individualized and person-centered services. Since first published, The ASAM Criteria has advocated for a shift from program-driven services to person-centered, individualized care. The new edition has a brand new layout.

  • There is a logical sequence from assessment to service planning to level of care placement and continuing care.
  • It will guide you better to the Dimensional Admission Criteria for each level of care.
Work to eliminate waiting lists and any barriers to access to care. It has always been the spirit of The ASAM Criteria, to increase access to care. Clients move flexibly through the levels of care, receiving whatever length of treatment they need. This helps eliminate waiting lists if coupled with more Dimension 6, Recovery Environment community support services.
There is a new section on working effectively with managed care and healthcare reform.
  • This will also help everyone manage care to be good stewards of resources and increase access to care.
Provide assessment-driven services rather than program-driven care. Use the structure of multidimensional assessment (6 ASAM Criteria dimensions) to cover all client needs. The six assessment dimensions of The ASAM Criteria provide the common language of holistic assessment.
The new edition expands the discussion of co-occurring disorders.
  • Integration with general health treatment is highlighted for the first time in this edition.
  • Across all health systems, the six dimensions are a common language of behavioral health assessment.
Engage and attract people into recovery. Use the whole continuum of care to increase access to, and lengths of, treatment. Dimension 4, Readiness to Change:
Assessing stage of change is as important   as assessing withdrawal and mental health needs.Dimension 5, Relapse, Continued Use, or Continued Problem Potential:
This is used to treat recurrences, not used as a discharge policy.
There is an expanded section on Dimension 5.

  • This will guide programs on dealing with relapse as a treatment issue.

 

If we fund and use the full continuum of care in The ASAM Criteria, we’ll realize the vision of:

  • Increasing access to care
  • Stretching resources to give people longer lengths of stay in the continuum of services
  • Improving engagement, ongoing monitoring and outcomes.

SOUL

If you think there are a lot of changes coming to healthcare you haven’t seen anything about changing systems until you see what’s happening in places like Myanmar (Burma). Well I haven’t seen it yet either, but I will….and very soon.

By the time you read this edition of TNT, I will be in Myanmar for an up-close and personal look at astounding scenery, temples, cultural transition and sights, sounds and smells so new to me. I’m going for a week of touristing – a new experience for Marcia and me as we meet up with Taylor, our son, for his last week traveling in SE Asia.

Our travel agent sent us a list of DOs and DON’Ts. It’s a quick lesson in cultural competence. Here are some off the list that fascinated me. I’ll add my comments in italics:

Typical Character

  • Friendly, helpful, honest, but proud.
  • Treat everyone with respect and you will be respected. (That’s good advice in any country)

Speaking

  • When addressing people, don’t leave out U (which stand for Mr) or Daw (which stand for Ms/Mrs)
  • Speak slowly and clearly. (But will they understand an Australian-Chinese-39 years in the USA accent?!)

Manners

  • Not always necessary to shake hands.
  • Don’t hug or kiss in public. (No PDAs = Public Displays of Affection)
  • Don’t touch any adult on the head. (I’m not one of those TV preacher healers and can’t think when I would touch anyone on the head in the USA, so that shouldn’t be hard)
  • Don’t step over any part of a person, as it is considered rude.(Imagination runs wild thinking about what that situation would be like)
  • Accept or give things with your right hand.
  • In Myanmar, unlike the Indian continent, nodding mean YES, and shaking head means NO. (Phew, that’s familiar)

Eating

  • Let the oldest be served first. (That’s good, since I’ll be the oldest)
  • Myanmar food is often complained about as ‘oily’.

Safety

  • Beware of cheats, swindlers, imposters. (I’m glad we don’t have any people like this in the USA!!)

Health

  • Stay away from narcotic drugs. (Now that’s good advice for a lot of people worldwide)
  • Health insurance is not available. (Just like the 45 to 50 million people in the USA)

Traveling

  • Accept that facilities may not be the best. (Serenity Prayer time)
  • Carry toilet paper in your bag. (Serenity Prayer time)

Religion

  • At religious places, remove footwear, but to remove headwear is not necessary.
  • Avoid shouting or laughing. (No loud Americans here please)
  • Tread Buddha images with respect.
  • Tuck away your feet. Don’t point it toward the pagoda or a monk.
  • Don’t play loud music in these areas. Note that Buddhist monks are not allowed to listen to music. (No booming, thumping music coming from the car beside you. Maybe this should be a rule in the USA)
  • Do not put Buddha statues or images on the floor or somewhere inappropriate.
  • Don’t touch sacred objects with disrespect. Hold them in your right- hand, or with both hands.
  • Leave a donation when possible. (At least the need for money is worldwide)
  • Show respect to monks, nuns, and novices (even if they are children). (“Even if they are children” – Now that’s different)
  • Don’t offer your hand to shake hands with a monk.
  • Sit lower than a monk and elders. (Don’t make your patients and clients do this with your treatment sessions)
  • Don’t offer food to a monk, nun, or a novice after noon time.
  • A woman should not touch a monk. (No women’s lib here)

This is going to be some experience. Can’t wait.

 

There’s still time for the special 10th anniversary celebration. The Tips and Topics book for $10 total (shipping and handling free) – that’s $1 for each year. After May 31, it will revert to regular pricing of $19.95 plus shipping.

Get selected relevant clinical and systems tips from the years of Tips and Topics all in one place.”Tips and Topics: Opening the Toolbox for Transforming Services and Systems” by David Mee-Lee, MD with Jennifer E. Harrison, MSW. (158 pages; usually sells for $19.95 plus shipping but through May 31, $10 all-inclusive, except for international orders)

You can buy in two ways:

  1. Go to http://www.changecompanies.net/products/product.php?id=TNT and buy online; or
  2. call The Change Companies at (888) 889-8866 and ask for the anniversary deal for the Tips and Topics book.

The special runs through May 31, 2013.

Preorder The ASAM Criteria and get more than the book

The new edition of The ASAM Criteria is coming in October.
If you preorder now, you receive 3 months of free access to the enhanced, web-based version when it releases. Find out more and preorder at http://www.ASAMcriteria.org

  • See video clips where I explain what’s new and what’s coming in the new edition.
  • Opt-in and sign up there to be kept in the loop on the new edition even before it releases in October.
  • See FAQs on The ASAM Criteria.
  • We’ll keep adding more at http://www.ASAMcriteria.org for all things ASAM criteria.

Until next time

Until next time

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

David

Vol. 11, No. 4

In This Issue
  • SAVVY : Readers’ suggestions on how to prevent harm andimprove safety
  • SKILLS : How to guide and help people in motivational work
  • SOUL : Finding the perfect guide

Thank-you for joining us for the July edition of Tips and Topics.

David Mee-Lee M.D.

SAVVY

In the May 2013 edition, I discussed ways to prevent harm and improve patient safety in addiction and mental health treatment.
I asked for feedback:  What’s on your Top 10 list of ways to improve patient safety and behavioral health care NOW!? – especially if you have any supporting evidence or data.

I promised to share readers’ suggestions.

Here are three and some editorial comments:

 

Reader #1
Hi Dr. Mee-Lee:

I read your latest Tips & Topics (May 2013) with great interest. As you know, approximately 90% of clients seeking treatment in community mental health centers have been exposed to trauma. Safety is absolutely enhanced by resisting the urge (from oneself but also the patient) to engage in premature trauma retrieval work. This advice has been repeated over and over by such luminaries in the field as Bessel van der Kolk, Judith Herman, Joan Turkus and Lisa Najavits.

 

Regards,

Harry Ayling, LCSW, diehard devotee to Tips & Topics  (Harry’s words, not mine).

 

–> Comment from David Mee-Lee

There has been a lot of attention over the past 15 years on co-occurring mental and substance-related disorders.  The more recent refinement of that attention is to be trauma-informed: to be aware of how many addiction and mental health clients present  with past histories of trauma.  When people with addiction sober up, intense feelings can rise to the surface.  It is always a fine balance to know how to address intense feelings which can’t be ignored.  Yet, at the same time it is important, as Harry says, to make sure that our clients are safe to deal with trauma; and not cope by returning to substance use or other self-destructive behaviors like cutting.

Of course, trauma-informed work is even more in our consciousness as we face the thousands of veterans returning home.
Take a look at a brand new journal from The Change Companies: “ComingHome: A Warrior’s Guide”
Reader #2
Dear David:
Thank you for your excellent comments on our health care costs and the Affordable Care Act (ACA).  I am personally offended by the sizeof the executive compensation packages, and the large bureaucracies funded to try to get paid (medical facilities) and to avoid paying (insurers).  A Google search of executive compensation packages in the insurance and medical care industries show many senior execs make over $1million per year, with some getting more than $40 million per year.  Soon the taxpayers will be contributing even more to their life styles.  Steven Brill documented many key issues in his fine article Bitter Pill: Why Our Health Care Costs So Much (Newsweek, Feb 20, 2013).  A big part of what impedes our ability to solve problems in this and other arenas (guns, food habits, worker safety) is the commandment “Thou shalt not interfere with profit.”  I think all of the measures designed to bring down costs will also produce a lot of howling and attempts to sabotage full implementation of the ACA.  The more people can be made aware of what goes on in other countries, the better.  It does not have to be this way.

 

Joan Zweben, Ph.D.

Berkeley, CA

 

–> Comment from David Mee-Lee

In Overview of the Uninsured in the United States: A Summary of the 2012 Current Population Survey Report, the “Census Bureau released data on health insurance coverage and the uninsured for 2011 on September 12, 2012.  Although there are four major government surveys that produce estimates of health insurance coverage, the Current Population Survey (CPS) is the most widely cited and receives national media attention. …. During 2011,an estimated 48.61 million people were without insurance, a statistically significant decrease of 1.34 million from the estimated 49.95 million uninsured in 2010.”http://aspe.hhs.gov/health/reports/2012/uninsuredintheus/ib.shtml

 

Regardless of your political leanings (right or left); or where you stand on the continuum of individual rights (right to buy health insurance or not) to collective action for the greater good (requiring health insurance of all so as to pool resources to allow universal coverage), the fact remains:  There are 40 to 50 million people who do not have health insurance in the USA.  This creates huge human costs, as well as significant healthcare costs, as scarce resources are used inefficiently and ineffectively.

 

As Joan says on this and other related issues, “It does not have to be this way.”

Reader #3
Dr. Mee-Lee:
Number One Way to improve patient safety and behavioral healthcare now:

Address the stigma in the 12-step based treatment community against methadone and Suboxone (buprenorphine and naloxone) maintenance for the treatment of opioid dependence (now opioid use disorder in DSM-5).  About 95% of treatment programs in the public sector are based on the 12-step philosophy, and are staffed by people who are undereducated about medications, and either covertly or openly biased against medication-assisted treatment.

There is NO scientific controversy that for established opioid dependence, medication- assisted treatment is the treatment of choice.  Clients must receive informed consent regarding this treatment option, but in my 25 years of experience in publicly funded treatment in California, this rarely happens.  This MUST change, as we are in the midst of the largest epidemic of opioid dependence since heroin use rose in the 60’s.

Please, devote not just one, but several issues of your newsletter to educating your readership on improving delivery of evidence-based treatment of opioid dependence.  You are a thought leader whose opinion is respected in the field; you are well positioned to lead the efforts to improve the treatment of opioid dependence. Young people are dying from overdoses after completing abstinence-based treatment programs; this needs to stop.

 

Sincerely,
Nancy Friel MFT
Senior Mental Health Counselor
County of Sacramento DHHS, DBH, Alcohol and Drug Services
 –> Comment from David Mee-Lee
There has been lively discussion on methadone and Medication Assisted Treatment (MAT) in previous editions of Tips and Topics.  Take a look at Jerry Shulman’s piece on MAT in the October 2008 guest tips edition.
In the May 2007 edition, we discussed harm reduction and methadone treatment followed by some readers’ comments in the June 2007 edition.

In the new edition of The ASAM Criteria, there is an expanded section on Opioid Treatment Services (OTS) to include opioid agonist medication like methadone and buprenorphine in Opioid Treatment Programs (OTP) and Office Based Opioid Treatment (OBOT); and opioid antagonist medication like naltrexone. Take a look at the updated website all about the new edition at www.ASAMcriteria.org

SKILLS

One of the skills I address very often in Tips and Topics is how to do truly individualized, person-centered work.  The recent third edition of Motivational Interviewing (MI) explains a  continuum of communication styles.  This distinction has really helped me understand MI.

 

Here’s the reference:Miller, William R; Rollnick, Stephen (2013): “Motivational Interviewing – Helping People Change” Third Edition, New York, NY., Guilford Press. Pages 4-5 and some resources on the third edition:

http://www.changecompanies.net/motivational_interviewing.php

 

 

TIP 1

Identify where you are on the continuum of communication styles from Directing to Guiding to Following

 

Directing <————-> Guiding <————–> Following

 

  • Here is an example of a Directing style for working with a client who says they want help to stop drinking:

 

It’s good that you want to stop drinking because you’re an alcoholic and you need to really accept that you suffer from addiction and develop a supportive recovery network. Here’s what I want you to do: go to an AA meeting every night this week and get some names and numbers so you can start calling people and developing that network. It is also important for you to stay away from those three friends of yours you usually drink with and start hanging around recovering people. Any questions?”

 

  • Here is an example of a Following style for working with a client who says they are depressed:

 

Clinician: So I understand you have been feeling down and blue lately.

 

Client: Yes, I’ve been really feeling depressed and don’t know what to do.

 

Clinician: So you feel lost and not sure how to handle your depression.

 

Client: Yes, I have no energy and can’t concentrate at work. Is there medication that can help me?

 

Clinician: So you having trouble with work in your concentration and energy level and wonder if medication would help.

 

Client: That’s right. What medication should I take because my primary care doctor’s medication didn’t seem to work well?

 

Clinician: You’d like me to tell you what medication would help.

 

Client: Yes, should I see a psychiatrist or is my family practitioner OK to prescribe?

 

Clinician: You’re wondering whether to see a psychiatrist or a family practitioner?

 

Client: Yes, I’m really depressed and don’t know what to do.

 

Clinician: You really feel lost and not sure how to handle your depression.

 

Client: Yes, what should I do – see a psychiatrist or is my family practitioner OK to prescribe?

 

Clinician: You’d really like to know whether to see a psychiatrist or a family practitioner.

 

At this point the client is really depressed and hopeless.  You’ve done nothing except follow the client around their presenting concerns, reflecting back what you hear.

There is some following that is important and necessary to do at first with a client so you know what they want and what to focus on.  But if that is all you do, they understandably get frustrated as you act like a therapy robot.

 

  • Here is an example of a Guiding style for working with both these clients. Guiding is a combination of Following and Directing in what Motivational Interviewing calls a “conversation about change”.

 

Clinician:  So I understand you want help to stop drinking. (Following)

 

Client: Yes, I’ve been trying to do that on my own for six months and am not getting anywhere.

 

Clinician: What have you tried that hasn’t been working? (Following)

 

Client: Well I went to some of those AA meetings, but I’m not as bad as those people.

 

Clinician: How many meetings did you go to? (Following)

 

Client: Two or three, but I didn’t get anything out of it except for one person I spoke to who seemed to really understand me.

 

Clinician: Did you get that person’s name and number? (Following)

 

Client: Yes, but I haven’t had any more contact.

 

Clinician:  Would it be OK with you if I gave a suggestion? (Seeking permission to be Directive)

 

Client: Sure, go ahead.

 

Clinician: How would you feel about calling that person and seeing if they would go to a different meeting, because sometimes certain meetings fit certain people better? (Directing)

 

Client: I guess I could do that.

 

Clinician: You sound a bit unsure if you want to do that (Following).  Do you need to think about it a bit more; or would you like to give it a try, at least one or two times? (Guiding).

 

 

And for the depressed client:

 

Clinician: So I understand you have been feeling down and blue lately (Following).

 

Client: Yes, I’ve been really feeling depressed and don’t know what to do.

 

Clinician: What has been most troubling about your depression? (Following)

 

Client: I have no energy and can’t concentrate at work. Is there medication that can help me?

 

Clinician: Have you taken medication before? (Following)

 

Client: My primary care doctor’s medication didn’t seem to work well.

 

Clinician: There are other methods besides medication that we could try if you were interested. (Directing)

 

Client: What do you mean?

 

Clinician: We could try cognitive behavioral therapy and exercise? (Directing)

 

Client: I’d rather take medication.

 

Clinician: So you feel more confident that medication would help the best. (Following)

 

Client: Yes, I’d like to see a psychiatrist to get my medication changed.

 

Clinician: So let’s arrange for a psychiatric consultation and track how you are doing. If medications don’t seem to be the full answer, maybe we could try some of these other approaches I mentioned. (Guiding)

 

 

Directing is easy to do, as it involves just telling people what to do to change regardless of whether they are ready to do that.  You have taken little time to listen to what goals and methods are important to them.

 

Following is also easy to do, as it involves just reflecting back what you hear they are saying.  This can be frustrating to the client if every interaction is a question and summarizing without moving forward to get some sense of direction of what to do next.

 

Guiding is the art of using both Directing and Following to ask enough questions to clarify what goals and methods are important to the client, but then building on that knowledge to collaborate and Guide the person in a facilitated self-change process.

SOUL

If you’ve ever done touristing in a foreign country, it’s a relief to have an informative guide,especially an English-speaking one.  Actually, only an English-speaking guide for me.  A good guide is one who knows how to balance “directing” and “following”; to get you where you want to go in the most efficient, effective and enjoyable way.

(That sounds a lot like good person-centered treatment – no wonder Motivational Interviewing is founded on good guiding.)

 

In May, we were in Yangon (Rangoon) for just a day!  There is no way anyone could see all the major temples, pagodas and top tourist spots.   So it’s really important to have a guide who can “follow” your lead about the sights you are most interested in seeing, in the limited time available.  At the same time, what we needed from Nandar, our female guide, was also to “direct” us- by listing the top recommendations for what could be done realistically in six hours.  Then collaborate with us on:

 

  • what sightseeing goals were important for us (which temples, markets and local crafts caught our fancy)
  • what methods would best achieve those goals (taxi, walking, timing at each spot)
  • what was the plan for the day – Now that sounds like a therapeutic alliance and a great service plan.

 

Imagine if Nandar had told us we had to go to the top five tourist spots whether we wanted to or not; stay there for a fixed amount of time, whether we had seen what we wanted or not; and then kicked us off the tour if we weren’t able to be the perfect tourist. (I know, it’s not the perfect analogy, but sounds a bit like some addiction treatment programs).  Nandar, I thought you were our guide, not a director/dictator!

 

What if we had a guide who followed us around all the time, passively walking in our footsteps?

We ask: “Where should we go next?”

Well where would you like to go?”

“I can’t decide which would be better – another temple or the silversmith crafts.”

“Well they are both interesting.”

“So what would you recommend?”

“You want me to decide for you?”

 

At this point, I would fire the guide who is not a guide.  She must have missed the Guide School training class on how to balance directing with following.

 

There are no perfect guides, perfect tourists, perfect counselors and clinicians plus no perfect patients and clients.  However if you can join up with someone who has a good sense of balance between directing and following, you can enjoy both the journey and the destination.

 

Whether you tour Yangon or Yakima, the museums of Florence, Italy or New York, New York,  or the temples of Thailand or Salt Lake City, may you find a good guide.

Until next time

Thanks for reading. See you in late August.

David

Vol. 11, No. 6

In This Issue
  • SAVVY & STUMP THE SHRINK : How to work with angry, frustrating clients
  • SKILLS : Emotional intelligence and creating a learning environment
  • SOUL : No talk, No relationship
  • SHARING SOLUTIONS : ASAM Criteria eLearnings
Welcome to all the new readers and longtime subscribers to Tips and Topics.
Thanks for joining us for the September issue.

David Mee-Lee M.D.

SAVVY & STUMP THE SHRINK

I always enjoy and appreciate it when readers send their feedback about eLearnings, webinars, Tips and Topics or presentations I have done.

This month I received the following message which combines words of appreciation along with a “meaty” and substantive question I know is shared by many other clinicians, supervisors and clinical directors.

So I have combined SAVVY and STUMP THE SHRINK this month. Here’s the email:

Dear Dr. Mee-Lee:

I hope this email finds you well. I have a “stump the shrink” question I’d love to get your take on, if you have the time/interest. I find questions/struggles exemplified by this scenario have a tendency to show up again and again. I think our staff has a hard time in these situations because they are confronted by feelings of frustration, anger, annoyance, ineffectiveness and, if they’re willing to go there, their own expectations and values that they’d like our clients to adopt . . .

I recently attended case conference at our inpatient substance use rehabilitation center (length of stay is based on assessed need, however,28 days is still the accepted target) and the team was consulting regarding a client with whom they were extremely frustrated. The client is a middle-aged man who presents with mixed personality disorder traits (cluster B -antisocial, borderline, histrionic, narcissistic).

The client had been at our inpatient centre for 6 days and, during that time:
  • repeatedly violated house rules around pay phone and cell phone use, as well as daily living structure. 
  • He also had a tendency to tell the staff that our programming was “stupid” and that he had nothing to learn from them or our programming, especially since this was his 2nd treatment episode with us.
  • The staff was growing weary from constantly reminding him of the house rules and, at this point, were asking me permission to place him on a tight behavior contract (e.g., if we have to remind him X more times about the pay phone or cell phone rules, then he will be considered non-compliant and choosing to engage in treatment-interfering behavior, which may warrant an administrative discharge).
The staff were clearly tired, exasperated, and approaching the limit of being willing to work with this client.
  • I tried to balance empathizing with their frustration and feelings of ineffectiveness,
  • while also engaging them in a discussion about our mandate, realistic and reasonable expectations (especially given the enduring nature of personality disorders, learning & behavior, and the brief nature of our treatment),
  • empathy for the client, his own expectations and values,
  • and the difference between behaviors we absolutely cannot tolerate (e.g., verbal or physical aggression toward other clients or staff) and behaviors that require us to stand solid and yet have the capacity to bend in the wind, if you will.

I won`t give you all of the details (because I am eager to hear what type of recommendations you would give to a team that was tired, frustrated, and understandably reverting to hard nosed methods), but I will say that by the end of the discussion they agreed that the behavior contract they were proposing was unlikely to accomplish anything other than giving us a reason to discharge the client.

Given the lack of evidence-based or efficacious brief treatments/approaches with personality disorders, I find that it becomes increasingly difficult to advise/inspire our staff in their work with co-occurring Axis I and Personality Disorders. In all of your busy-ness, if you have the time and interest to give your take and how you would approach such a scenario (in the shoes of the therapist and floor staff working with this client), it would be greatly appreciated — especially since you are a bit of a celebrity around here

I circulate your Tips & Topics each month (with a bit of commenting and orienting on my part) and a common question we like to throw around is, “What would David Mee-Lee say/do?” lol.

Thank you so much for your time, and for the extremely useful and engaging Tips & Topics — I truly believe it is the staff’s favorite email that I send out!

Warmest regards,

Phuong-Anh

Phuong-Anh Urga, Ph.D.

Montreal, Quebec, Canada

My response (supplemented by Tips in SKILLS):

Hello Phuong-Anh:

 

Thank-you for that nice feedback. It is really gratifying to know that Tips and Topics is helping make a difference to you and your team.

As regards your Stump the Shrink question, indeed this is an often-heard issue.  It has come up a lot over the years, but especially with some programs in Alabama and Louisiana where I am currently doing teleconference supervision.

Take another look at SKILLS in the Feb., 2013 edition.  This link should get you there.  Especially note numbers 2 and 3 in SKILLS tip#1.
Most importantly, help staff begin to reframe how to use the behavioral problems and “rule-breaking” etc., as an opportunity:
  • To recognize that treatment progress and outcomes are not going well.  As with any poor outcome – whether stabilizing someone’s blood pressure or blood sugar, their asthma, their depression – their addiction is really the same.
  • After that, the next step is to assess what is not going well.
  • Then collaborate with the client on a modified treatment plan. Then watch if things improve.
We wouldn’t just criticize a patient for having their blood pressure go up. We wouldn’t expect them to contract to control their blood pressure on their own. We would explore with them what’s going wrong, and how we can help them fix it. The same with anger, outbursts and rule-breaking…….

 

In the case of this client, we would be asking these questions and assessing along with him:
  • Why is he even in the program?
  • What does he want?
  • What is so important to be on the phone all the time?
  • What does he feel is stupid about the program?
  • What made him decide to choose to be in the program in the first place?
  • Is he getting what he wants? And if not, what can we do together to reach his goal?
Use the six ASAM Criteria dimensions to re-assess:
  • Dimension 1, Acute Intoxication and/or Withdrawal Potential

Is he acting up because he is in some withdrawal or even using on the side?

  • Dimension 2, BiomedicalConditions and Complications
Are there some physical health problems making him more frustrated -e.g. pain or migraine headaches or something else going around a co-occurring physical health problem?
  • Dimension 3, Emotional,Behavioral or Cognitive Conditions and Complications
Similarly are there issues that are stressing him?  Anger over something going on at home – or whomever he is talking to all the time on the phone? (Dimension 6, Recovery Environment).  Does he have an unstable concurrent mental health diagnosis?
  • Dimension 4, Readiness to Change
Readiness to change -or not- is an important area of focus. When I hear cases like this, the first thing I want to check is:
…What is the treatment contract?
…What made the client decide to be in treatment?
…What does he want?
Many behavior problems arise when we clinicians try to do “Recovery, relapse prevention” when our client is actually at “Precontemplation” for recovery, but at “Action” perhaps for other things like: getting someone off their back, or keeping a job or a relationship, or for staying out of jail or getting off Probation?
  • Dimension 5, Relapse, Continued Use or Continued Problem Potential
Is it possible your client is having addiction cravings to use and doesn’t know how to handle those?  Are there mental health flare-ups? He is possibly exhibiting in your program all kinds of struggles that he similarly gets into at home or work?  All of this comesback to the central question: Why is he in treatment? What does he want?
  • Dimension 6, Recovery Environment

Your client may have some family, work or other recovery environment pressures – e.g., money, housing, legal issues frustrating him. That could be contributing to his negativity about being there.

—-> So what is the staff’s goal? 
  • What can he (the client) and we (the staff) learn from how he handles frustration here in our program, which also happens outside in the ‘real world’? (Assessment)
  • What alternate strategies and skills can we help him learn and practice in the program, which he can also apply outside? Then he won’t have to come to these “stupid” programs. (Skills)

 

—–> It isn’t about our just trying to clamp down and stop the behavior. 
  • How can we relate to clients in an Adult-Adult interaction (Transactional Analysis) rather than a Parent-Child relationship?
  • Behavioral contracts and the like just perpetuate a victim, Parent-Child interaction. This doesn’t help him, or the staff, learn from this microcosm of the real world.
 
Bottom Line 
…When there is “rule breaking,” assess what is not going well.
…Tie the behaviors to the client’s treatment plan.
…Don’t make separate behavioral contracts.
…Create programs to be a safe, supportive environment where clients can understand and practice new ways of being.

… The same frustrations and behaviors that happen ‘out there’ also happen in the program.

Thanks for being a faithful reader and spreading it around.
David

SKILLS

So… What do we do about clients’ behavioral and emotional outbursts, especially in residential treatment programs?

 

On August 9, 2013 National Public Radio’s Science Friday interviewed two experts in social-emotional learning: Marc Brackett, Director of Yale University’s Center for Emotional Intelligence; and Maurice Elias, Professor, Psychology Director of Rutgers University’s Social and Emotional Learning Lab.

http://www.sciencefriday.com/topics/body-brain/segment/08/09/2013/reading-writing-rithmetic-and-respect.html

 

The program’s theme was on emotional intelligence. While the focus was on what schools and teachers should be doing in educational settings, the conversation referred to many principles applicable to treatment settings. In behavioral health, we also create an environment of learning, to facilitate lasting positive self-change.

 

TIP 1

Consider these points about schools. How can we relate them to our daily work in behavioral health?

 

1. Emotional intelligence is our way of being smart in the world.
We develop the set of skills needed to get along in our interpersonal relationships.

  • People in treatment have often been raised in families who themselves were never taught about emotional intelligence.
  • Many have never developed the skills to be smart in the world. They are not skilled about negotiating relationships. Our clients need us to create a safe and healing environment to learn emotional intelligence.
  • What they don’t need is a “school” where the focus is on behavior control, rule-breaking and “punishments.”

 

2. Schools and teachers do not do direct instruction of these skills.
Yet these skills are teachable. Students can be helped to develop a sophisticated emotional vocabulary and research-based strategies to regulate their emotions. Many people can only identify a few emotions; many have no emotional vocabulary to make sense of what is bubbling up inside them.

  • Clients can often have defiant outbursts and don’t comply with house rules. They probably have a very limited understanding of what they are feeling, and what they are reacting to. They are not skilled at acting differently and constructively, since they most likely have a limited repertoire of emotions and behaviors.
  • What is our job in treatment? To help our client become an explorer of his/her own feelings and behaviors – to think through what is going on and how to thrive.
  • What must we watch out for? That we do not perpetuate our clients’ externally- oriented perspectives where others are blamed for what is going wrong. We can reinforce this by responding to outbursts with rules and procedures. This then puts the responsibility for controlling emotions and keeping the peace on the staff! It is our clinical challenge to harness the teachable moment of an outburst.

 

3. Ability to learn at school is affected by a student’s emotional state while they are learning.

  • Students can’t learn if preoccupied with feelings and fears they don’t have a good handle on.
  • It is the same in treatment. When clients struggle to understand what they are feeling, thinking and why they are, it is doubly hard to figure out what to do about it.
  • In treatment, we must create a therapeutic environment to promote learning, not compliance.

 

4. Teach students how to calm themselves down when stressed or even when they are elated.

  • We must help clients find strategies they can use themselves,not just in the program, but more importantly when they are on their own in their outside world.
  • Simply expecting clients to manage interpersonal disputes effectively when they have never been taught is like teachers expecting students to know calculus just because they have enrolled in the class.

 

5. Teachers need to pay attention to the students’ emotional cues and create an engaging learning environment.

  • Clients frequently behave in exasperating and frustrating ways. For the staff, that’s a signal that the client is out of their depth in emotional intelligence.
  • The clinician is now alerted to the need for engaging the client in a learning process, not a disciplinary process.

 

TIP 2

Help people “name their emotions to tame their emotions.

Marc Brackett coined RULER to develop critical and inter-related emotional skills. Whena person creates a mental model of what an experience is, then it’s possible to figure out what one’s feelings and needs.   This helps you regulate them.

Here is what the acronym RULER means:

 

Recognize emotions in oneself and others.

Understand where emotions come from and the causes of emotions.

Label emotions and increase your emotional vocabulary.

Express emotions rather than holding them in.

Regulate emotions so as to get needs met, be smart in the world to get along in interpersonal relationships.

 

Help clients identify and explore their RULER. Focus the therapeutic community and staff energies on learning and growing, not compliance and discharge.

SOUL

The headline in the Sacramento Bee newspaper on Saturday, September 28read: “
Obama, Rouhani break ice on phone” FIRST DIRECT TOP-LEVEL TALKS SINCE 1979 – “Barack Obama and Hassan Rouhani spoke Friday by telephone in the first conversation between the presidents of the United States and Iran in more than 30 years.

Experts on Iran used a wide range of superlatives to discuss the call: “hugely positive,” “historic but long-overdue moment,” a “groundbreaking event.” “The phone call lasted only 15 minutes, but it offered the best hope in years for the two countries to settle their disagreements.”

 

I know I am politically naive. But it seems to me that if you don’t talk to people, it’s hard to form any kind of working relationship, let alone hope to settle disagreements. So, yes, maybe in the world of politics, talking to someone for 15 minutes after 30 years is pretty amazing. But on another level, you don’t have to be a rocket scientist to figure out that if you:

  • don’t talk for 30 years
  • don’t try to give each side some mutual respect
  • don’t use any methods other than the threat of bombs, sanctions, force and violence

………….that the chance of settling disagreements might seem a little far off!

 

The world of international politics is way over my head and outside of my expertise. But what is amazing to me much closer to my area of expertise is that we do our own version of the “no talk, no relationship” method in behavioral health and criminal justice settings.

 

As we just discussed in SAVVY and SKILLS this month, it is too easy to stick to “behavior control” methods to manage behavioral and emotional outbursts rather than to talk and build a “working alliance” method to create a learning experience for our clients.

 

Worse still are how high-risk inmates of prisons are housed with very little human contact and relationship. They are allowed only an hour out of their cell, with all their comings and goings controlled electronically via switches and gates.

 

Some forward-thinking prisons have discovered that respectful human interaction works wonders. Previously out-of-control inmates have shown dramatic improvements in the health and safety of inmates, correctional officers and the overall facility.

 

So maybe there are some places and world regions where the “no talk, no relationship”, power and control methods work well to settle disagreements.  I just know I don’t want to be anywhere near those countries or politicians – oops, I take that back.

 

I don’t want to move away from the USA. (I wonder when politicians in the USA will discover talking and relationship to settle disagreements?) I guess I’ll just have to enjoy the Government shutdown looming this week.

SHARING SOLUTIONS

Here is Dr. Phuong-Anh Urga again:

Firstly, I’d like to congratulate you–and The Change Companies–on your work that has resulted in the ASAM (American Society of Addiction Medicine) e-learning modules.I have completed them myself and have piloted them with some newly hired clinicians. Based on the feedback, I intend to incorporate them into my organization’s training and integration of new staff (it will be much more cost efficient and effective than providing the trainings myself, which I have done for the past few years now). I wonder how/if the modules will change with the launch of the revised criteria — any insight you might be able to provide without violating top security clearance would be appreciated before I purchase the site licenses.

 

My response:

I’m so glad you appreciated the ASAM eLearning modules.  We will have a new eLearning module on the new edition; it will be about an hour long. Also we are updating the two original modules to take into account some terminology changes from the new edition. However the essential principles and content will be the same as what you took, just updated for the 2013 edition.  I’ll certainly announce that in Tips and Topics, but you can also keep up to date at www.ASAMcriteria.org and check out the special preorder offer for the new edition of The ASAM Criteria that is running out.

Until next time

Thanks for joining us this month. I’ll be back in late October.

David

Vol. 11, No. 7

In This Issue
  • SAVVY : What’s new in The ASAM Criteria?
  • SKILLS : Integrated care and managing care
  • SOUL : Malala Yousafzai – the inspiring 16 year old
  • SHARING SOLUTIONS : Final days for special ASAM Criteria preorder offer

Welcome to the October edition of Tips and Topics. Thanks for reading.

David Mee-Lee M.D.

SAVVY

This week, the American Society of Addiction Medicine (ASAM) will release the new edition of ASAM’s criteria: “The ASAM Criteria – Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions.” As Chief Editor, I am especially excited as October 24, 2013 culminates over two years of direct work on the new edition. (It has been 12 years since the last edition of ASAM’s criteria.)

 

For those of you familiar with The ASAM Criteria, you’ll be pleasantly surprised once you get your hands on the new manual. It is attractive, user-friendly and leaps and bounds ahead of previous editions. There is new content and it helps you apply the criteria in a variety of clinical settings and for different populations.

 

Both for long-time Criteria users and for readers who do not know The ASAM Criteria, here are highlights of what you will see in the new edition. (There is also more information about what’s new in this year’s May 2013 edition of Tips and Topics.


TIP 1

Expand your knowledge about multidimensional assessment and the levels of care.

*Changes in Dimension 1, Acute Intoxication and/or Withdrawal Potential
Instead of detoxification services, the new edition now refers to withdrawal management services.This is because the liver “detoxifies” but clinicians “manage withdrawal.”

This isn’t just playing with words. There are good reasons to think about managing a patient’s withdrawal rather than just “detoxifying” the patient.

Common Case Scenario

  • Patients are often placed in high-intensity, high-cost hospital levels of care for detoxification to make sure they don’t have a withdrawal seizure.
  • However, they are discharged after 3-4 days or whenever the seizure danger has passed, only to find some people use again even within a week or two.
  • Why does this happen when we already detoxified them? The answer is that we hospitalized the person until the danger of seizures passed, but didn’tmanage the person’s withdrawal, which can take much longer than the few days of seizure danger.
  • There are 5 levels of withdrawal management in the adult criteria.
    Too often treatment occurs just in Level 4-WM (Medically Managed Intensive Inpatient Withdrawal Management). This can cost $600, $800 or even $1,000 per day. If all 5 levels are used, as needed, a patient can receive close to 2 weeks
    of withdrawal management support, for what it costs for a few days in Level 4-WM.
  • By contrast, one day in a 24 hour supportive Level 3.2-WM (Clinically Managed Residential Withdrawal Management) can cost $100 or $200 per day. Do the math: a patient can receive 5-6 days of 24-hour withdrawal management support for everyday in a high intensity hospital-based service.

 

 

*Level 1, Outpatient Services

Outpatient services are often used as the entry point at the beginning of recovery, or a brief “aftercare” level for people who have “graduated” from intensive addiction treatment. In the new edition, we emphasize that addiction is a chronic illness, and many clients need ongoing disease management in Level 1 – indefinitely.
  • How often does a patient need to be seen for ongoing recovery monitoring? Short answer: it depends on that individual’s current severity of illness and level of function. If the person’s addiction is unstable and they need closer monitoring, then the “dose”, frequency and intensity of Level 1 care may require that- at first- the patient be seen weekly or even twice weekly. After that, as the person stabilizes, the intervals between appointments can be lengthened.
  • Level 1 now becomes a level of care to help clients maintain their recovery for successful wellness and health.
  • Again, how do I understand the levels of care in the new edition?
    Consider these parallels. How does your doctor manage hypertension, or asthma or diabetes? How does a psychiatrist manage schizophrenia, bipolar disorder or chronic panic disorder or major depression? Disease management does not mean closing the case after 10 aftercare sessions.

 

*Level 3, Residential Services

This level is fundamentally the same in the new edition of The ASAM Criteria, but there are 2 levels worth highlighting. One is Level 3.1, and its difference from the other residential levels; and the other is Level 3.3 with its new name.

Level 3.1. Clinically Managed Low Intensity Residential

  • It is qualitatively different from Levels 3.3, 3.5 and 3.7.
  • Level 3.1 is 24 hour supportive living mixed with some intensity of outpatient services
  • In contrast, the other level 3 programs are 24 hour treatment settings for those in imminent danger.
  • The new edition explains further “imminent danger” in Dimensions 4, 5 & 6.
  • For example–
    An individual may not even think he has an addiction problem. Even though he is intoxicated, and not in withdrawal, he is intent on driving when it is obvious he is impaired. He needs 24-hour stabilization in a residential setting.
  • Another example–
    A client has overwhelming impulses to continue drinking or drugging. He has existing liver or psychotic illness. Continued heavy use with acute signs and symptoms places him in imminent danger of severe liver or psychotic problems. This calls for 24 hour treatment to prevent an acute flare-up.

 

Level 3.3: “Clinically Managed Population-Specific High-Intensity Residential Services

  • This is a new name for Level 3.3 and here’s why:
  • The PURPOSE of Level 3.3 programs has always been: to deliver high-intensity services and to provide them in a deliberately repetitive fashion.
  • Which populations does this level serve? The special needs of individuals such as the elderly, the cognitively-impaired or developmentally-delayed.
  • Another population is patients with chronic and Intense disease who require a program which allows sufficient time – to integrate the lessons and experiences of treatment into their daily lives.
  • Typically, level 3.3 clients need a slower pace of treatment because of mental health problems or reduced cognitive functioning (Dimension 3), or because of the chronicity of their illness (Dimensions 4 and 5).
  • Summary: this level is for specific populations; high intensity work still is needed; treatment is conducted at a slower pace.
Learn about the ASAM Criteria Dimensions

If you are not familiar with the ASAM Criteria dimensions, take a look at last month’s edition: http://changecompanies.net/tipsntopics/?s=The+ASAM+Criteria+six+dimensions

 

Notice the change in the numbering system
The old edition used Roman numerals.
The new edition uses regular Arabic numerals- for Levels of Care.

So Level III is now Level3. Level IV is now Level 4 etc.

TIP 2

Broaden your perspectives on addiction treatment

There are 2 new chapters in The ASAM Criteria, 3rd edition which move into areas which have not gained much respect in addiction treatment in the past:

Tobacco Use Disorder

Gambling Disorder

 

In fact, a significant number of programs still view nicotine addiction as one drug addiction which can wait until later: “You can’t expect a person to quit everything at once. We don’t allow smoking in the groups or in the building, but we do have a smoking gazebo on the grounds where patients can smoke in predesigned breaks.”

 

–> I’m still looking for the program that has the cocaine, heroin, marijuana or Xanax gazebo for the patients not ready to quit all those drugs at once!! <–

 

For both Gambling and Tobacco Use Disorders, the new edition makes the case for a continuum of levels of care for these types of addiction, just as we have had for other substance use disorders.

 

 

TIP 3

Apply the criteria to special populations

The editors have responded to feedback from counselors and clinicians who have expressed difficulty applying the criteria to special populations:
—-older adults

—-parents or prospective parents receiving addiction treatment concurrently with their children

—-those in safety-sensitive occupations like physicians and pilots

—-clients in criminal justice settings.

 

Mandated Clients
Many clients come from criminal justice drug courts, probation and parole or even still reside in prison treatment settings.
For example…
A judge often mandates a client to a specific level of care and length of stay, not based on an assessment of what will achieve good outcomes, but rather concerned about public safety. The ASAM Criteria recommends that a judge mandates assessment and treatment adherence which places the responsibility on clients to “do treatment and change,” rather than give the impression that the client can “do time” in a program for a fixed length of stay.

 

What does the judge’s mandate require from the clinicians and programs involved with this particular client?
–> To carefully monitor the person’s risk to public safety

–> Inform the judge, probation and parole officer when a mandated client is not doing treatment and simply sitting in a program.

SKILLS

TIP 1

Cultivate interdisciplinary relationships with other health systems

Here are the facts:

  • There are millions more people who after January 1, 2014will now be covered by health insurance and have access to addiction treatment
  • 23.1 million people 12 years and older needed treatment for an illicit drug or alcohol use problem and only 2.5 million receive specialty addiction treatment (2012 National Survey on Drug Use and Health, NSDUH, September 2013)

How will addiction treatment agencies increase access to care when we already have waiting lists and can’t even meet treatment-on-demand?

 

The new edition addresses the need to reach out to other health systems where most people withaddiction first show up:

  •  Integration of addiction treatment services with mental health- co-occurring capable; co-occurring enhanced; complexity capable programs
  • Increasing Screening, Brief Intervention, Referral and Treatment (SBIRT) in Level 0.5, Early Intervention
  • Integration of addiction and general healthcare services – Patient Centered Health Care Homes
  • Integration of primary care into addiction treatment settings


TIP 2

Learn how to manage care yourself

A new section on working effectively with managed care and healthcare reform helps everyone manage care to “bend the cost curve” – meaning reducing the rate of healthcare inflation and costs.  This is a responsibility of ALL if we are to eliminate waiting lists and make way for the millions of potential new patients who deserve and need addiction treatment.

 

When asking a managed care utilization reviewer to authorize payment for your treatment services, go over in your clinical head the following steps in the information and be ready to communicate/convey them to the care manager on the phone:

 

1. What are the problems and priorities you are concerned about?

2. Which ASAM Criteria dimensions do they belong to?

3. What are you going to do in the treatment plan for those problems? What services?  How much and how frequently does the client need those services?

4. What is the level of care that is the least intensive, but safe level to provide the treatment plan?

 

Here is an example that follows those steps: (Clinician response in italics)  

 

Q1.  What are the problems and priorities you are concerned about?
” The patient has impulses and cravings to continue using.”

 

Q2. Which ASAM Criteria dimensions do they belong to? –
“Dimension 5, Relapse, Continued Use or Continued Problem Potential”

 

Q3. What are you going to do in the treatment plan for those problems? What services?  How much & how frequently does the client need those services? “Cognitive behavioral therapy, peer refusal skill building, medication management and relaxation and contingency management strategies – throughout the day, on a daily basis, for several hours a day, because the client’s cravings and impulses are intense, frequent and daily. Without this dose and frequency of services, my client will have a significant flare-up of liver problems and psychosis.”

 

Q4. What is the level of care that is the least intensive, but safe level to provide the treatment plan?
“Level 2.5 partial hospital combined with Level 3.1 supportive living”

 

Some clinicians request payment authorization by saying such things as:
“We need another week because the patient is at high relapse potential.”  Such clinicians will need to be prepared to answer some more searching questions from the authorizer like:
What do you mean by “high relapse potential”?
What are you doing in the treatment plan for the high relapse potential?
What about the relapse prevention plan you say you are developing with the patient can only be done in your level of care?
Why cannot those same strategies be delivered safely in a less intensive setting?
If all a clinician can say is to repeat the statement that the patient’s potential for relapse is very high, then you can be assured that the managed care utilization reviewer will consider that as inadequate information to explain why further treatment is needed in your program.  Most likely payment for those services will be denied.

 

Learning to manage care yourself means:

  •     To be good stewards of resources so we can increase access to care
  •      Stretching limited resources to provide all the levels of care a person needs for recovery

SOUL

Malala Yousafzai is now 16 years old. She teaches and travels the globe talking about the importance of education, especially for girls and women. The Pakistani girl, shot by the Taliban for her efforts, has been hailed as the youngest person ever nominated for the Nobel Peace Prize.

http://www.utsandiego.com/news/2013/Oct/10/malala-yousafzai-pakistan-nobel-peace-prize/

 

When I was a 11 year old boy in Australia, I was writing little stories for the Sunday paper trying to win a prize.  I even got to go on television to receive my prize of a watch for my essay.  Malala blogged for the BBC in 2009 as she defied a Taliban edict banning girls from going to school.  She was also 11.

 

Malala was targeted and shot in the head and neck October 9, 2012 – a year ago this month – following all the publicity she received for opposing that Taliban campaign to close schools.  She continues to speak out eloquently and courageously.

 

I am proud to speak out and advocate for a broad range of effective and efficient services for people with addiction and co-occurring conditions, which I have trumpeted since the 1980’s. I will be especially gratified to hold the new edition of The ASAM Criteria and introduce it to everyone on Thursday, October 24.

 

Then I think of Malala Yousafzai.

SHARING SOLUTIONS

No pressure – but I really don’t want you to miss out on the special preorder offer when you buy the new edition of The ASAM Criteria. Go to www.ASAMcriteria.org to order and get the offer that is in it last days until the end of October.

Until next time

See you again in late November.  Thanks for reading.

David

Vol. 11, No. 9

Welcome and Season’s Greetings to everyone around the world. I wish you a healthy, meaningful and serene 2014.

David Mee-Lee M.D.

SAVVY

On December 10, 2013,the National Institutes of Health released a press statement with the headline: “Stimulant-addicted patients can quit smoking without hindering treatment.” The sub-headline said: “New NIH study dispels concerns about addressing tobacco addiction among substance abuse patients. ” http://www.nih.gov/news/health/dec2013/nida-10.htm

 

With the new year just around the corner, this is a good time for healthcare providers and addiction treatment professionals in particular, to resolve that 2014 will be the year we start taking nicotine addiction seriously. If you are still a tobacco user, could this not be a New Year’s resolution and gift to yourself which keeps giving every day and will pay dividends many times over?

 

Easy enough for me to say, as I have never been a tobacco user.

 

TIP 1

It is time to face the facts that nicotine addiction or tobacco use disorder is as deadly as other addiction illness.

 

According to the Substance Abuse and Mental Health Services Administration in 2008:

  • 63 percent of people who had a substance use disorder in the past year also reported current tobacco use, compared to 28 percent of the general population.
  • “Smoking tobacco causes more deaths among patients in substance abuse treatment than the substance which brought them to treatment. “
  • Check again that second bullet point: Patients may have gone into addiction treatment for cocaine, alcohol, heroin or some other drug, but smoking tobacco is what causes more deaths than the very drug that caused them to seek treatment in the first place! (Nicotine addiction is not the ‘kinder, gentler’ drug addiction, it is the killer for many.)
  • Despite this, most addiction treatment programs do not address smoking cessation.

National Institute onDrug Abuse (NIDA) Director Dr. Nora D. Volkow said: “However, treating their tobacco addiction may not only reduce the negative health consequences associated with smoking, but could also potentially improve substance use disorder treatment outcomes.”

 

–> Here are the CONCLUSIONS in the Abstract of the study this press release was trumpeting:

“These results suggest that providing smoking-cessation treatment to illicit stimulant-dependent patients in outpatient substance use disorder treatment will not worsen, and may enhance, abstinence from non-nicotine substance use.”

 

Dr. Theresa Winhusen,from the University of Cincinnati College of Medicine and first author on the study said: “These findings, coupled with past research, should reassure clinicians that providing smoking-cessation treatment in conjunction with treatment for other substance use disorders will be beneficial to their patients.”

 

TIP 2

Review the DSM-5 criteria for Tobacco Use Disorder.

You’ll notice that tobacco (or more accurately, nicotine) causes the same kind of addiction disorder as other drugs. How is it then, that many still consider it different from other drug addiction?

 

Tobacco Use Disorder is defined by the following criteria in DSM-5:

 

A problematic pattern of tobacco use leading to clinically significant impairment or distress as manifested by at least two of the following, occurring in a 12-month period:
1.  Tobacco is often taken in larger amounts or over a longer period than was intended.

2.   There is a persistent desire or unsuccessful efforts to cut down or control tobacco use.

3.   A great deal of time is spent in activities necessary to obtain or use tobacco.

4.   Craving, or a strong desire or urge to use tobacco.

5. Recurrent tobacco use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., interference with work).

6.  Continued tobacco use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of tobacco (e.g., arguments with others about tobacco use).

7. Important social, occupational, or recreational activities are given up or reduced because of tobacco use.

8.   Recurrent substance use in situations in which it is physically hazardous (e.g., smoking in bed).

9.   Tobacco use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by tobacco.

10.   Tolerance, as defined by either of the following:

a.  A need for markedly increased amounts of tobacco to achieve the desired effect.

b.  A markedly diminished effect with continued use of the same amount of tobacco.

11. Withdrawal, as manifested by either of the following:

a. The characteristic withdrawal syndrome for tobacco (refer to Criteria A and B of the criteria set for Tobacco Withdrawal)

b. Tobacco (or a closely related substance, such as nicotine) is taken to relieve or avoid withdrawal symptoms.

(DSM-5, page 571 in hard covered edition)

 

References:

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

 

Winhusen TM, et al: “A randomized trial of concurrent smoking-cessation and substance use disorder treatment in stimulant-dependent smokers.” J Clin Psychiatry. 2013 Dec 10.

SKILLS

When a clinician or program decides that tobacco use disorder and nicotine addiction are the same addiction illness as alcohol, heroin, cocaine or any other substance use disorder, the first impact is on the counseling staff.

 

The new edition of The ASAM Criteria (2013) has a special section on Tobacco Use Disorder pp. 367-392.  To read an article from the co-authors of this section, Drs. Blank and Karan, go to the “WHAT’S NEW” tab at www.ASAMcriteria.org, and then click on Read full article: NewSection in The ASAM Criteria: Tobacco Use Disorder.

 

TIP 1

Examine this case example from The ASAM Criteria chapter on Tobacco Use Disorder

 

Case 6 (page 391) 

TH is a 50-year-old addiction counselor who works at a residential addiction treatment center. The center has decided that they are going to begin treating tobacco addiction along with all other addictions. The staff is not going to be able to smoke at all at work, and will not be allowed to come to work smelling of tobacco smoke.   TH is in recovery from addiction to alcohol and pain medications. He has been sober for 23 years and always felt that tobacco was not part of his disease. He feels that he has extra rapport with patients since he goes out smoking with them on breaks.   TH has often advised patients who wanted to stop smoking that they should wait at least a year before they even consider stopping, because “it is too hard to quit more than one thing at a time.”   TH has been told by his doctor that his frequent bouts of bronchitis are directly related to his smoking, and that he needs to stop before he does permanent damage to his lungs. TH is about 40 pounds overweight and fears that if he stops smoking, he will gain even more weight. He has never tried to quit, and is angry about his workplace forcing him to stop.

 

This is one of seven case studies that illustrate treatment and placement principles. What is interesting in Case 6 is that counselor TH “feels that he has extra rapport with patients since he goes out smoking with them on breaks.It is true that many programs have stopped smoking inside the treatment program building, but will have a smoking gazebo on the grounds where counselors like TH can “bond” with clients while joining them smoking.

 

My mischievous poke at such programs is to ask where is the alcohol gazebo where counselors can share a beer; or the heroin gazebo to shoot up together? And what about a benzodiazepine gazebo where patients can bring their favorite tranquilizer to share with each other?

 

 

TIP 2

Note this rhetorical question: Would it be OK for a counselor whohad a beer or glass of wine at lunch to lead a group session with alcohol on his or her breath?

 

I can think of no program or team that would be OK with this. Yet the same program would think nothing of letting a counselor smoke together with clients and then lead group treatment reeking of tobacco smoke.

 

So as more and more programs start to take nicotine addiction seriously, the same expectations for tobacco users will apply to alcohol using staff: if you use your drug in breaks at work, you cannot do individual or group counseling with either alcohol or tobacco odor on your breath or clothing. This means:

  • Either don’t drink or smoke in breaks while on the job
  • Or if you do, there has to be a long period of time for all evidence of use to dissipate before counseling. For smokers, that means a change of clean clothes as tobacco smoke does not quickly dissipate.

For counselors like TH in the case study, the inconvenience of having to change clothes after every smoke break may ultimately just get too much to handle.  Programs in transition are providing smoking cessation programs for staff first, before moving the whole program to tobacco-free for patients.

Reference:

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-OccurringConditions. Third Edition. Carson City, NV: The Change Companies.

SOUL

A few weeks ago in Australia, I visited my childhood neighbor who has known me since I was three years old. I’ll call her Mrs. Martin – not her real name. She was telling me how hard it has been to talk with her oncologist and be heard. Joan has ovarian cancer which went into remission but recently metastasized to her bowel and is now inoperable.

 

The chemotherapy left her weak, emotionally and physically drained, and using a walking stick. Until now, she has never had to use a stick even though approaching 90 years of age. Joan’s physician wanted her to undergo more chemotherapy despite the patient’s wishes to have a break from the awful treatment. Joan was ready to take whatever path her cancer would lead her, but she wanted some quality of life and not treatment that was worse than the disease.

 

Somehow she could not be heard. It needed her son to be intensely assertive for the oncologist to hear Joan’s wishes.

 

When I visited Mrs. Martin, she had just returned from ten days at an alternative holistic health retreat where they use a combination of massage, diet, colonics and who knows what else. Before I arrived she had already gone for a morning walk without any sight of a walking stick. She greeted me with: “I’m a new woman.”She was optimistic, beaming, feisty and totally different from her son’s report a few weeks earlier, which sounded as if she was on her deathbed.

 

The cancer isn’t cured and she will have darker days. But I was first inspired by the faith and positive attitude Joan beamed; and then sobered by how hard it is for patients to be heard by well-intentioned, but “deaf” physicians and healthcare providers who do not engage and listen to their clients and patients.

 

Joan was scheduled to see her oncologist two days after our visit. This time, she will present in a totally improved condition to her physician who will perhaps wonder what worked. Joan stated she would not be telling the physician where she has been and what she’d been doing that brought her back to such a state of well-being.

 

He wouldn’t understand, she mused. And I tend to agree with her.

SHARING SOLUTIONS

I often receive emails and questions from providers and clinicians on what to do when a payer or managed care company is not using The ASAM Criteria correctly. I also receive questions in reverse about providers or programs not using The ASAM Criteria correctly.

 

1. “Using” the ASAM Criteria means different things to different organizations and providers. So take a look at the article I wrote for Counselor Magazine: “How to Really Use the New Edition of The ASAM Criteria: What to Do and What Not to Do”.  You can access it at www.ASAMcriteria.org .Click on “WHAT’S NEW.”  Scroll down to the article/link for the November-December 2013 edition of Counselor Magazine.  Article is entitled:”How to Really Use the New Edition of the ASAM Criteria: What to Do and What Not to Do.”  (There are other articles there as well.)

 

2. Perhaps you are a provider or payer having concerns about how The ASAM Criteria are being used. Feel free to complete an Incident Report. There’s one for patients, providers and programs and a different one for payers and managed care organizations. Go to www.ASAMcriteria.org. Click on FAQ tab.  Search for: How do I report incidents of misuse of The ASAM Criteria?

 

3. There are opportunities for training on The ASAM Criteria. This happens via eTraining modules or via onsite workshops and conferences nationally.  Learn about eTraining at the RESOURCES & TRAINING tab.  For workshops and conferences near you, click on the EVENTS tab at www.ASAMcriteria.org

 

4. There also exists an enhanced web version of the ASAM book.  Click on the BOOK & WEB tab.  Take a test drive with the informative video.

Until next time

Happy New Year and see you again in late January.

 

David

Vol. 11, No. 12

In This Issue
  • SAVVY, SKILLS & STUMP THE SHRINK : A combined “conversation” on working with mandated clients
  • SOUL : Changing the context to avoid droughts and storms in helping people

Welcome to all new readers to the March edition of Tips and Topics.  Thanks to all for reading this month.

David Mee-Lee M.D.

SAVVY, SKILLS & STUMP THE SHRINK

This month, I presented a webinar on The ASAM Criteria and DSM-5.  A participant wrote to me with some follow-up questions.  We ended up having an email “conversation” as we clarified questions and responses to the initial questions.

(If you want to hear the Addiction Technology Transfer Center (ATTC) Network webinar, you can access it at www.ASAMcriteria.org.  Click on News & Events and you’ll see it there).

So forMarch, here’s a combined SAVVY, SKILLS and STUMP THE SHRINK. I will share with you the “conversation”.

My Webinar Point- about “doing time”

I made a point that treatment providers, especially when working with mandated clients, are responsible for making sure that clients are “doing treatment” not “doing time” in the program – i.e. not just going through the motions.

Question #1:

Howcan you tell if a person is just “doing time, not treatment”?

Hi David,

What other specific criteria should providers gauge to determine whether a client is just “sitting in the program” or “doing time”?  For example, say the client just wants to get a job and maintains that attitude throughout treatment – in effect, turning treatment into a vocational training program. Would you consider this one example of merely “sitting in treatment?” What should be done, in “treatment” or not? 

Response #1:

Youcan turn “doing time” into active treatment.

“Doing time” is when a person is not taking responsibility for their treatment and their treatment plan.  If your client just wants a job but is in a treatment program, it is fine to make the goal of treatment: to get a job.  That’s what he wants and is a good place to start to engage him in treatment.  Presumably however, he has been referred to an addiction program or mental health because he has an addiction and/or MH problem. Say he doesn’t see that and thinks he just has a job problem, then the treatment plan focus would be: do motivational work around helping him get a job.  At the same time examine with him how has not had a job; or when he does get a job he loses it due to addiction and/or MH problems.

Even with the focus on getting a job, he is not just involved in a vocational training program, because he would be assessing why he doesn’t have a job or can’t keep one. Treatment will emphasize:

*      His examining how he is going to keep a job if he does not address the addiction/MH problems.

*      His sharing in group why he thinks he does not have a behavioral health problem, yet he has not had a job.  OR he shares how he lost his job because he was not showing up, or was hung-over.  OR he shares that due to mental health problems he got fired, or that he couldn’t make it through a job interview because he was so depressed or unstable.

*      Executing a “discovery” plan not a “recovery” plan – discovering any connections between addiction/MH problems that interfere with getting or keeping a job.

*      Active and meaningful participation and working on a collaborative plan. This is “doing treatment”, involving stages of change work to see if the client can connect the dots: that if he is to going to land a job, at some point he will need to address his addiction and/or MH problems.

Say your client just sits there and doesn’t participate in collaborative treatment planning. Then he is not doing treatment, he is “doing time.”  We shouldn’t continue treatment.  If he is not changing his treatment plan in a positive direction, he is essentially choosing not to do treatment, and has a right to leave.

My Webinar Point – DSM-5 SUD and Homelessness

In the new DSM-5 criteria for Substance Use Disorder (SUD), there are 11 criteria with a requirement for at least 2 of the 11 to diagnose SUD.   Some of these relate to how substance use interferes with meeting life expectations like work, family and social obligations.

Question #2:

Are the homeless exempt from certain SUD criteria?

 

In working with a homeless population it seems the degree of social isolation obscures the impact of their substance use disorder given the extent and degree of social isolation. In effect, the degree of social functioning required of them is much lower in light of the lack of role obligations that they must fulfill. Does this make them “exempt” from some of the DSM-5 substance use disorder criteria?

Response #2:

Many homeless will still meet sufficient criteria to qualify for an SUD.

As you suggest, a socially isolated homeless person may not have work, family or social obligations.  Thus they may not meet the social obligation criteria. However, such a homeless person could meet the other criteria – only 2-3 of 11 are needed to have mild SUD.

Here are the first 4 they could meet:
1. Substance is often taken in larger amounts or over a longer period than was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control substance use.

3. A great deal of time is spent in activities necessary to obtain substance, use, or recover from the substance’s effects.

4. Craving or a strong desire or urge to use the substance. (DSM-5, SUD, criteria 1-4 of 11)

I hope this helps,

David

 
My Webinar Point- about “Graduation”

When I discuss program-driven treatment rather than person-centered, outcomes-driven treatment, I encourage participants to move away from “graduation” as aconcept and practice in the treatment of addiction (and actually any illness).

Question #3:

What did you mean about ‘graduating’ from the program’s policies and procedures?

Yes, this helps! If ever there was a critical thinker, it’s you, David.  I enjoyed tracking your logic and appreciate your way of explaining.

 

One last thing – in response to the question of why its erroneous to use the term graduation in the realm of addiction, you said something about clients’ graduation, but only satisfying graduation of the program’s policies and procedures…or something along those lines. This point grabbed my attention. I was hoping you could articulate it once more and perhaps expand upon it. On that point, I read your piece on RCA Ceremonies and don’t recall coming across it. (March 2011 edition of Tips and Topics)

Thank you for responding to my e-mail and making yourself accessible.

Response #3:

Focus on functional improvement not program compliance.

Thanks for your nice feedback.  Take a look at Tips and Topic (TNT) – February 2013 edition.  I raised concerns that an overemphasis on compliance to program rules, norms and assignments overshadows a person-centered, assessment-based, outcomes-driven approach. Progress in a person’s function based on their individualized treatment plan determines when they transfer to another level of care, not compliance with the program’s policies and procedures, or phases.

I think this addresses what you want, but let me know if not.

Thanks,

David

Question #4:

How do you work with a client who says the “right things”?

OK,I have one more question in response to your answer in regards to “doing time” in treatment.  Say, the legally-mandated client takes a compliant-orientated stance and “gives in.” Or perhaps he feeds the treatment staff what they want to hear by apparently acknowledging the connection between drug use and employment within the first several week ofIntensive Outpatient (IOP) treatment.  It’s not a unique or peculiar situation to have this kind of mandated client then say they have a job problem and that their drug problem is now under control. They remain “dug in” to that position by posturing as if “everything’s all good” and “I got this” type of mentality with respect to all other aspects of “treatment.” Thus would the treatment plan still be a “discovery plan” focused on the client’s need to obtain employment?

 

Would you please tell me how you might work with such a client.

Response #4:

Give your client the chance to follow his plan first. Closely monitor outcomes.

Take a look at the following editions of Tips and Topics, especially the difference between “compliance” and “adherence”.  We don’t want any client to be “compliant” and say what we want them to say (“feeds the treatment staff what they want to hear or not”).  Webster’s Dictionary defines “comply” as follows: to act in accordance with another’s wishes, or with rules and regulations.  It defines “adhere” as: to cling, cleave (to be steadfast, hold fast), stick fast.

Perhaps your client believes he has it all under control (“everything’s all good” and “I got this”.)  At that point, we can share with the client anything we see in his behavior and/or thinking and/or relationships we think would threaten his getting or keeping a job.  What if he doesn’t agree?  Then you develop a plan to track how he is doing with his job or job hunting.  Help him identify what would be the first sign(s) to recognize that he is heading in a direction of losing the job, or not even getting the job. If you track this closely with him, he/you can discover if indeed he has everything under control, or whether his plan is starting to unravel.  Close monitoring is vital.  We don’t want to wait until it all blows up before he changes his treatment plan.

For example:
If he still wants to hangout with substance-using friends, not go to AA or other support groups, and still thinks he can get or keep a job, then agree to have him try his plan: i.e. the plan to “keep hanging out with using friends; not attending AA” ‘treatment plan.’ See if his plans work.  Keep close tabs with him on recognizing the first signs that his plan is not working.

Say his treatment plan is actually working- i.e. the  “keep hanging out with using friends; no AA” treatment plan.   Maybe he’s either getting a job or keeping one. Understandably from your experience, you doubt that he will be able to sustain that stance/decision.  So what do you say in your sessions with him?  You agree to keep going with his plan; but with him you carefully watch what happens. With humility, you express that you hope you are wrong but you think his plan is a risky one.  If his plan starts to unravel, then he will be more open to trying a plan that incorporates your ideas, because his plan didn’t work.  What you did give him is the chance to make his own discoveries and decisions.

November 2007:

January 2004:

December 2006:

Hope this helps.

David

Question #5:

When do you finally discharge a person?

Thanks! David that helps. So in developing a plan to track how she/he is doing toward job obtainment this might include listing jobs of interest; applying to X number of jobs per week; listing potential barriers to employment; practicing job interviewing skills, etc?  AND what if the client consistently fails to successfully follow through–at what point would it merit a discharge?

 

You’ve shared this excellent example of MOTIVATIONAL ENHANCEMENT technique and what comes to mind is the consent forms which used to state the purpose ofthe consent to Adult Client Services was to ‘monitor compliance’.   Ever since hearing the compliance vs. adherence story, I STOPPED using the word compliance in my consent forms.

 

In speaking with Probation Officers and Intake Workers from criminal justice services who ask if a client is being compliant, I ask them if they are sure that is what they want from a client.  I then offer the explanation of how temporary and superficial “compliance” is.

Response #5:

Discharge when the person is not making positive changes in the treatment plan.

Thanks for that interesting update on your use of “compliance” versus “adherence”.  A person could be in “compliance” with a court order to do treatment, with which the person agrees to do.  But once they get to treatment, you don’t want “compliance”, you want “adherence” with the collaborative treatment plan in which the person had an integral part in developing.

Regarding:

So in developing a plan to track how she/he is doing toward job obtainment this might include listing jobs of interest; applying to X amount of jobs per week; listing potential barriers to employment; practicing job interviewing skills, etc? 

Yes, correct, as these are strategies that are Specific, Measurable, Achievable, Realistic and Time limited (SMART).  If the person does whatever they agree to do, then treatment keeps going.

Regarding:

AND what if the client consistently fails to successfully follow through–at what point would it merit a discharge?

If the person does not do what they agreed to do, assess why not.  Perhaps they said ‘yes’ too quickly when they meant ‘maybe’.  Or they really want to follow through, but it was harder to do.  Or they found a better way to get to their goal and so did that instead.  Whatever is revealed when you assess the lack of follow-through, if your client agrees to change their treatment plan in a positive direction, then continue treatment.  There is no need to discharge.

For example:

If a person did not follow through with a job interview they thought would be easy, practice role-playing the job interview process.  If they now agree to practice role-playing to prepare better for a job interview, this is a positive direction. Keep going in treatment.  (You can tell the Probation Officer that your client is in “compliance” with the court order to do treatment and is “adherent” to the collaborative treatment plan.)

What if your client does not want to adjust the treatment plan in a positive direction using role-playing or another acceptable strategy?   At that point, the client is choosing no further treatment.  This is their right and they can leave treatment.  You are not kicking them out – they are not doing treatment.  If you let them stay, then you would be “enabling” – allowing them to “do time” not “do treatment”.  They would be non-adherent (not following through) to the treatment plan they created collaboratively. But they also would be out of compliance with the court order to do treatment.  Hope you see the distinction.

*******

The decision flow makes perfect sense, David.

Thanks again for taking the time to put forth a thorough response.

References:

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

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.

SOUL

I am an avid reader of weather.com and the Weather page of the local newspapers.  This is not because I am finding the latest facts to have an intelligent weather conversation with the next person I meet.  It is because of two realities facing me at home and at work.

*      California had its driest year in history in 2013. This year we have so far received less than half the rain we should have by now.  We are in a drought. We have been doing our best to cut water use – collecting water in the shower while waiting for the water to warm up and using it to water the plants; not turning on garden sprinklers; and “if it’s yellow, let it mellow; if it’s brown, flush it down” (sorry for the bathroom talk).

*      At work, my commute is often an airplane ride into potentially snowy or stormy airports.  It is not good to be scheduled for a workshop or keynote presentation and be stuck at an airport in another state!  So I am always anticipating a Plan B if there is bad weather predicted en route or for my destination.

 

So this year there has been a strange phenomenon where I check every day hoping to see the weather prediction of either 100% precipitation or 0% precipitation – depending on whether I am home or on the road.

 

If I am at home, I rejoice to see 100% rain predicted because that means we are one step closer to breaking the drought.

 

If about to go on aroad trip, I want to see 0% rain or snow predicted, so I am not stressed about getting to the conference on time.

 

It’s funny how the context can totally change what we want by 100%. It’s a bit like when working with mandated clients.  You can either side with the victim-side of the client (“They made me come”) by saying something like: “Iknow you don’t want to be here, but you have to be, so suck it up and see if you can get something out of the program.”

 

Or, you can change the context and say: “Thank-you for choosing to work with me, so I can help you get people off your back and help you keep your job, or get your children back, or stay out of jail.”

 

I don’t want to be in an unproductive drought or a stressful storm.  By changing the context, you can avoid droughts and storms in your work with people too.

 

I hope it rains…well not next week when I’m traveling.

Until next time

See you again in late April.

David

Vol.12 , No. 7

Welcome to the October edition of Tips and Topics (TNT). I’m glad you could join us.

David Mee-Lee M.D.

SAVVY

It was a year ago this month the latest edition of The ASAM Criteria was released. If you haven’t been briefed on what’s new in the 2013 edition, you can take a look at the October 2013 edition of Tips and Topics http://www.tipsntopics.com/2013/10/

or even do a two-hour eTraining module for continuing education credits on an “Introduction to The ASAM Criteria”. Check it out at http://www.asamcriteria.org and click on Resources & Training. There’s lots of other resources on bringing you up to speed.

 

I am often asked whether The ASAM Criteria can be used in mental health treatment systems as well as for addiction treatment. I’m biased of course. Not only is it useful in mental health, but also in this era of healthcare reform where integratedcare is increasingly necessary, The ASAM Criteria can help general health teams as well.

 

TIP 1

The ASAM Criteria six dimensional assessment provides a comprehensive structure to provide and manage addiction, mental and general health care.

 

Here is an update on what I reviewed in the Volume 4, No. 10 edition in March 2007 http://www.tipsntopics.com/2007/03/march-2007/#more-81

 

The common language of the six assessment dimensions of The ASAM Criteria can be used to determine multidimensional assessment (MDA) of severity and level of function of any health care client. Here are the six assessment dimensions of the MDA:

 

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

(The ASAM Criteria 2013, pp 43-53)

 

For each dimension, I’ll outline how why it is useful and important to consider each assessment dimension if you are:

  • A general health clinician – whether in the emergency room, primary care, health clinic or specialty practice
  • A mental health clinician – whether in emergency psychiatric services, private practice or a mental health clinic
  • An addiction treatment counselor or clinician – whether in outpatient or residential services or private practice
  • A care manager – whether in a managed care company or treatment agency

 

Dimension 1: Acute intoxication and/or withdrawal potential

  • Emergency room personnel too often treat the complications of addiction and take care of the broken leg or head trauma from a drunk driving accident, but don’t link the patient to needed addiction treatment. They would never simply stabilize a patient’s asthma attack or diabetic coma without linking them to ongoing asthma or diabetes care.
  • Surgeons may do a successful appendectomy for acute appendicitis only to find the patient agitated and in delirium tremens (DTs) three days later. Nobody checked the patient’s alcohol history to discover he/she is a daily heavy drinker and needed withdrawal management along with the appendectomy.
  • Mental health professionals should be checking: Is this major depression? Or is the person crashing from cocaine or other stimulants? Is this really anxiety disorder, or is the client in benzodiazepine or alcohol withdrawal? Is this really bipolar disorder, or is the person using uppers and downers and having mood swings as part of an addiction problem?
  • Addiction clinicians are checking the person’s recent substance use history to assess the need for withdrawal management; and in ongoing care using urine drug screen monitoring and other tests to check for use and intoxication.
  • Care managers can use the five levels of withdrawal management (WM) to provide and pay for a flexible continuum of WM services that not only uses resources efficiently, but can provide at least two weeks of WM support for what is often spent in 3-4 days at an acute care “detox” unit.

 

Dimension 2: Biomedical conditions and complications

  • All clinicians assess a person’s physical health needs, which are the focus of this dimension.
  • But emergency personnel and primary care workers can easily become entangled in a chronic pain patient’s use of medication, which may now have crossed the line into addiction.
  • Mental health and addiction clinicians also often struggle with the interface between a person’s chronic pain and their depression, anxiety or substance use disorder. How much does the patient’s pain need better pain management? Or are the frequent requests for more pain medication simply addiction?
  • Care managers in managed care companies will frequently authorize huge sums of money for expensive medications, physical health tests or procedures while micromanaging and denying payment for needed outpatient sessions or inpatient and residential levels of care in addiction treatment.
  • Care managers in treatment now work in an era of healthcare reform that now requires good linkage with primary care physicians and ongoing disease management.

 

Dimension 3: Emotional/behavioral/cognitive conditions and complications

  • Mental illness suffers nearly the same discrimination and stigma as addiction. Emergency room personnel can easily treat the acute suicidal overdose or self-inflicted cutting lacerations, but fall down on linking the patient to ongoing mental health services.
  • Primary care physicians prescribe the majority of antidepressants and anti-anxiety medications more than psychiatrists. But what about the psychosocial aspects? How well can they collaborate with therapists to provide whole care?
  • What about all those family members who present with somatic complaints when what is really fueling the headaches, stomach upsets and pain are family behavioral health problems?
  • There is now more attention on co-occurring disorders. Both mental health and addiction personnel are more fully embracing at least the need to ask questions about addiction and mental health, as well as coordinate care for any co-occurring disorders.
  • If not already doing this, Care managers in managed care should support funding for integrated care rather than create the dilemma clinicians have traditionally faced: Which diagnosis to make the primary one to ensure payment – mental disorder or substance use disorder?

 

Dimension 4: Readiness to Change

  • For many health care workers this is the less understood and more neglected assessment dimension of all. This dimension is as important to assess and treat as whether a patient is having a withdrawal seizure, bleeding to death,or suicidal or homicidal.
  • Millions of dollars are wasted in unfilled or partially used prescriptions. No client will adhere to a medication, lifestyle or cognitive change if the treatment plan is driven only by what the clinician, counselor or doctor wants for them.
  • Even in general health care, the rhetoric has shifted to the importance of patient-centered care and shared decision-making. What are the person’s priorities and goals? What quality of life do they want? What treatment strategies are a good fit for them and what ones are not?
  • Alliance building, engagement, and motivational enhancement is critical not just in addiction treatment, but also in mental health and healthcare in general.

 

Dimension 5: Relapse/Continued Use/Continued Problem potential

  • Dimension 5 is not just about drinking and drugging relapse or continued use.Oncologists, internists, and family physicians, focus on how to prevent a cancer recurrence; or another diabetic coma or heart attack. Judges, probation and parole officers, and police are concerned with how to prevent another arrest, probation violation or some illegal activity.
  • Addiction and mental health too often see treatment as isolated episodes of acute care for withdrawal management or crisis intervention.
  • Nowadays mental health clinicians however are thinking more about how to prevent that psychotic or manic episode, or another suicidal or self-mutilation injury, or another domestic violence situation. Increasingly the focus is on such methods as a Wellness Recovery Action Plan (WRAP).
  • The addiction field has long talked about relapse prevention. Where addiction treatment still struggles is in what to do with flare-ups of addiction and substance use while a person is in treatment. I have written about this before- most recently in the July 2014 edition of Tips and Topics. Check it out if you missed it at http://www.tipsntopics.com/2014/07/
  • Care managers in addiction managed care and treatment could learn more from chronic disease management of physical health and of severe mental illness. Much can be learned from community-oriented supports and outreach, which proactively prevents deterioration or intervenes early with flare-ups and worsening outcomes.

 

Dimension 6: Recovery Environment

  • With changes in how healthcare is being financed, hospitals are now penalized if a patient returns for readmission within 30 days. Previously, a returning patient filled a bed and generated revenue. What is critical now is that a patient’s family supports, living situation and environmental vulnerabilities and resources are assessed and addressed. This is part of the shift from acute care to ongoing disease management and health and wellness.
  • Addiction and mental health professionals are well aware of the following recovery environment issues: Who does a person live with? Is there even a place to live? Who is the financial and emotional support -or not? Are there transportation, childcare, criminal justice, work, school or financial problems? It is important to assess and service these issues.
  • Even general healthcare knows that when a patient is recovering from a heart attack, the person who has family and supportive friends around will do better than the isolated person.
  • The environment makes a big difference to patient comfort and recovery. Birthing centers now look more like a hotel suite than a cold sterile labor and delivery room.
  • Care managers in managed care companies and insurance benefit plans still don’t give the financial support and respect for the necessary recovery support services inherent in Dimension 6. Care managers on treatment teams too often can feel like second-class citizens on the treatment team hierarchy.In fact their work is so critical to success. Fortunately also peer specialists are now joining the team.

 

TIP 2

What about the LOCUS (Level of Care Utilization System) versus The ASAM Criteria?

 

This is a question I hear from time to time. The LOCUS evaluation parameters were influenced by the ASAM multidimensional assessment and other placement tools. In 1998 the LOCUS was introduced by the American Association of Community Psychiatrists (AACP) and was designed more specifically for mental health treatment systems.

 

The ASAM Second Revised Edition (ASAM PPC-2R) was published in 2001 containing criteria for co-occurring disorders. It was specifically broadened and updated to allow the assessment dimensions to apply to both mental health and addiction.

 

Both sets of criteria focus on a multidimensional assessment of the client. Both assess severity and level of function in a variety of important clinical and psychosocial areas. If this is a question that your treatment system is facing, you can see more about this in the March 2008 edition of Tips and Topics.

http://www.tipsntopics.com/2008/03/march-2008/#more-56

 

Reference:

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.

SKILLS

The field has had no standardized assessment tool to implement the ASAM Criteria. The multidimensional assessment is a powerful structure and clinical guide as discussed in SAVVY above. Furthermore, coming in 2015 will be a whole new opportunity for the field to unite around The ASAM Criteria Software.

 

Arising out of the research of David Gastfriend, M.D. (when he was Associate Professor of Psychiatry, Harvard Medical School and led millions of dollars of research on the ASAM Patient Placement Criteria for over a decade) the ASAM Criteria Software fills an important void.

 

The new software is based on research software extensively tested in Norway, other countries and US agencies.The Substance Abuse and Mental Health Services Administration (SAMHSA) invested millions of dollars to make the software compatible with all the major Electronic Healthcare Record systems.

 

TIP 1

Get acquainted with what is coming in 2015 to provide a standardized assessment to implement The ASAM Criteria.

 

The ASAM Criteria Software provides counselors, clinicians and other treatment team members with a computer-guided, structured interview for assessing and caring for adult patients with addictive, substance-related and co-occurring conditions.While the research has been done with adults, there is nothing to stop its being used with youth.

 

The software offers:

  • Data entry screens
  • Data management and clinical decision support (CDS) software
  • Outputs of an electronic and hard copy of treatment priorities and the least intensive, but safe, efficient and effective placement setting.
  • Research-quality questions (including tools such as the Addiction Severity Index (ASI), the Clinical Institute Withdrawal Assessment for AlcoholRevised, CIWA-Ar, and the Clinical Institute Narcotic Assessment, CINA instruments) and extensive algorithmic branching
  • An output of a 3-5 page report detailing a patient’s Diagnostic and Statistical Manual (DSM) substance use disorder diagnoses, severity and imminent risks and the recommended levels of care.

 

How does The ASAM Criteria book relate to The ASAM Criteria Software?

The ASAM Criteria book and The ASAM Criteria Software are companion text and application.

  • The book delineates the dimensions, requirements and decision rules that comprise ASAM’s criteria.
  • The software provides the approved structured interview to guide the assessment and calculate the complex decision tree to yield suggested levels of care.
  • The book and the software should be used in tandem, the book to provide the background and guidance for proper use of the software, and the software to enable comprehensive, standardized evaluation.
  • Effective, reliable treatment planning for adults is enhanced by using the book and software together.

Stay tuned at http://www.ASAMcriteria.org and click on the Software tab. We’ll let you know as soon as there are more specifics on how to access The ASAM Criteria Software. It won’t be free, but it will be affordable.

SOUL

 

70

There was absolutely no doubt what I would write for SOUL this month. I was getting ready to complete this month’s edition when the message from my very pregnant daughter was that contractions had started and were intensifying.

 

It was SUNday morning as the SUN was rising when Miya and Paulo scurried to the hospital – contractions now spiking every three minutes. Even with all their preparation for a calm, all natural birth event, labor pains are just what they’re called….labor.

 

Two hours after arriving at the hospital Miya’s labor of love was successful and we are all blessed to have grandchild and granddaughter #2 to beam about. Big sister, Luna, now two and a half welcomed her baby sister, not yet fully aware that she will now have to share the attention.

 

It is always curious as to what inspires parents to name their children. One day I’ll explain why we named our three children Miya, Taylor and Mackenzie. But for SOUL this month the spotlight is on Luna and baby Sol – our own Moon and Sun.

 

At the risk of being too cute, it was auspicious that:

  • Sol arrived on a SUNday
  • As the SUN was rising – what would have really been a surprise was if Sol wasn’t a daughter but a son!
  • Just earlier in the month I clicked this photo knowing that Sol was the intended name
  • In Portuguese Sol is pronounced SOUL

And to top it off, the rental car I was assigned on my business trip this week was an Hyundai Soul model.

 

Here comes the sun…welcome to the world, Sol.

Until next time

I’m glad you could join us this month. See you again in late November.
Thanks for reading.

David

SAVVY & STUMP THE SHRINK

Recently, a reader raised the issue of how to balance clinical thinking and judgment with strict interpretations of criteria and guidelines. “Criteria” refers to both placement and diagnostic types of criteria- for example, The ASAM Criteria or other utilization management criteria (placement) and DSM-5 (the Diagnostic and Statistical Manual of the American Psychiatric Association (diagnostic). There are also other sets of “Guidelines” like best practices or evidence-based practice protocols.Here is the STUMP THE SHRINK question I edited for clarity: 

“I was hoping you could provide some feedback on a recent discussion I had with colleagues regarding ASAM Criteria assessment Dimension 4, Readiness to Change for Level1, Outpatient Services. My co-worker was asking for input regarding a client who met Level 1 placement criteria in every dimension except for criterion “a” in Dimension 4.

(Criterion “a” in Dimension 4, Level 1 states: “The patient expresses willingness to participate in treatment planning and to attend all scheduled activities mutually agreed upon in the treatment plan.” Page 192-  this is my insertion for those not familiar with The ASAM Criteria 2013).

 

The client walked out at the end of the assessment unwilling to enter treatment. She was in denial that she had an alcohol problem that required treatment and had come to the assessment to avoid legal consequences.

 

The focus of the discussion with my colleagues was on the fact that the patient doesn’t fit Level 1 because she is not willing and walked out towards the end of the assessment. I thought the focus should be more on how do we motivate her to become willing. I would appreciate your thoughts.”

 

TIP 1

Compare and contrast strict interpretations of criteria with using clinical thinking and judgment

 

Case #1

Strict interpretation: Criterion “a” says the patient expresses willingness to participate and attend treatment. She walked out at the end of the assessment unwilling to enter treatment. End of story. No further thinking required. Patient does not meet criterion “a” and can’t be admitted to Level 1 Outpatient Services.

 

Clinical thinking and judgment: The client showed up and stayed until the end of the assessment. She clearly wants something.If she didn’t, she wouldn’t have shown up in the first place. She appears to want to avoid legal consequences but doesn’t see she has an alcohol problem. That is a critical Dimension 4, Readiness to Change treatment priority- to engage her into treatment around what she wants: to avoid legal consequences.

 

Strict interpretation: The client is “in denial” and doesn’t want treatment for sobriety and recovery; and is not willing to enter treatment. I can’t make her be willing and stop her from walking out, so she can’t be in Level 1 because she didn’t meet Dimension 4, criterion “a”.

 

Clinical thinking and judgment: This client is a prime candidate for motivational enhancement and interviewing strategies. She is at ‘Action’ stage for avoiding legal consequences. At the same time, she is in ‘Precontemplation’ stage for working on alcohol abstinence and sobriety. If I proceed and present treatment as though she showed up for sobriety, recovery and relapse prevention, I will not be on the right path. This focus does not match her stage of change. My focus is not important to her, and I’ll fail to engage her in treatment. She is likely to be turned off treatment altogether, and encourage her to walk away. (Alternatively she may enter treatment, but just sit there and passively comply, instead of focus on change.)

 

Strict interpretation: The client does not meet all criteria listed for Level 1 in The ASAM Criteria. Case closed.

 

Clinical thinking and judgment: This woman certainly meets all criteria for Level 1 if I develop a “mutually agreed upon…treatment plan” focused on avoiding legal consequences not focused on abstinence, sobriety and recovery.

 

In each dimension and level of care, The ASAM Criteria is meant to guide clinical thinking. Using the criteria is not meant to shackle counselors and clinicians to check off a criteria checklist. They should not bypass clinical thinking in how to engage a client and how to collaborate on treatment goals which makes sense to the client.

 

 

TIP 2

Note what the American Psychiatric Association says about diagnostic criteria and clinical judgment

Diagnostic Criteria Sets 

“For each disorder included in DSM, a set of diagnostic criteria indicate what symptoms must be present (and for how long) as well as symptoms, disorders, and conditions that must not be present in order to qualify for a particular diagnosis. Many users of DSM find these diagnostic criteria particularly useful because they provide a concise description of each disorder. Furthermore, use of diagnostic criteria has been shown to increase diagnostic reliability (i.e., likelihood that different users will assign the same diagnosis to an individual). However, it is important to remember that these criteria are meant to be used as guidelines informed by clinical judgment and are not meant to be used in a cookbook fashion” (italics added for emphasis).

http://www.psychiatry.org/practice/dsm

References:

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

 

Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies.

For more information on the new edition: www.ASAMcriteria.org

SKILLS

Case #2

Another agency that also “uses” The ASAM Criteria provided documentation on a client case. They believed their paperwork explained and justified why their client needed Level 3.5, Clinically-Managed High Intensity Residential Services.

 

Below you can read excerpts from this counselor’s paperwork. It is an example of simply quoting from the Criteria book to justify a level of care. The “Clinical Observation” data does not support the criteria they quoted.

 

This case is especially relevant because the client had already been in their Level 3.5 service for over four months when she was discharged to outpatient services. Within a day of discharge, the client used alcohol. Now the treatment program readmitted her for more weeks in their residential program. In addition, the agency’s program is often represented to clients as being a six-month program, which is inconsistent with the spirit and content of The ASAM Criteria.

 

Here is the documentation on Dimension 4 assessment:

Dimension 4: Readiness to Change:

According to ASAM Criteria, the client meets criteria (d) Client requires structured therapy and 24-hour programmatic milieu to promote treatment progress and recovery,because motivational interventions have failed at less intensive level of care and are assessed as not likely to succeed in the future at a less intensive level of care.

(e) Client’s perspective impairs his/her ability to make behavior changes without repeated, structured, clinically directed motivational interventions, delivered in a 24 hour milieu. Interventions are judged as not likely to succeed at a less intensive level of care.

 

Clinical Observation: Client has acknowledged that she does have a drug problem and has verbalized that her desire for treatment is externally motivated. Client has not internalized motivation for change, and the causes of her addiction. She needs to internalize her motivation for treatment, and identify her relapse triggers. Client needs to continue to remain in Level 3.5 so that she learns to internalize her motivation and identify the reasons for her continued use.

 

TIP 1

Explaining why a client needs a certain level of care is much more than simply quoting the criteria from The ASAM Criteria book or any otherguidelines. You must demonstrate how the clinical assessment data and observations match the criteria quoted.

 

In Case #2, there was no clinical observation data in any of the six dimensions that demonstrated the client was in imminent danger needing 24-hour care in a residential setting. The criteria quoted for Dimension 4, Readiness to Change were referenced from page 258, criteria (d) and (e) in The ASAM Criteria (2013).

 

Here’s how the “clinical observations” do not match the criteria:

  • The client had been admitted to Level 3.5, residential services for five months and no motivational interventions at a less intensive level of care were considered or attempted.
  • Nor was there any clinical data provided indicating that motivational interventions would be unsuccessful in a less intensive level of care.
  • The client acknowledged having a drug problem even though her desire for treatment was externally motivated for legal problems.
  • Helping the client to internalize a connection between her drinking and the external motivators requires motivational strategies, which can be provided safely in an outpatient level of care.
  • There was no clinical data demonstrating that motivational strategies could only be delivered in a 24-hour treatment setting.
  • Readmitting the client to Level 3.5 residential treatment for even more weeks only further shelters the client away from developing the skills necessary for community reintegration.

Utilization management criteria such as in The ASAM Criteria are to help guide clinical decision-making and judgment…….not the other way around. In other words,clinical thinking and decision-making comes first and then that guides what criteria are chosen and used to explain decisions about treatment and level of care.

 

It is not the printed criteria (quoted from the book) which explains how to assign the level of care. It is the clinical decision-making about the client’s severity and needs that point to which criteria apply.

SOUL

This month I worked and touristed in Hong Kong after my last visit 20 years ago. It was a fascinating experience as you can imagine. It wasn’t exactly getting in touch with my roots even though my ancestors did originate in southern China, not far from Hong Kong. After all, I was born and raised in Australia; so were my parents; and my mother’s mother too. So I am more familiar with CrocodileDundee than Chinese Dragons.

 

But since Chinese NewYear was just February 19, SOUL this month should be about some things Chinese!

 

Over the last few years, I have had my awareness and knowledge upgraded regarding a very Chinese art and science called Feng shui. Here are a couple of explanations:

  • “Feng shui is a Chinese philosophical system of harmonizing everyone with the surrounding environment. The term feng shui literally translates as “wind-water” in English. The feng shui practice discusses architecture in metaphoric terms of “invisible forces” that bind the universe, earth, and humanity together, known as qi.” http://en.wikipedia.org/wiki/Feng_shui
  • “Feng shui is an ancient art and science developed over 3,000years ago in China. It is a complex body of knowledge that reveals how to balance the energies of any given space to assure the health and good fortune for people inhabiting it.” http://fengshui.about.com/od/fengshuiglossary/

Our home has been transformed with the help of our Feng shui consultant who has opened my skeptical, Western-ingrained eyes to come to respect some ancient wisdom.

 

Here is just one example which might give you an idea of how this works:

For 17 years, we have had a TV and media cabinet in our bedroom. (True feng shui prinicples discourage TVs in bedrooms as it does not harmonize with the intention of the bedroom as a place for rest, rejuvenation and romance.) This cabinet had doors which allowed us to close them so the TV, DVD player would not dominate the room. It wasn’t especially large, but it did certainly jut out a bit so there wasn’t an easy flow walking by it. It also somewhat obstructed a peaceful view out to the trees and greenery n the backyard. For years, though,we had just become accustomed to moving around it. One day last month, it dawned on us that with flat screen TVs now, we didn’t need as large a space for such a cabinet. We moved it out of the room. Amazing!

 

This is where Feng shui “eyes” come in.

 

It was a surprisingly happy, satisfying feeling to suddenly experience what now felt like a spacious path from the bedroom door to the master bathroom. It wasn’t like we had to squeeze by the cabinet before, but for years the qi (or flow) had been blocked or at least impeded. Now the space flows beautifully. We can feel, see and enjoy it.

 

You might want to get in touch with any Chinese wisdom hiding within your being and take a look at the furniture arrangement in your home. You might just open up the qi to transform your space too.

Belated Happy Chinese New Year!

SHARING SOLUTIONS & STORIES

1. Do you want an easy way to see the current edition of Tips and Topics? Would you like to explore the Archives of 12 years of back issues? Have you been forwarding Tips and Topics to friends and colleagues? You can point them to sign up so they directly receive each edition in their inbox. Now you can access directly at http://www.tipsntopics.com

 

2. Here’s an opportunity to pause in the middle of each week – to evaluate and recognize how your daily choices can bring joy to your life. Check out the free weekly storytelling of Don Kuhl, Founder of The Change Companies.
Go straight to: http://www.mindfulmidweek.com

 

3. Now for something fun, intriguing yet stimulating. Check out the antics of the world’s most powerful superhero! He is learning the science of self-help. His stories are based on actual theories of behavior change; they reveal how supernatural abilities are no match for how everyday people make changes in their lives. Scott Provence, Vice President of Product Development at The Change Companies is the inventor.
Go to: http://www.illsaveyouandotherlies.com

Until next time

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

David

Vol.12, No.12

Welcome to the many new subscribers to Tips and Topics. Hello to all for the March edition. 

David Mee-Lee M.D.

SAVVY

Last week, I had lunch with Laura and some of her care management team. Laura is a 46-year-old transgender person (not her real name nor age) who from a very early age was aware that she was not in sync with her assigned gender identity. While born with male sex characteristics and assigned a male identity as Larry (not his real name), Laura, for most of her life, assumed the outside presentation as a male gender. She sometimes felt like she was acting as a male identity for her work and public persona, however was not really stressed or impaired by those gender identity issues.

 

What Laura was more interested in talking about was how she was doing well with her substance use disorder and recovery while also doing well as a transgender woman – a transgender individual who identifies as a woman.

 

Before I met Laura, I was not sure she really was as untroubled by the combination of her addiction and her gender identity issues as was reported to me by the care management team. After hearing her story of addiction and recovery, I was persuaded she indeed did not suffer from Gender Dysphoria as presented in DSM-5 (2013). The previous relevant diagnosis in DSM-IV-TR was Gender Identity Disorder. But not all people who assume a gender opposite to what was assigned at birth are distressed.  So in DSM-5 the focus of the new diagnosis, Gender Dysphoria, is on people who are impaired and in pain over their gender identity. This dysphoria is what creates the designation as a disorder, rather than the identity issues themselves.

 

TIP 1

Distinguish between gender dysphoria and gender identity issues

Gender Dsyphoria in adolescents and adults is a diagnosis characterized by “a marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least 2 of six criteria.”(DSM-5, 2013, page 452). The diagnostic criteria revolve around a strong desire to assume a gender identity, expression or behavior different from those of the opposite gender assigned at birth.

 

What makes the difference between the current diagnosis (Gender Dsyphoria) and the previous Gender Identity Disorder? The current diagnosis points to the presence of: “clinically significant distress or impairment in social, occupational, or other important areas of functioning.” Laura certainly has a strong desire to be “of the other gender” and “to be treated as the other gender.” She has very understanding and supportive parents. Her personality style is one that’s engaging and she radiates resilience. In addition, she lives in a more accepting environment. Due to these factors, Laura has rarely been distressed or impaired in any way by gender identity clashes.

 

Even with supportive parents, it is understandable how Gender Dysphoria develops. Listen to the compelling story of “A Mother Comes To Terms With Her Transgender Child” in a March 16, 2015 segment of National Public Radio’s Here & Now program. You will hear how the dysphoria develops and then is resolved, as Mimi Lemay struggled with the journey of her daughter Mia towards becoming her son, Jacob.

http://hereandnow.wbur.org/2015/03/16/trans-son-letter 

 

TIP 2

Become familiar with current Transgender Terminology

 

The National Center for Transgender Equality updated terminology in their January 2014 glossary of terms.

http://transequality.org/issues/resources/transgender-terminology 

 

Here are a few highlights to note:

  • “Transgender is correctly used as an adjective, not a noun.” e.g., “transgender people” is appropriate but “transgenders” is often viewed as disrespectful.”
  • “Trans” is shorthand for “transgender”.
  • “Transgender Man: A term for a transgender individual who currently identifies as a man (see also “FTM”).”
  • “Transgender Woman: A term for a transgender individual who currently identifies as a woman (see also “MTF”).”
  • “Gender Identity: An individual’s internal sense of being male, female, or something else. Since gender identity is internal, one’s gender identity is not necessarily visible to others.”
  • “Transsexual: An older term for people whose gender identity is different from their assigned sex at birth who seeks to transition from male to female or female to male. Many do not prefer this term because it is thought to sound overly clinical.”
  • “Cross-dresser: A term for people who dress in clothing traditionally or stereotypically worn by the other sex, but who generally have no intent to live full-time as the other gender. The older term “transvestite” is considered derogatory by many in the United States.”

References:

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

 

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) Washington, DC, American Psychiatric Association.

 

Gee, Beck: “Treating Trans” Addiction Professional, March 2, 105

Access at: http://www.addictionpro.com/blogs/nalgap/treating-trans

 

Transgender Terminology, National Center for Transgender Equality. Up dated January 2014.

Access at: http://transequality.org/issues/resources/transgender-terminology

SKILLS

Have you noticed how there is more in the media about transgender individuals -whether that be the journey of Chaz Bono, the only child of American entertainers Sonny and Cher. She was born Chastity Bono and is now a transgender man. Or more recently Bruce Jenner, the former U.S. track and field athlete and current television figure, as he transitions to be a transgender woman.

 

Transparent is an American comedy-drama television series produced for Amazon Studios that debuted on February 6, 2014. The story revolves around a Los Angeles family and their lives following the discovery that the person they knew as their father, Mort, is a transgender individual. (Wikipedia).

 

TIP 1

When treating transgender people in addiction treatment, are your policies and procedures designed with “understanding the humanity of Trans individuals”?

 

In his article, Beck Gee emphasizes the need to see Trans people as “individuals who struggle with addiction just as any other person.”

http://www.addictionpro.com/blogs/nalgap/treating-trans 

 

Here are some of the points his article raises:

  • Does your paperwork assume that the sex the client was assigned at birth equals their gender? Does the gender box indicate male or female? Or is there room for a person to define their own identity?
  • When deciding where to place a person – in the male or female section of the program, could you let the transgender person decide where they feel most comfortable?
  • How safe do Trans people feel in your services? Do all clients feel safe and accepted, including Trans people? “Do you have gender-neutral bathrooms…Is your staff trained properly, from facility maintenance to Nurses to Techs to CEOs?”

 

TIP 2

The ASAM Criteria’s multidimensional assessment provides a good “review of systems” to include all relevant clinical factors in treating transgender individuals.

 

In finding the balance between the focus on addiction recovery and transgender considerations, clinical issues in each Dimension include, but are not limited to:

 

Dimension 1: Acute intoxication and/or withdrawal potential    

  • Does the Trans individual use alcohol and other drugs to cope with any dysphoria over transgender issues and/or is the client’s use simply addiction in a person who happens to be a transgender individual? (Laura said clearly that her addiction was causally unrelated to her transgender issues and I discovered that I agreed with her.)

Dimension 2: Biomedical conditions and complications

  • Is the person contemplating or undergoing Sex Reassignment Surgery or hormonal therapy to develop sex characteristics of the gender to which they are transitioning?
  • If hormonal therapy, is it affecting other physical health areas? (Laura joked about how initially the hormonal therapy she was taking gave her an intimate understanding of “PMS – premenstrual syndrome”.)

Dimension 3: Emotional/behavioral/cognitive conditions and complications

  • Distinguish between gender identity issues and gender dysphoria. Not everyone who faces the incongruence between their assigned gender at birth and the gender they feel most drawn to be, are distressed to the degree of meeting diagnostic criteria for a disorder.
  • Review the following with the transgender person: What needs and problems are arising due their gender identity issues? What strengths, skills and resources might a client have which protects them from dysphoria? (Laura had temperament and resilience along with supportive parents and an accepting environment which explained her non-distress in her transgender journey.)

Dimension 4: Readiness to Change

  • At what stage of change is the transgender individual at regarding their addiction versus their gender identity issues?
  • How much are they able to focus on addiction recovery versus their stage of transgender transition?
  • How does the treatment team balance a focus on transgender issues versus addiction recovery? (Laura was ready to focus on addiction recovery after some initial ambivalence; she was not feeling a need to focus on transgender issues. It is easy for treatment teams to get distracted by the transgender issues.)

Dimension 5: Relapse/Continued Use/Continued Problem potential

  • To what degree does gender dysphoria contribute to relapse or continued use or problem potential?
  • As with any co-occurring disorder, can the individual and team treat both disorders as primary disorders needing ongoing monitoring to reduce flare-ups?

Dimension 6: Recovery Environment

  • Are there any family members or significant others who are helpful to the transgender individual in their addiction recovery? Are family or significant others problematic to the transgender person?
  • Are there any school, work and other social concerns related to transgender issues? (Before Laura openly declared her female identity, she said that dressing as Larry  in men’s suits and ties at work felt incongruous and like she was “acting” for many years.)
  • How understanding are self-help/mutual help groups to transgender individuals in addiction recovery?

Whether you use The ASAM Criteria or not, these dimensions structure a holistic perspective of all people, including transgender individuals.

 

References:

Gee, Beck: “Treating Trans” Addiction Professional, March 2, 105

Access at: http://www.addictionpro.com/blogs/nalgap/treating-trans

 

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.

SOUL

I’ll have to check the Archives of 12 years of Tips & Topics (TNT) editions to see if I have ever written a SOUL section on Sex before. I don’t think I have. Some readers tell me that when they receive TNT in their inbox, the first section they skip to is SOUL. (With “Sex” in the Subject line of this month’s email, I expect a lot more skipping!)

 

It’s satisfying that readers enjoy this section, because SOUL is probably the part I enjoy writing the most…..I can just let it flow, without the requirement to be too academic, checking author references, articles, papers and the scientific literature.

 

But back to sex. Having talked to Laura about her transgender journey, I began thinking how sex, gender identity, gay rights, same-sex marriage, transgender, cross-dressing and on and on are so much in the media all the time.

 

Sex in advertising has been a long-held tradition that still keeps on working to capture most people’s attention. A skimpily-clad woman has nothing to do with gas mileage and engine capacity of an automobile, but somehow they always seem to be present (or draped around) cars at the auto show or in car advertisements.

 

Like religion and politics, sex is one of those topics tricky to maneuver in social intercourse….that’s “social” intercourse, not “sexual” intercourse. Everyone has had experience and knows what you are referring to. Yet it is a topic we all tiptoe around with everyone, except your most trusted friend, lover or ally.

 

Some male politicians have been known to denounce the evils of homosexuality, only to be caught being intimate with a male staff member. Or after declaring their support for family values and faithfulness, it is discovered they are having a baby with their journalist lover. Governors have lost face and their positions over sex. Presidents have damaged relationships and trust over sex, not to mention millions of marriages languishing in barrenness or ending in divorce over sex.

 

I haven’t talked about the wonders of sex and the joys and ecstasy of sex. I wonder if you’ll have to wait another 12 years for that edition of SOUL.

 

Enjoy.

Until next time

Thanks for joining us this month. See you again in late April.                                 

David

Vol. 13, No. 5

Welcome to the August edition of Tips and Topics and to all our new subscribers. Thanks for joining us this month.

David Mee-Lee M.D.

SAVVY

The older I get, the more I think the greatest gift is good health. If you have health insurance, contemplate what it must be like to not have that peace of mind. Regardless of your political party leanings, before the Affordable Care Act (ACA) there were about 47 million Americans who had no health insurance nor peace of mind.

 

The New York Times

(8/12/15, A11, Pear, Subscription Publication) reported: 

  • The number of Americans without health insurance “continues to decline and has dropped by 15.8 million, or one-third, since 2013.”

TIME (8/12/15) reported:

  • Nearly 90% of Americans now have health insurance.
  • Overall, “the percentage of people in the US who were uninsured was 9.2%” during the first quarter of this year.”

I’ve always thought of Medicaid as just for poor and disabled people; and historically it has been an adjunct to state welfare programs. However “Medicaid has evolved….to the nation’s largest health insurer.” (JAMA, July 28, 2015, p.343).

  • “Medicaid insures more than 71.1 million people (an increase of 12.3 million since the first Marketplace open enrollment began) and
  • In 2015, Medicaid is projected to account for $343 billion in total spending.” (JAMA)

Addiction Treatment

Medicaid is playing an increasingly important role as a payer for services provided to individuals with addiction in the United States. There have been some exciting developments regarding The ASAM Criteria in Medicaid’s expanding role……”exciting” for me anyway, because I have been on a mission for 25 years to have The ASAM Criteria accepted as the model for addiction treatment’s continuum of care.

 

Last month, the Center for Medicare and Medicaid Services (CMS) announced new opportunities for states to design service delivery systems for Medicaid beneficiaries with a substance use disorder (SUD). Numerous federal authorities are offering states the flexibility to implement system reforms to improve care, enhance treatment and offer recovery supports for SUD. The ASAM Criteria is mentioned in several places as integral to that service delivery design.

 

Here are excerpts from that announcement. If you want to read more, here’s the link:

http://medicaid.gov/federal-policy-guidance/downloads/smd15003.pdf

  • “An estimated 12% of adult Medicaid beneficiaries ages 18-64 have an SUD.
  • An estimated 15% of uninsured individuals who could be newly eligible for Medicaid coverage in the New Adult Group have an SUD.
  • CMS is committed to helping states effectively serve these individuals and introduce benefit, practice and payment reforms through the technical assistance and coverage initiatives described below.”

“States have compelling reasons to provide Medicaid coverage for the identification and treatment of SUD, many of which are given urgency by the national opioid epidemic. Untreated substance use disorders are associated with increased risks for a variety of mental and physical conditions that are costly.”

  • “In 2009, health insurance payers spent $24 billion to treat SUD. Of those expenditures, Medicaid accounted for 21%.
  • Two of the top ten reasons for Medicaid 30-day hospital readmissions are SUD-related.
  • Individuals with SUD and co-morbid medical conditions account for high Medicaid costs, such that $3.3 billion was expended in one year on behalf of 575,000 beneficiaries with SUD as a secondary diagnosis.
  • Beyond health care risk, the economic costs associated with SUD are significant. States and the federal government spend billions every year on the collateral impact associated with SUD, including criminal justice, public assistance and lost productivity costs.
  • Alarmingly, the rate of fatal drug overdose in the U.S. has quadrupled between 1999 and 2010.
  • Drug overdose has become the leading cause of injury death, causing more deaths than traffic crashes.
  • Other problems also relate to opioid prescribing including opioid exposed pregnancies, drugged driving, and increases in Hepatitis C and in some circumstances HIV from prescription opioid injection.”

“As states expand Medicaid coverage to millions of new beneficiaries that may have been previously uninsured, states are also expanding access to behavioral health services including covering these services in Alternative Benefit Plans as required by the Affordable Care Act. CMS has received a number of requests from states and stakeholders interested in enhancing care for individuals with SUD.”

 

The CMS announcement mentioned examples of practice changes including “Enhancing provider competencies to deliver SUD services with fidelity to industry standard models, such as the American Society for Addiction Medicine (ASAM) Criteria.”

Here are more excerpts from the CMS announcement that align with what The ASAM Criteria has been advocating since the first edition in 1991:

 

Strong Network Development Plan”

“States will be asked to develop a network development and resource plan to ensure there is a sufficient network of knowledgeable providers in each of the levels of care recognized by ASAM and recovery support services. In addition, the state should have the resources to ensure that providers have the ability to deliver services consistent with the ASAM Criteria and provide evidence-based SUD practices. The network should be sufficiently robust so that access can be assured in the event that some providers stop participating in Medicaid, are suspended or terminated.”

 

Care Coordination Design

“Coordination of care design is integral to SUD delivery reform. This entails developing processes to ensure seamless transitions and information sharing between levels and settings of care (withdrawal management, short-term inpatient, short-term residential, partial hospitalization, outpatient, post-discharge, recovery services and supports), as well as a collaboration between types of health care (primary, mental health, pharmacological, and long-term supports and services). CMS encourages states to test how to best achieve care transitions across the care continuum, including aftercare and recovery support services.”

 

“Short-term acute SUD treatment may occur in inpatient settings and/or residential settings. …Inpatient services are described by the ASAM Criteria as occurring in Level 4.0 settings, which are medically managed services. Inpatient services are provided, monitored and observed by licensed physician and nursing staff when the acute biomedical, emotional, behavioral and cognitive problems are so severe that they require inpatient treatment or primary medical and nursing care. “

 

“Residential services are provided in in ASAM Level 3.1, 3.3, 3.5 and 3.7 settings, which are clinically managed and medically monitored services typically provided in freestanding, appropriately licensed facilities or residential treatment facilities without acute medical care capacity. “

 

California was one of the first states to seize new opportunities from CMS for demonstration projects. These projects are approved under section 1115 of the Social Security Act (Act) to ensure that a continuum of care is available to individuals with SUD. Section 1115 demonstration projects allow states to test innovative policy and delivery approaches that promote the objectives of the Medicaid program.

 

The California Initiative

California calls its Medicaid services “Medi-Cal.” This month Medi-Cal received some welcome news from CMS. Here, in part, was California’s announcement on August 13, 2015:

The Department of Health Care Services (DHCS) announces the Center for Medicare & Medicaid Services (CMS) approval of California’s Drug Medi-Cal Organized Delivery System (DMC-ODS) Waiver amendment which provides a continuum of care for substance use disorder treatment services.”

 

As the Chief Editor of The ASAM Criteria who happens to live in California, I can’t help but feel proud that we now have a chance to truly implement the spirit and content of the Criteria in my home state. And who knows- maybe many more states in the USA.

 

TIP 1

If your state is considering enhancing care for individuals with SUD, take a look at what California is just now embarking on in their system of care redesign.

 

Here is the introduction to California’s system re-design states:

 

“The Drug Medi-Cal Organized Delivery System (DMC-ODS) provides a continuum of care modeled after the American Society of Addiction Medicine Criteria for substance use disorder treatment services, enables more local control and accountability, provides greater administrative oversight, creates utilization controls to improve care and efficient use of resources, implements evidenced based practices in substance abuse treatment, and coordinates with other systems of care.

This approach provides the beneficiary with access to the care and system interaction needed in order to achieve sustainable recovery. The DMC-ODS will demonstrate how organized substance use disorder care increases the success of DMC beneficiaries while decreasing other system health care costs.”

 

The State Implementation Plan and Standard Terms and Conditions for the DMC-ODS are located at http://www.dhcs.ca.gov/provgovpart/Pages/Drug-Medi-Cal-Organized-Delivery-System.aspx

 

Reference:

Mann, Cindy and Osius, Elizabeth (2015): “Medicaid’s New Role in the Health Care System” Journal of the American Medical Association (JAMA), Volume 314, No. 4 pp. 343-344.

SKILLS & SHARING SOLUTIONS

If your agency, county or state is preparing to implement The ASAM Criteria, here are some tips to get you started.

 

TIP 1

Involve all systems and stakeholders in the implementation process from Day 1.

 

Whenever I am asked to train or consult for a “kick-off” for implementing The ASAM Criteria, one of the first strong recommendations I offer is to make sure ALL stakeholders affected by The ASAM Criteria are in the room from the beginning.

 

Why is this? Because implementing the true spirit and content of the Criteria affects everything:

* How you engage and attract people into recovery;    

* How you conduct screening and assessments;

* How you collaborate with clients, patients, families and referral sources on individualized treatment;

* How you design, deliver and pay for a continuum of addiction services; and

* How you move people through a disease management continuum of care.

* Not least of all, how you select and train staff on all these processes.

 

Implications for stakeholders

  • Counselors and clinical staff will need to move away from program-driven services to individualized, person-centered, outcomes-driven treatment.
  • Administrators and supervisors must figure out how to use economies of scale to provide a broad continuum of care, to stretch resources to achieve good outcomes.
  • Payers and managed care companies will have to ‘speak’ the common language of The ASAM Criteria – to collaborate with treatment providers on care and utilization management decisions.
  • Quality improvement and auditors must understand the correct application of The ASAM Criteria and what it really means for documentation, treatment plans and continuing care decisions.
  • Referral sources, especially mandated treatment settings like Drug Court and other criminal justice personnel, Child Protective Services, employers and schools, will have to understand that mandating assessment and treatment adherence is the correct stance – rather than mandating a particular level of care and length of stay.

TIP 2

Broaden understanding of the clinical application of The ASAM Criteria beyond intake, admission and level of care placement.

 

Some counselors and clinicians think The ASAM Criteria is a checklist of levels of care to justify admission to the program. Then they think they are done- to pursue treatment as usual. Nothing could be further from the truth, which is why we removed the wording “patient placement” from the 460-page 3rd edition (2013) book.

 

It is much more than initial placement criteria. That’s why there are multiple chapters on application of the criteria to special populations. There are chapters on working effectively with managed care, tobacco use disorder and gambling disorder. Appendices on withdrawal management instruments were added to address Dimension 5, Relapse, Continued Use or Continued Problem Potential.

 

Take a look at www.ASAMCriteria.org and “How to Really Use the New Edition of The ASAM Criteria: What to Do and What Not to Do” Counselor Magazine Nov-Dec., 2013

See more: http://www.counselormagazine.com/2013/Nov-Dec/ASAM_Criteria/#sthash.wOk2zq6r.dpuf

 

There are some proprietary instruments to help you. The Change Companies® is the sole distributor for Evince Clinical Assessments, the field’s most complete system of clinically-driven assessment, diagnostic and patient placement and planning tools compatible with the DSM-5 and The ASAM Criteria – Third Edition.

 

Included in this comprehensive system is the DAPPER (Dimensional Assessment for Patient Placement Engagement and Recovery), the assessment tool most closely aligned with the new ASAM Criteria. To view a description and sample pages click https://www.changecompanies.net/products/?id=DA-T

 

TIP 3

Consider Interactive Journaling to help you use Evidence-Based Practices.

 

Many states now require counselors and programs to use Evidenced-Based Practices. In this new initiative California requires at least two of the following evidenced-based treatment practices (EBPs):

1. Motivational Interviewing

2. Cognitive-Behavioral Therapy

3. Relapse Prevention

4. Trauma-Informed Treatment

5. Psycho-Education

 

What too few realize is that there is actually one evidence-based practice that incorporates most of these EBPs above in one method. Interactive Journaling (IJ) is an EBP on the Substance Abuse and Mental Health Services (SAMHSA) National Registry of Evidence-based Programs and Practices (NREPP)

 

If you missed it, you can read all about IJ in the May 2014 edition of Tips and Topics:

https://www.changecompanies.net/blogs/tipsntopics/2014/05/

 

TIP 4

For a Standardized Assessment learn more about The ASAM Criteria Software.

The ASAM Criteria Software is now branded as Continuum ™, The ASAM Criteria Decision Engine. Continuum ™ provides counselors, clinicians and other treatment team members with a computer-guided, structured interview for assessing and caring for patients with addictive, substance-related and co-occurring conditions. By branding the software as “Continuum” it means The ASAM Criteria isn’t just about assessment at the front intake part of treatment in order to make a placement decision. It means that The ASAM Criteria is about ongoing chronic disease management across a whole continuum of care.

 

The book and Continuum ™ are companion text and application. The text delineates the dimensions, levels of care, and decision rules comprising The ASAM Criteria. The software provides an approved structured interview to guide adult assessment and calculate the complex decision tree to yield suggested levels of care, which are verified through the text.

 

For more information, go to the website www.asamcontinuum.org

 

Reference:

Miller, W. R. (2014). Interactive Journaling® as a Clinical Tool. Journal of Mental Health Counseling, 36(1), 31-42.

SOUL

Have you ever been stuck in gridlock on the highway with no clue why you are now in a parking lot!? You see some drivers pulling out to the shoulder, trying to catch a glimpse of what’s up ahead: “Is it a bad car accident? Or roadwork? A collapsed bridge? Is it 4 lanes narrowing down to 2? Maybe it’s just thousands of people interested in going to the same place as me?”

 

When you hear sirens and ambulances, you guess there is indeed an accident. Then you settle back for the long wait while cars crawl by rubbernecking at human tragedy. What’s frustrating is when you have no idea why you are speeding along at 3 miles per hour.

 

Switch scenes now. You’re sitting on a plane which was late taking off and now late arriving. This is threatening the very close connection to your next plane that you can’t wait to board. You want to get home after a long week “on the road”. Yes, that’s me.

 

Here’s my beef with airplane pilots. They can see perfectly well why the plane is 50 feet from the jet bridge and why we aren’t docking to let connecting passengers race to their next gate. Haven’t they ever been in a gridlocked parking lot on the highway? Don’t they know what it feels like to be stuck- with no idea why we aren’t moving?

 

Yes, they do usually give some brief explanation but:

  • Sometimes it is so general, it doesn’t help: “Folks, we aren’t at the gate yet, so please stay seated with your seat-belts fastened and your luggage stowed.”
  • Then a long silence with no explanation on why we are not at the gate yet. Is it because the gate is occupied by another plane that is nowhere near ready to push back? If so I almost certainly will miss my connection. Or is there a new trainee struggling to operate the jet bridge joystick and wobbling all over the airport, missing alignment with the plane door? Could we be waiting for a tow vehicle to hook up the plane to pull us into the gate? Pilot…..please tell us what is going on!
  • Even when they do tell us something more specific like: “There isn’t a gate agent yet to maneuver the jet bridge” or “There is a plane occupying our gate” or “We’re waiting for a tow vehicle,” they never keep you informed. They are up front looking through the windshield. We passengers have blank walls and no-smoking signs to look at. A few play-by-play updates would be nice: “Looks like the gate agents are busy, still no-one showing up. I’ve called them again.” Or “The plane does look like it is starting to push back, shouldn’t be long now.” Or “I can see the tow operator headed our way.”
  • Worst of all, is when they say: “It’s just going to be a few minutes and we’ll be at the gate” and then you get radio silence with no explanation and no updates AND it certainly is NOT a few minutes.

Maybe I’ve had too many frustrating plane trips lately, but next time I sit next to a pilot traveling to their next assignment, I’m going to bare my SOUL.

Until next time

Thanks for reading this month. See you in late September.                                

David

March 2016

Vol. #13, No. 12


In this issue

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

David Mee-Lee M.D.


(more…)

Getting Real about Gambling Disorder and Speeding again

Vol. 14, No. 1

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

David Mee-Lee M.D.

SAVVY

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

 

“Hi Dr. Mee-Lee:

 

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

 

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

 

Thanks for taking the time to read and consider this.

 

Rick Berman LPC, CADCIII, CGACII

Director, Problem Gambling Services

Lewis & Clark Graduate School of Education and Counseling

4445 SW Barbur Blvd. Suite 205

Portland, Oregon 97239

E-mail: eberman@lclark.edu

 

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

 

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

 

TIP 1

Why Consider Gambling Disorder?

 

American Society of Addiction Medicine (ASAM) Definition of Addiction

 

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

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

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

 

Statistics on Gambling Disorder

 

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

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

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

* For 6-9 million Americans, gambling is a damaging behavior that can harm relationships, family life, and careers. (SAMHSA – http://blog.samhsa.gov/?s=Gambling+Disorder#.VYXAHGCnRfQ)

 

TIP 2

Getting Real about Health Coverage for Gambling Disorder

 

(The ASAM Criteria 2013, page 358)

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

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

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

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

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

 

TIP 3

Getting Real about Staff Credentials and Competence for Gambling Disorder

 

(The ASAM Criteria 2013, page 358)

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

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

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

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

 

TIP 4

Getting Real about Filling Gaps for Gambling Disorder

 

2013 NATIONAL SURVEY OF PROBLEM GAMBLING SERVICES: 

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

 

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

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

* Problem gambling treatment availability.

* Need to increase the number of treatment providers.

* Improve research.

* Increase the number of prevention providers.

* Improve information management services.

* Increase the size of administrative staff.

 

References

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

 

2013 NATIONAL SURVEY OF PROBLEM GAMBLING SERVICES

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

 

Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies.

For more information on the new edition: www.ASAMcriteria.org

 

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

http://www.asam.org/quality-practice/definition-of-addiction

SKILLS

Note the following about gambling:

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

 

TIP 1

Getting Real about Screening and Assessment for Gambling Disorder

(The ASAM Criteria 2013, page 361)

 

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

 

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

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

Two screening tools are recommended.

 

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

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

 

The “Lie/Bet” two item questionnaire are:

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

 

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

 

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

 

 

TIP 2

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

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

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

 

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

Sample Questions:

1. Substance Use Disorder:

  • Are there current signs of withdrawal?

1. Gambling Disorder:

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

 

2. Substance Use Disorder:

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

2. GamblingDisorder:

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

3. Substance Use Disorder:

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

3. Gambling Disorder:

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

 

ASAM Criteria Dimension 2: Biomedical Conditions and Complications

Sample Questions:

1. Substance Use Disorder:

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

1. Gambling Disorder:

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

2. Substance Use Disorder:

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

2. Gambling Disorder:

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

 

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

Sample Questions:

1. Substance Use Disorder:

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

1. Gambling Disorder:

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

ASAM Criteria Dimension 4:  Readiness To Change

Sample Questions:

1. Substance Use Disorder:

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

1. Gambling Disorder:

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

 

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

Sample Questions:

1. Substance Use Disorder:

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

1. Gambling Disorder:

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

  

ASAM Criteria Dimension 6:  Recovery Environment

Sample Questions:

1. Substance Use Disorder:

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

1. Gambling Disorder:

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

SOUL

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

 

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

 

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

January, 2006 https://www.changecompanies.net/blogs/tipsntopics/2006/01/

May, 2010 https://www.changecompanies.net/blogs/tipsntopics/2010/05/

October 2011 https://www.changecompanies.net/blogs/tipsntopics/2011/10/

 

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

 

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

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

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

Interactive Journaling:

page-001
This 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.”Safe Bet” – Problem Gambling Prevention and Education

Minimum purchase of 25

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

 page-001-1


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.”Safe Bet Facilitator Guide”

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

 

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

Until next time

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

Sincerely,

David

Mainstreaming COD into AA/NA; Hong Kong

Vol.14, No. 2

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

David Mee-Lee M.D.

SAVVY & STUMP THE SHRINK

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

 

Hi David:

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

 

Amy, MS, LADC, CCS

 

TIP 1

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

 

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

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

 

TIP 2

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

 

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

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

 

TIP 3

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

 

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

 

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

 

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

 

You can read the whole pamphlet at:

http://www.aa.org/assets/en_US/p-11_aamembersMedDrug.pdf

 

Disclaimer

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

SKILLS

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

 

TIP 1

Diagnosis-specific suggestions when linking people to AA/NA

 

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

 

1. Schizoid or socially-avoidant people

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

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

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

 

2. People with Borderline Personality Disorder

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

 

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

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

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

 

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

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

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

 

TIP 2

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

 

Teach these skills to your clients:

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

SOUL

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

 

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

TRAINS 

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

411ba4a6-94e4-4f04-91ab-e3f766735424

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

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

FOOD  

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

d84a0fe8-743b-4f99-94f0-10cb059f9069

SHOPPING

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

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

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

https://www.youtube.com/embed/F6uT6gwyY1k?rel=0&autoplay=1

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

Until next time

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

All the best,

David

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

Vol.14, No. 3

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

David Mee-Lee M.D.

SAVVY

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

 

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

  

TIP 1

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

 

Reader #1

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

Lynda K. 31 years clean in NA/AA

 

My response

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

Thanks for the info.

David

 

Reader #2

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

Phyllis B

 

 

Reader #3

Hi David:

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

Susan B

 

My comment

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

 

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

 

 

Reader #4

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

 

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

 

I did not read in your information about Cocaine Anonymous (CA).  In their 12-Step meetings they have adopted the 12-Step program outlined in AA.   The meetings are warm and welcoming, and they welcome you to come as you are.  They allow you to share your experience, strength and hope in any way that is comfortable for you.  You do not have to walk on eggshells in Cocaine Anonymous.  “We are here and We are Free” Please visit ca4la.org.  I love Cocaine Anonymous and the 12-Step program outlined in the Big Book of Alcoholics Anonymous.  It got me in contact with a Power that was greater than me, that Power I choose to call God.  I understand this is not a religious program but a spiritual program that saved my life after 29 years of drugging.

 

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

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

 

My comment

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

 

 

Reader #5

Dear Dr. Mee Lee,

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

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

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

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

Lisa B

 

My response

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

David

TIP 2

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

Reader #6

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

 

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

 

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

 

Thank you

Bill Stearns

Reader #7

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

 

My response and comment

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

SKILLS

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

 

TIP 1

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

 

Reader #8

Greetings, David:

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

 

Some other thoughts that seem relevant:

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

Michael G

 

My comment

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

 

 

Reader #9

Dr. Mee-Lee,

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

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

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

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

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

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

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

Anyway, thanks, and nice work.

Anonymous Mike W

 

My comment

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

SOUL

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

 

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

 

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

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

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

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

 

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

 

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

Best Practices; Alterations; Jim Gaffigan

Vol. #14, No.4

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

David Mee-Lee M.D.

SAVVY

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

 

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

 

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

https://www.changecompanies.net/blogs/tipsntopics/2007/08/

 

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

https://www.changecompanies.net/blogs/tipsntopics/2007/10/

 

Here’s what Jennifer Harrison wrote and referenced:

 

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

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

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

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

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

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

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

 

 

TIP 1

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

 

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

 

 

TIP 2

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

 

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

SKILLS

Dr. Jennifer Harrison continues:

 

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

 

TIP 1

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

 

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

 

Here is an example of altering a best practice:

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

 

The result of this alteration?

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

 

References

 

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

 

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

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

SOUL

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

 

If you don’t know Jim Gaffigan, it’s time for a laugh (if you share my kind of humor). Actually, I’ve run into a bump before when I’ve been all enthusiastic about a comedian and showed the video to friends, only to see stone faces and not a peep of a chuckle. So here’s a link to Jim Gaffigan’s piece on visiting McDonald’s. I enjoy it every time and maybe you will too. https://vimeo.com/40843163

 

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

 

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

 

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

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

 

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

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

Vol. #14, No. 7

David Mee-Lee M.D.

SAVVY AND CONFERENCE ANNOUNCEMENT

Upcoming Conference:

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

http://www.usjt.com/Conferences/2016/7th-Annual-Western-Conference-on-Behavioral-Health-and-Addictive-Disorders/ 

Hope to see you there.

David

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

Kevin was asked to give one of about 10 faculty talks that afternoon as part of Longwood University’s debate-related activities. He talked about “Addiction and Public Policy” and covered many topics that I have written and spoken about before – only he covered them not in a day’s workshop, but in 14 minutes. You can see his presentation at: https://youtu.be/5UP5njyders

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

TIP 1

Review how attitudes and terminology about addiction, perpetuates stigma

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

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

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

https://www.changecompanies.net/blogs/tipsntopics/2015/09/

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

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

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

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

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

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

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

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

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

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

 

TIP 2

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

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

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

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

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

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

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

 

TIP 3

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

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

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

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

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

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

 

TIP 4

Consider these Addiction and Public Policy Issues

Public policy implications:

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

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

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

https://www.changecompanies.net/blogs/tipsntopics/2015/10/

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

4. Eliminate waiting lists.

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

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

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

SKILLS AND STUMP THE SHRINK

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

https://www.changecompanies.net/blogs/tipsntopics/2015/08/

TIP 1

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

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

Dr. Mee-Lee,

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

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

Paul Kiernan, LADC Clinical Services Specialist

Division for Behavioral Health

Bureau of Drug and Alcohol Services

Clinical Services Unit

Concord, NH

Email address: paul.kiernan@dhhs.nh.gov

 

My response:

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

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

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

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

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

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

Paul’s Reaction to my Response

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

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

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

Thank you

TIP 2

ASAM Criteria Level 3.3 and Dealing with Behavior Problems

Another question from Paul

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

My response:

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

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

https://www.changecompanies.net/blogs/tipsntopics/2013/02/

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

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

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

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

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

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

Paul’s Reaction to my Response

Dr. Mee-Lee,

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

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

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

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

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

Again I am so grateful for your correspondence.

Cheers,

Paul

Reference:

Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies.

For more information on the new edition: www.ASAMcriteria.org

SOUL

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

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

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

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

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

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

http://talkingpointsmemo.com/livewire/trump-lewd-comments-women-2005-hot-mic

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

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

Until next time

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

David

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

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.

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

November 2012 – Tips & Topics – november-2012-tips-topics

Vol. 10, No. 8 November 2012
In This Issue

SAVVY – Alternate terms for “Relapse”; ASAM’s definition of relapse
SKILLS – How to deal with substance use in residential treatment settings
SOUL – When not being chosen was good!

Welcome to the November edition of Tips and Topics. I hope you have been able to balance some family and friends time with the commercial push to have you shop till you drop.

Senior Vice President
of The Change Companies®

(more…)

How to move systems from programs to people.
Reframing “resistance” in systems change.
Soothing the customer.
When to increase the level of care intensity.

Vol. 10, No. 3 June, 2012

Welcome to the June edition of Tips and Topics (TNT) and to all the new subscribers. You can see nine years of back issues of TNT on The Change Companies’ website and download any of the previous editions.

Senior Vice President
of The Change Companies®

(more…)

April 2011 – Tips & Topics – april-2011-tips-topics

TIPS & TOPICS from David Mee-Lee, M.D.
Volume 9, No. 1
April 2011

In this issue

— SAVVY –The 3 Ps to Understanding the Big Picture of Healthcare
— SKILLS –Clinical Implications of the 3 Ps
— SOUL –Celebrating anniversaries
— SHARING- Some readers’ comments
— Until Next Time

Welcome to the start of the 9th year of publishing TIPS and TOPICS (TNT).  It was April 2003 when I started this experiment which has blossomed into a widely-read and appreciated resource (at least that’s what many readers tell me – the others don’t say anything- they just don’t read TNT!)

(more…)

June 2011 – Tips & Topics – june-2011-tips-topics

TIPS & TOPICS from David Mee-Lee, M.D.
Volume 9, No.3
June 2011

In this issue

— SAVVY   Top 10 reasons to use the ASAM Criteria
— SKILLS  How close your services are to the spirit/use of the ASAM Criteria
— SOUL   R&D – not doing the same old thing
— Until Next Time

Welcome and thank-you for joining us for the June edition.
(more…)

November 2010 – Tips & Topics – november-2010-tips-and-topics

TIPS and TOPICS from David Mee-Lee, M.D.
Volume 8, No. 7
November 2010

In this issue

-SAVVY: Checklists that improve care and reduce mistakes

-SKILLS: Convert checklists in your clinical head into a working checklist accessible to all

-SOUL: Seeing through their eyes
-STUMP THE SHRINK: What about program and behavior contracts?
-Until Next Time

Thanks for joining us for the November edition of TIPS and TOPICS (TNT).  Wishing you a great holiday season.

(more…)

August 2011 – Tips & Topics – august-2011-tips-topics

TIPS & TOPICS from David Mee-Lee, M.D.

Volume 9, No. 5

August 2011

_______________________________________

In this issue
— SAVVY – A new definition of addiction from ASAM
— SKILLS – What the new definition means to you, your program and systems

— SOUL – Charley horse
— SHARING- Readers’ comments

— Until Next Time

(more…)

May 2011 – Tips & Topics – may-2001-tips-topics

TIPS & TOPICS from David Mee-Lee, M.D.
Volume 9, No.2
May 2011

_________________________________
In this issue

— SAVVY – Teaching tips that work
— SKILLS –Practice these teaching techniques
— SOUL – Tornadoes and dodging bullets
— SHAMELESS SELLING – Tips from the TNT book
— Until Next Time

(more…)

February 2010 – Tips & Topics – february-2010-tips-topics

TIPS & TOPICS from David Mee-Lee, M.D.
Volume 7, No.10
February 2010

In this issue
— SAVVY   Guiding Principles for Treatment Planning
— SKILLS   Documentation that Makes Sense to Clients
— SOUL Sudden Death and Living Each Day
— STUMP THE SHRINK  Missing appointments and Drug Courts
— Until Next Time

Welcome to the February edition of TIPS and TOPICS.
The content of my previous website is almost fully merged with The Change Companies revamped website with still a few items to post. You can find TIPS and TOPICS Archives if you click on “Tips & Topics” at The Change Companies home page- www.changecompanies.net.  The complete Search function is still being put in place. Stay tuned.

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May 2010 – Tips & Topics – may-2010-tips-topics

TIPS and TOPICS from David Mee-Lee, M.D.

Volume 8, No. 2


May 2010

In this issue

SAVVY   Assessment Issues in Co-Occurring Disorders
SKILLS   What does the client want?  Understanding retention and resistance
SOUL A recovering Speeder
SHARING SOLUTIONS Innovations from Readers
Until Next Time

Thank-you for joining us for this month’s edition of TIPS and TOPICS.

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September 2010 – Tips & Topics – september-2010-tips-topics

TIPS and TOPICS from David Mee-Lee, M.D.
Volume 8, No. 5
September 2010

In this issue

-SAVVY: Psychiatric diagnosis gone wild!

-SKILLS: Working with People, not diagnoses

-SOUL: My favorite meals

-STUMP THE SHRINK:
Substance Abuse /Dependence-one size fits all?

-SHARING SOLUTIONS: Readers share their experiences with aging

-Until Next Time

Welcome to the September edition of TIPS and TOPICS.
A number of readers were prompted by the July/August edition to share their experiences with aging parents. Excerpts of their comments and wisdom appear in the occasional section-SHARING SOLUTIONS.

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July-August 2010 – Tips & Topics – july-august-2010

TIPS and TOPICS
from David Mee-Lee, M.D.

Volume 8, No. 4

July-August 2010

In this issue

SAVVY Aging by the numbers; and tips on eldercare

SKILLS Facing your fears, saying good-bye, and planning the future

SOUL What is Your Legacy?

SHAMELESS SELLING The new Tips n Topics book just released! Plus a freebie

Until Next Time

Welcome to a combined July-August edition of TIPS and TOPICS.

With summer vacation on our mind (here in the northern hemisphere at least), I took it easy these two months. But what I include in this edition is not light summer reading. It is, in fact, a topic I have not addressed before in any detail partly because it can be a sad and depressing focus for discussion. I’m speaking of aging, elder care, dying and death. Still want to read on?

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December 2007 – Tips & Topics – december-2007

TIPS & TOPICS
Volume 5, No.8
December 2007

In this issue
— SAVVY
— SKILLS
— STUMP THE SHRINK
— SOUL
— Until Next Time

Welcome to the many new subscribers, as well as those who have read TIPS and TOPICS for over four years now.

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July/August 2007 – Tips & Topics – julyaugust-2007

TIPS & TOPICS
Volume 5, No.4
July/August 2007

In this issue
— SAVVY
— SKILLS
— SOUL
— SHAMELESS SELLING
— Until Next Time

Welcome to a combined July-August edition of TIPS and TOPICS (TNT). In August I am leaving the warmth of summer in California to enjoy family and friends in wintry Australia.

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February 2007 – Tips & Topics – february-2007

TIPS & TOPICS
Volume 4, No.9
February 2007

In this issue
— SAVVY
— SKILLS
— SOUL
— Until Next Time

Thanks for joining us this month. Have you ever worked where there are disagreements and conflict? You might want to read on.

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November 2007 – Tips & Topics – november-2007

TIPS & TOPICS
Volume 5, No.7
November 2007

In this issue
— SAVVY
— SKILLS
— SOUL
— Until Next Time

Welcome to the November edition; and if you are in the USA, Happy Thanksgiving. We’re glad you join us every month. But if you find yourself with too much e-mail, and want to unsubscribe, you can do that at the links at the end of this newsletter.

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December 2006 – Tips & Topics – december-2006

TIPS & TOPICS
Volume 4, No.7
December 2006

In this issue
– SAVVY
– SKILLS
– SOUL
– STUMP THE SHRINK
– Until Next Time

Happy and Healthy New Year for 2007!

Thanks to all who responded to my request in last month’s edition for your TTT from TNT (Your Top Ten Tips from TIPS and TOPICS). It’s not too late to submit your list; read SUGGESTIONS in the Oct-Nov 2006 issue.

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December 2005 – Tips & Topics – december-2005

TIPS & TOPICS
Volume 3, No.6
December 2005

In this issue
– SAVVY
– SKILLS
– SOUL
– STUMP THE SHRINK…….
– Until Next Time

Happy New Year! By the time you read this, for most it will be 2006. I hope you receive the best gift of all this year – good health. Welcome to all the new subscribers who have joined us since last month. You can browse back issues of TIPS and TOPICS by going to the homepage of www.DMLMD.com . Click on ‘Read Back Issues’. There is also now a printable version of each edition.

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July/August 2005 – Tips & Topics – julyaugust-2005

TIPS & TOPICS
Volume 3, No.4
July-August 2005

In this issue
– SAVVY
– SKILLS
– SOUL
– SHAMELESS SELLING
– Until Next Time

Welcome to this two months’ combined edition of TIPS and TOPICS. The summer vacation lethargy has slowed this edition from a promised early month issue to a just-before-the-end-of-the-month publication date. But here it is.

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January 2005 – Tips & Topics – january-2005

TIPS & TOPICS
Volume 2, No. 9
January 2005

In this issue
– SAVVY
– SKILLS
– SOUL
– SHAMELESS SELLING
– Until Next Time

Welcome readers!

Happy New Year! Actually January is nearly over and it seems 2005 is already in full swing.

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April 2005 – Tips & Topics – april-2005

TIPS & TOPICS
Volume 3, No.1
April 2005

In this issue
– SAVVY
– SKILLS
– SOUL
– Until Next Time

Welcome readers!

In April 2003, the very first edition of TIPS and TOPICS “rolled off the presses”. It is hard to believe that this edition starts our third year. Thanks for reading all those months and if you are a new subscriber, welcome to what is becoming perhaps an “institution”.

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September 2006 – Tips & Topics – september-2006

TIPS & TOPICS 
Volume 4, No.5
September 2006

In this issue
– SAVVY
– SKILLS
– SOUL
– SUCCESS STORIES
– Until Next Time

Welcome to the September issue of TIPS and TOPICS. If you are receiving this in October, it is because we have been playing catch-up all month. Hopefully you will actually receive the October issue in October!

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May 2003

Vol 1, No.2
In this issue


SAVVY | SKILLS | SOUL | STUMP THE SHRINK

David Mee-Lee


 

WELCOME!

Welcome back to this second edition of TIPS and TOPICS.

The response to the first edition was very positive and satisfying. If you are receiving TIPS and TOPICS for the first time, thanks for signing up along with over a hundred of your colleagues. For a few of you with whom I have had professional contact in the past, I took the liberty of sending this along to you this month. If you would like to keep receiving it, I’ll be happy to send it. But if you are overwhelmed with information already and would rather not receive TIPS and TOPICS free each month, then I totally understand if you unsubscribe (see Unsubscribe link at the very end).

Thanks to all of you who wrote and expressed appreciation and gave feedback. It seems TIPS and TOPICS has already filled a need for many of you. I hope this edition will also be as useful to many.

SAVVY

Over the past month, I was asked to consult about two patients. Between them, both had been hospitalized in acute care medical and psychiatric units five times in the past six months. They were admitted for depression, suicidal feelings and ideation. One had a serious overdose and one even had electroconvulsive therapy (ECT). Alcohol and cocaine were the drugs involved. One of the consultation questions asked of me was this: What should be the focus of treatment given the patient’s poor follow through with treatment, “denial”, and multiple readmissions in a period of months?

In both cases, the substance dependence was correctly recognized as an important element in the patient’s history and treatment needs. However, in both cases, the clinician’s major emphasis was on the mental health problems – partly because those were the most acute presenting symptoms. Very little assessment of the substance use was done to tease apart to what degree the psychiatric symptoms were a result of the addiction problem; or to what degree the symptoms were truly a co-occurring disorder. Both programs were not very savvy about addiction treatment, let alone integrated dual diagnosis treatment.

Tips:

  • If a person is suffering from depression or any other psychiatric presentation, and is actively using alcohol and/or other drugs, specific assessment of both the mental health and substance use is needed. Is there a mental health problem where substance use may be attempts to self medicate the psychiatric disorder? Is this a substance use disorder in which the mental health symptoms are a result of addiction illness? Or is it a true dual diagnosis?
  • It is necessary to understand the difference between Substance Use Disorders and Substance-Induced Disorders. They are both under the category of Substance-Related Disorders (See DSM-IV Text Revision, 2000). This can help tease apart some of these assessment dilemmas.
  • If a person is in an early stage of readiness to change (notice I am downplaying the use of the term “denial”) and demonstrates ambivalence or lack of understanding about addiction, this is an active treatment issue. It is not a reason to exclude a person from treatment, or to provide only passive education about addiction.

SKILLS

Given the prevalence of co-occurring mental and substance-related disorders (dual diagnosis) it is good that both mental health and addiction treatment clinicians are so much more aware about dual diagnosis. However, awareness without clinical savvy can lead to knee-jerk over-reactions. Addiction treatment professionals too quickly can refer a client for a psychiatric evaluation without taking even a little time for more careful assessment and gathering of history data. Mental health professionals similarly can often rush to medicate symptoms before determining if they are looking at a substance-induced disorder or a true dual diagnosis.

Tips:

  • A Substance-Induced Mood Disorder, for example, “is distinguished from a primary Mood Disorder by considering the onset, course, and other factors. Substance-Induced Mood Disorders arise only in association with intoxication or withdrawal states, whereas primary Mood Disorders may precede the onset of substance use or may occur in periods of sustained abstinence.” (Page 405 DSM-IV Text Revision)
  • Take the history and timelines to check the relationship between substance use and addiction problems and the appearance of mental health problems. Not all mood swings are Bipolar Disorder – it could be that the person is using uppers and downers, stimulants and depressant substances. Not all heavy drinking is alcoholic drinking – it may be that the client is drinking at night until he passes out, in an attempt to deal with the severe insomnia of Major Depression.
  • Even after four weeks following detox, people can still have problems with depression, anxiety and mood swings etc. While we want to give people the benefit of medication if necessary, there is also a period of psychosocial adjustment after detox. If an individual has few (if any) positive recovery tools to deal with stress or discomfort- (e.g. dealing with cravings or mood swings) mental health symptoms can still be present after detox. These symptoms may be a part of normal addiction recovery and not positive proof that a co-occurring mental disorder exists.

If you want to learn more about these assessment dilemmas, you can check out the Home Study Course: “Dilemmas in Dual Diagnosis Assessment, Engagement and Treatmentat Professional Psych Seminars, www.psych sem.com.

SOUL

I am writing this section on Mother’s Day at 6:30 AM in a basic, but comfortable tent cabin in Yosemite National Park. What a privilege to be able to drive under four hours to such a place of astounding beauty. But last night, in an incongruous juxtaposition of experiences (sorry for the fancy words) we were in a lodge lounge packed with people cheering on the Sacramento Kings in the NBA Playoffs. If you are not a basketball fan, you would not know that the Sacramento fans are the most loyal and noisy fans in the USA. The Kings lost in double overtime. The prospects look bleak. Chris Webber, the King’s star player, is out for the rest of the playoffs with a torn cartilage in his left knee.

Two games ago, the Kings looked on track to take it all and win the championship this year. Frank Sinatra said it all in his gritty song “That’s Life” – “riding high in April, shot down in May”. In those final minutes of the game, the battle with the Dallas Mavericks seesawed between victory and defeat. Participating in the emotion and passion in the room, you would have thought the most important event in the world was a basketball game. Many of you didn’t even know the game was on, couldn’t care less and won’t ever care.

Outside, the sky is perfectly blue; the air crisp and clear; the sheer granite rocks tower all around us. One can look across the meadow to see Yosemite Falls pounding over the rock face. Half Dome stands huge, tall and impressive. Beside Yosemite’s picture-postcard beauty, we are here to meet up with our college freshman son on a geology class field trip. He gets to hike this grand National Park for two days- and for college credit!

In my view, there’s nothing wrong with the emotion and passion of a tight playoff game. And in the battles over budget cuts, competing theories of treatment, and advocacy for our various rights and noble initiatives, there’s nothing wrong with emotion and passion. But budgets come and go. Theories and rights rise and fall in importance, and basketball games will be forgotten next week. The grandeur of Yosemite, the emotion and passion around our mother and family remain way beyond April and May. I remind myself and perhaps you too, about priorities, perspective and permanence. What really is important? What do you really want for you, your family and the people we serve?

STUMP the SHRINK

Question:

Dr. Mee-Lee:
“I am reviewing a document and they have used the term “substance related” disorder and said they got it from the ASAM material. Is that the official new term? I had just heard two weeks ago that the term was “substance use” disorder. I have been in the field 22 years and have been through a number of these changes and don’t like the former term as it seems to refer to “related” disorders but not necessarily inclusive of substance use directly. Please advise if you have any insight to the “official” terminology. Thanks!”
Jane (real person, but not real name)

Answer:

Dear Jane:
“As regards the term “substance-related disorders”, we are using the language of DSM -IV. Substance-Related Disorders are made up of two categories: Substance Use Disorders (Substance Abuse and Substance Dependence); and Substance-Induced Disorders (Substance Intoxication and Substance Withdrawal and a whole host of other Substance Induced Disorders like Alcohol Induced Depression; or Amphetamine Induced Psychosis etc.) So it depends on the patient and their presentation as to what their diagnosis is. In the ASAM Patient Placement Criteria, we use all of the terms depending on what the history and assessment reveals. In other words, the term “substance-related disorders” is not replacing substance use disorders. ” Substance-Related Disorders” is the overarching DSM-IV chapter for both addiction disorders and for psychiatric disorders induced by substances. These substance-induced disorders are psychiatric disorders that are “related” to the substance, but are not the specific addiction or Substance Use Disorder (Abuse or Dependence). Check out the DSM and it should make sense, but let me know if not.”

Until next time

I would welcome any Success Stories on implementing any of the TIPS and TOPICS, or any questions to Stump the Shrink! Send those along. Just tell me how much identifying data you are comfortable with my sharing in this ezine. All the best until next time.

David.

June 2006 – Tips & Topics – june-2006

TIPS & TOPICS
Volume 4, No.3
June 2006

In this issue
– SAVVY
– SKILLS
– SOUL
– STUMP THE SHRINK
– Until Next Time

Welcome to the June edition of TIPS and TOPICS (TNT). We won’t call it the June/July issue even though you are receiving it in the first few days of July. You will however receive a combined July/August edition sometime in August – as is our custom in the summer.

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April 2003 – Tips & Topics – april-2003

Why I started this Ezine!
>> Clinicians have ongoing clinical questions that need answers!

I have been training and consulting for over 25 years, but fulltime for nearly the last seven years. I travel the country & get repeated requests for answers to questions on the American Society of Addiction Medicine (ASAM) Patient Placement Criteria and other topics. People ask about books, videos and audio learning materials they can obtain. They want help to implement and apply knowledge and skills presented in one or two-day workshops. An Ezine is one way to answer those common questions and requests more efficiently.

>> To help people apply new-found knowledge!

Budget deficits are hitting almost every state. Attending a workshop can change one’s knowledge and skills immediately. However, fewer can afford to take the time and funds to learn onsite at a workshop. Continual learning is essential, but a challenge to achieve without some ongoing prompting, supervision or assistance. An Ezine is a vehicle to provide supplements and support to previous workshop attendees, or to those who have so far been unable to get to an onsite training.

>>Because I want to make a difference in our field!

Out of sight, out of mind! I want my work to make a real difference in providing, managing and funding person-centered services. An Ezine is a channel available to stay in touch and keep making positive changes in our work. It is a way to feed “Tips and Topics” to healthcare providers sincerely interested in applying concepts and skills to change( for the better) the way we serve people in behavioral health.

What to expect from the Ezine
>> You will receive it once a month.
Please forward it to other interested individuals. Suggest that colleagues sign up on my website.

>> It will be a relatively brief communication.
While, on occasion, I may excerpt or include material from other sources (appropriately referenced of course), most material will be original and be focused on practical tips and topics in the following areas:
— implementation of the ASAM Patient Placement Criteria;
— providing and documenting individualized person- centered services;
— clinical and systems issues to do with co-occurring mental and substance-related disorders (dual diagnosis);
— ways to engage, empower and collaborate with people in getting what they want and changing what they want.

>> There will be 3 Sections: SAVVY, SKILLS, and SOUL
Each section will hopefully imrpove who we are as professionals and as people – it’s not just about “doing”, but also about the “being”!
“Savvy”- to improve our knowledge, wisdom and practical grasp of topics;
“Skills” to focus on tips to improve practical competence;
“Soul” to enrich a person’s total self – both yourself and others;
>>From time to time, I will add in “Successes” & “Stump the Shrink”
In “Successes”, I’ll share what has been working for you and others in the practice of “doing” and “being”.
In “Stump the Shrink”, I will focus on questions and dilemmas you and others face in the “real world. ” I’ll try to answer them; or perhaps I’ll be stumped for a good answer.

>> YOU CAN EXPECT THE NEXT ISSUE TO BE MUCH SHORTER.

So enough introduction. On with it!

December 2003 – Tips & Topics – december-2003


TIPS and TOPICS
Vol 1, No.8
December 2003

In this issue
– SAVVY
– SKILLS
– SOUL
– SUCCESS STORIES
– SHAMELESS SELLING
– Until next time

WELCOME!

Holiday greetings everyone! Thank you for reading this December edition of TIPS and TOPICS. I enjoy sharing some thoughts with you each month. I am glad that many of you find some tidbit to help you think about the work we do for the people we serve.

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November 2003 – Tips & Topics – november-2003

TIPS and TOPICS
Volume 1, No. 7
November 2003

In this issue
– SAVVY……..
– SKILLS……..
– SOUL………
– STUMP the SHRINK…
– Until next time……

WELCOME!

Welcome to November’s edition of TIPS and TOPICS. Thanks to all of you who take the time to write to tell me how you are appreciating and using the TIPS and TOPICS with your team and agency. I may not have written you back, but I do read all your messages and am very grateful for your comments and questions.

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April 2004 – Tips & Topics – april-2004

TIPS and TOPICS
Vol 2, No.1
April 2004

In this issue
– SAVVY
– SKILLS
– SOUL
– STUMP THE SHRINK
– SUCCESS STORIES
– Until next time

WELCOME!

This April edition of TIPS and TOPICS marks the beginning of the second year of these monthly bits and pieces from me to you. If you have been getting these from the very first edition, I hope they have been useful in your work and life. If you are new to TIPS and TOPICS, welcome to an unscripted array of issues that arise from reflections about my training and consulting practice (often as I sit on airplanes).

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March 2004 – Tips & Topics – march-2004

TIPS and TOPICS
Vol 1, No.11
March 2004

In this issue
– SAVVY
– SKILLS
– SOUL
– Until next time

WELCOME!

Recently I was training on the ASAM Criteria. I was surprised by some fundamental misunderstandings even from people using the criteria for many years. As you may know, I have been involved with, and chaired the development of the Patient Placement Criteria (PPC) for the Treatment of Substance Related Disorders of the American Society of Addiction Medicine (ASAM) since its beginning in the late 1980’s. For those of you who do not know the ASAM PPC, these are consensus criteria that match people with substance use problems to the appropriate level of care within a broad continuum of services.

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June/July 2004 – Tips & Topics – junejuly-2004

TIPS and TOPICS
Vol 2, No.3
June-July 2004

In this issue
– SAVVY
– SKILLS
– SOUL
– STUMP THE SHRINK
– Until next time

WELCOME!

Welcome to the June/July edition of TIPS and TOPICS. This monthly publication just suddenly turned into a two-editions-in-the-summer, “monthly” newsletter! You will receive a July/August edition around mid to late August. You can also see this and previous editions on my website.

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January 2004 – Tips & Topics – january-2004

TIPS and TOPICS
Volume 1, No. 9
January 2004

In this issue
– SAVVY
– SKILLS
– SOUL
– STUMP the SHRINK
– SUCCESS STORIES
– Until next time

WELCOME!

It is already moving towards February. I know it is clichéd to say, but I can’t believe how fast the year is racing by. I hope you are as busy (in the productive sense) as I am. But I also hope you have more balance in your life than I have at present. I have already broken my New Year’s resolution for more balance. By declaring this here I am putting myself on notice to check the balance-meter more often and more effectively.

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June 2009 – Tips & Topics – june-2009

TIPS & TOPICS
Volume 7, No.3
June 2009

In this issue
— SAVVY
— SKILLS
— SOUL
— STUMP THE SHRINK
— SUCCESS STORY & SHARING SOLUTIONS
— Until Next Time

Welcome to the June edition of TIPS and TOPICS. I’m glad you could join us.

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May 2009 – Tips & Topics – may-2009

TIPS & TOPICS
Volume 7, No.2
May 2009

In this issue
– SAVVY
– SKILLS
– SOUL
– SHAMELESS SELLING
– Until Next Time

Welcome to the many new subscribers who joined us this month for your first edition of TIPS and TOPICS. Thanks to all who have expressed appreciation and sent along nice feedback.

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February 2009 – Tips & Topics – february

TIPS & TOPICS
Volume 6, No.10
February 2009

In this issue
— SAVVY
— SKILLS
— SOUL
— STUMP THE SHRINK
— SUCCESS STORY
— Until Next Time

Welcome to all the new readers who joined us this month and to our long-term readers as well. I understand we all receive a lot of information in our inbox each day; I appreciate your taking the time to look this edition over.

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January 2009

Volume 6, No.9 | January 2009
In this issue


SAVVY | SKILLS | SOUL | SOCIAL COMMUNITY | Q & As

David Mee-Lee M.D.


 

Welcome to the New Year and a couple of significant events: a new President of the USA with all the accompanying hope and optimism (at least for the over 50% of voters); and equally earth-shattering, the launch of my new website www.davidmeelee.com More on that later.

SAVVY

Recently I was asked to present a workshop to help keep the behavioral health team healthy, especially in these tough economic times. I use a very illuminating exercise I heard about 8 years ago at the University of California, San Diego (UCSD) Summer Clinical Institute in Addiction Studies. It uses the familiar image of an iceberg to show that there is a visible culture and a much larger invisible culture hidden below the waterline. Problems you see on the surface are impacted by deeply held attitudes and beliefs- under water, out of view.

If you Google “culture iceberg” you’ll find many ways this metaphor has been used. I heard Dr. Schiff use a version which has become very useful for teams to discover what lies beneath common surface problems like high staff turnover rates, or treatment and service plans that are general and non-individualized.

In SAVVY, let’s look at high staff turnover rates; and in SKILLS, we’ll take a look at general and generic treatment plans.

  • Identify the hidden cultural norms, assumptions and beliefs of your treatment culture by looking below the surface of the Culture Iceberg.

Imagine 10% of the iceberg showing above the surface and the huge 90% below. You see the polices, procedures, symbols and rituals in your treatment culture but not the norms, assumptions and beliefs that profoundly influence and affect what really is happening.

On the surface, you have a policy and procedure to be welcoming to all clients and consumers. On the wall is the framed Mission Statement saying people are the agency’s most valuable resource. Then we have to lay staff off or give them unmanageable case loads. Clients call and get an answering machine with complicated prompts that even a sober, mentally-stable genius would struggle with. Then, if a caller does reach a person, they are placed on a waiting list as if their problems were no more important than a football fan waiting to get a ticket to the Super Bowl.

Take a look at a common organizational problem —> high staff turnover rates.

That is the visible, surface problem. Here’s how you get to the hidden cultural norms and assumptions fueling and perpetuating visible problems. You can get to hidden norms by completing the sentence: “It’s OK to…….”, and you can get to hidden assumptions and beliefs by following that with: “Because…..”

So, for example, beneath high staff turnover rates problem might lie: “It’s OK to have staff leave after a short period, because we pay low salaries and can only attract entry level candidates.” Here are some other possible hidden norms and assumptions and beliefs beneath this surface problem.
Hidden Norms and Assumptions

* It’s OK to not orient new staff well because they will leave soon anyway.

* It’s OK to bad-mouth management and each other, because we don’t have respect for each other.

* It’s OK to be overworked because we can’t turn clients away and they have to be seen.

* It’s OK to be discontent and complain because nobody in management cares anyway.

Feel free to add more if this is an organizational problem where you work. But you can see how getting below the surface can identify what might be fueling the visible issue. Sometimes what is beneath everything cannot be changed immediately and it helps to just know what is going on, so you can decrease expectations for a swift resolution.

For example:
If you cannot turn any client away and the demands for service are immense, staff can anticipate that they will be overworked until a solution can be found to have more manageable caseloads. Similarly, supervisors and clinicians will understand that they are in “crisis mode.” They may not be able to do as thorough clinical and documentation work as they would like. Naturally this will not make life easy. However these realizations can relieve some of the stress that comes from feeling bad about not doing your best work; and to understand that your supervisor is not a heartless slave-driver.

On the other hand, if the hidden norm is identified as a lack of respect for each other and no policy or procedure for conflict resolution exists, then this can be addressed immediately. With the commitment to develop and use a conflict resolution policy and procedure, the team can begin to turn around a culture of disrespect, gossip and back-stabbing.

(See TIPS and TOPICS, February 2007 for a sample Conflict Resolution Policy and Procedure – keep checking back for this to be on the website shortly)

References and Resources:

1. Steven Schiff, Ph.D. “Organizational Culture and Treatment Implications”. Presented at 30th University of California, San Diego (UCSD) Summer Clinical Institute in Addiction Studies, La Jolla, CA. August 1, 2001. The Culture Iceberg is work of Dr. Steven Simon, Culture Change Consultants, Inc. 2005 Palmer Ave., #105 Larchmont, NY 10538 www.culturechange.com

2. NIATx – Network for the Improvement of Addiction Treatment www.Niatx.net

 

SKILLS

Concern about general, generic and non-individualized treatment plans is almost a universal issue in accreditation surveys and quality audits as well as in documentation supervision and paperwork reviews. Clinicians also struggle to make treatment and service planning meaningful. This is one issue the whole team can look at; or if you are a private practice clinician, this is also an occupational hazard for you too.

  • General and generic treatment plans may have multiple causes. Expose the invisible culture beneath this problem.

Some of the causes may be: skills-deficits, feeling overwhelmed with caseloads, ignorance, laziness, lack of critical thinking, philosophical rebellion against documentation, fixed, program-driven perspectives or more.

Here are some ideas to get you started. Participants in past workshops have raised these.

Hidden Norms and Assumptions:

* It’s OK to write general treatment plans because we don’t really use them anyway.

* It’s OK to just get the paperwork done because our caseloads are too high.

* It’s OK to write the problems without the client because they aren’t thinking straight anyway.

* It’s OK to give everyone basically the same plan because the program is pre-scheduled with a set curriculum and manual.

* It’s OK to write the plan for the client because the client is in denial, mandated and doesn’t want treatment anyway.

* It’s OK for treatment plans to look much the same for all clients because everyone has the same basic problems.

* It’s OK to have the same plan because the client keeps relapsing and has been here five times with the same problems.

* It’s OK to write general plans because we’ve been doing it this way for years.

* It’s OK to not individualize treatment because that’s the only way I’m willing to get the paperwork done.

* It’s OK to put less effort into treatment planning because treatment plans don’t help clients recover anyway.

Maybe these aren’t your team’s top ten hidden assumptions. See what you come up with. Solutions will follow if the team can get to Preparation and Action.

SOUL

A few weeks ago, I watched an interview with the National Transportation Safety Board’s spokesperson on NBC’s Today Show (January 16). She was talking about the “Miracle on the Hudson River” where the US Airways flight “landed” safely with all 155 passengers and crew safe, sound and soggy. She said that “usually we are focusing on what went wrong. But in this case, there was so much that went right; and we want to learn from that too.”

That same day on National Public Radio’s Talk of the Nation, Science Friday program, the discussion was about how copper can decrease microbial counts and perhaps help in preventing hospital infections which kill more people than HIV and breast cancer combined!

In one experiment, patients’ beds, surfaces in their rooms, and other equipment are being changed to copper to gauge if this will improve infection rates. Apparently you have a 1 in 20 chance of contracting a hospital infection just by checking yourself in for inpatient treatment; and a 1 in 20 chance of dying.

All this got me thinking about what a risk patients and clients take to get treatment. It shouldn’t be that they get sick and die, even as they come for help. Obviously I want people to keep coming for help. I believe treatment heals many more than it harms.

We work in behavioral health, not physical health. We may not amputate the wrong leg, take out the wrong kidney or leave surgical forceps in a patient’s abdomen. But we all create a treatment culture: it can be a healing one or not. Does it inspire, attract and welcome people? Encourage them to embrace recovery?

Does it “infect” individuals, discourage them, dishearten them?

There is a lot of pressure on us to treat problems and pathology. As when a plane crashes, we do want to identify what went wrong. But, just like Flight No. 1549, we want to focus equal time and energy on learning from what went well in people’s lives. Doing more of what works is as instructive and effective as doing less of what hasn’t worked. And it is a lot more hopeful and attractive to engage people around what works than around what is wrong.

 

SOCIAL COMMUNITY

Thanks to everybody for your feedback on the website. More is welcome. Your comments and suggestions are appreciated. I’ve received many common questions which are answered in the next section.

If you haven’t already clicked on the new website, it’s still a Beta version and new things will be coming.
I hope you will take a look. It’s a good beginning of what I hope will eventually be a place for us to:

–> get information
–> share information
–> create open source assessment and treatment planning forms and software; policies and procedures; treatment supports and whatever else our social community sees useful
–> get consultation and learning opportunities
–> buy useful products and services
–> link with other resources and people; Take a look at a video interview about co-occurring disorders at www.AfflictedandAffected.com in Archived Shows.

It’s not Facebook, MySpace or Amazon.com. It’s davidmeelee.com. It will be evolving over time.

Simple Website Q & As

Q: With the new website now, do I need to re-subscribe to Tips N Topics?
A: No! Your email address is the same and still in our database as before.

Q: When will be all the Tips N Topics issues be up on the website?
A: Very soon! Keep checking back as we’re updating that section regularly.

Q: On the calendar, how can I tell if trainings are open to the public or not?
A: The perfect solution has not yet been finalized, but we intend to state “Open to Public” right in the date box. Details on the training will be available as well.

Q: I don’t see a “Home” tab on the website?
A: You can always click on the logos in the upper lefthand corner to get to the Home Page. There is also a link to “Home” at the bottom of every page.

Q: Will your email address change also?
A: Yes very soon- but emails to the ‘old’ address info@dmlmd.com will still get to us. We’ll let you know when the address changes.

Q: Are you going to add other things to your site?
A: Yes. Coming soon- products to buy, more free resources, links I recommend among other things.

 

Until Next Time

Thanks for reading. See you later in February.

David

September 2008 – Tips & Topics – 36

TIPS & TOPICS
Volume 6, No.5

September 2008

In this issue
— SAVVY
— SKILLS
— SOUL
— SUCCESS STORY
— SHAMELESS SELLING
— Until Next Time

Welcome to all our new subscribers and to everyone after the summer (or winter) break.

This month in the USA, it has been National Alcohol and Drug Addiction Recovery Month. Even though we are at the very end of September, I will continue this focus in this edition of TIPS and TOPICS.

(more…)

March 2008 – Tips & Topics – march-2008

TIPS & TOPICS
Volume 5, No.11
March 2008

In this issue
— SAVVY
— SKILLS
— SOUL
— SHAMELESS SELLING
— As a RESULT of your FEEDBACK
— Until Next Time

Welcome to March’s Tips and Topics (TNT), especially to the many new subscribers. As usual we are running late, so this March edition will likely get to you in early April. It is after all, free, so I guess you get what you pay for!

(more…)

January 2008

Volume 5, No.9 | January 2008
In this issue


SAVVY | SKILLS | SOUL

David Mee-Lee M.D.


 

Happy New Year and may 2008 be a successful and productive year for you and your team.

January’s edition takes a fresh look at the Mission, Vision & Values of both your agency and your personal work. Similarly I also am taking a fresh look at my Mission, Vision & Values and -my website, www.DMLMD.com.

I am evaluating the website – what works, what doesn’t, what’s relevant, outdated, helpful, useless, unfriendly, missing, time-saving, cumbersome, easy, difficult. You name it —- the good and the bad! I want my website to be really useful to all the people I serve, including you, the readers of TIPS & TOPICS.

Many of you have given me helpful feedback about TNT. Now I’d like to harness your feedback to help me revamp the website. I want it to serve you better, and build on the community of TNT readers. So I’d like to meet you where you’re at: I need your opinion.

Look for a second email where you can express your opinions. There just might be some prizes for three randomly selected responders. We all love free stuff!

 

SAVVY

It seems there are hardly any cities, counties, states and health care systems NOT thinking about, planning for, or actively working on integrating services for people with co-occurring substance use and mental health problems. Administrators may decide to re- define their mission to better serve people with multiple needs. That doesn’t mean every frontline worker is ready and willing to suddenly shift focus. I have consulted with systems on this, and here are a few steps I suggest:

Tip 1

  • Assemble team members to take a fresh look at the Mission, Vision and Values of the agency or system involved in the change process.

Addiction counselors may not be interested in working with those “crazy” psychiatric patients, and mental health clinicians in working with “those people – those out of control alcoholics and addicts”. In fact these sentiments partly explain why clinicians may have chosen their ‘specialty’ in the first place. Suddenly they are now expected to work with clients with both problems (not that they weren’t actually working with them already.) The juices for working with co-occurring disorders don’t just automatically flow simply because administration declares a new direction.

Where does a system start in the change process? Team members will be challenged on their attitudes, perspectives and comfort zone of work competence. Include all important stakeholders to fashion the Mission. This meeting sets the context, and establishes the process of collaboration with all involved parties. It gives each person the opportunity to take responsibility for re-committing to his/her job. It is a time (if they are honest in their heart) when some may decide/declare they are not interested in, or committed to the new Mission.

When you arrive at discussing Values, the team identifies principles before policies, procedures and personalities. This discussion usually provokes the inevitable disagreements over “what to do” in a variety of clinical situations. What do we do if a client shows up to treatment having used alcohol or some other drug on the way? What do we do when a client refuses to take medication? What do we do when a client wants to stop methamphetamine or heroin, but keep drinking alcohol or smoking marijuana? When we discuss and name Values before a concrete clinical situation arises, this creates an anchor, a solid reference point to guide what to do in the heat of the moment.

–> For example, suppose your team agreed on this Value:
“Any relapse -whether in addiction or mental health – will be addressed as a crisis in a client’s treatment. This requires evaluation of the crisis and a revision of the service plan. We will not suspend, discharge from treatment, or have zero tolerance for relapse with any client – whether a substance use or mental health crisis.”

–> When the Value is discussed as a group, all team members have the chance to air their various points of view.

Tip 2

  • Develop individualized agency development plans and individualized staff development plans that recognize all agencies, program sites and team members are likely to be at different levels of preparedness to integrate co- occurring services.

Most clinicians are familiar with Stages of Change, and understand that clients seek help at different “stages of readiness.” Agencies (or program sites within an agency) are no different, just a larger organism. Staff also may be at different “stages” on being ready to adopt more integrated services. However, all would be expected to develop a formal plan that begins where they are comfortable, but also requires that they progress toward better integrated services.

–> Change leaders, technical assistance (TA) staff or consultants guide each agency/service site in the development of an “individualized agency development plan” matched to the stage of change and readiness for integrated services of that unit or provider.

–> They then monitor the progress of the individualized plans inside each agency in their service network.

–> Similarly each team member fashions an “individualized staff development plan.” This is done in collaboration with their supervisor, Change leader or TA consultant. The plan should honor each team member’s stage of readiness. It provides for training to increase awareness of the need for integrated services, as well as the skills to engage and treat people with co-occurring disorders.

–> Change leaders are personnel who have embraced the mission for integrated services. They are committed to improving services to the co- occurring population. To give Change leaders time to meaningfully participate in this mission, administrators and supervisors may need to adjust caseloads, job descriptions or duties.

SKILLS

It is fairly easy to stage training workshops, write up elaborate strategic plans and sketch out impressive timelines for goals/tasks to integrate services. The more challenging task is actually making change happen, the type of change which ends up making a difference on a daily basis to the people we serve in the trenches.

Tip 1

  • Develop specific implications for each Value raised in discussions of the new Mission and Vision.

Nearly every agency and company has a Mission Statement which very few team members can recall, let alone articulate, or explain concrete implications of the Mission.

–> Test yourself. Can you recite right now your agency’s Mission Statement without looking it up?
–> Have you always thought of it as being so generically lofty, “motherhood and apple pie,” so broad as to be of little practical use in the dilemmas and pressures of daily life on the job?

A good next step is to comprehensively explore and list all the implications for each Value you created. Let’s work with the example Value above.

It states: “Any relapse -whether in addiction or mental health – will be addressed as a crisis in a client’s treatment. This requires evaluation of the crisis and a revision of the service plan. We will not suspend, discharge from treatment, or have zero tolerance for relapse with any client – whether a substance use or mental health crisis.”

What would be the implications of such a Value? The list could include:

–> If a crisis of substance use, suicidal, violent or self-mutilation behavior, psychosis, mood instability should occur, all clients will receive timely assessment to address any immediate needs. We will revise the treatment plan to improve the client’s progress and outcome.

–>If a client’s relapse triggers reactions in other clients, this provides the opportunity to assist both the relapsing client, as well as helping other clients learn from their reactions to the relapse and crisis.

–> No client will be excluded from treatment because symptoms recur. But if a client deliberately undermines treatment by enticing others to use substances or violates boundaries with violence or impulsive behavior, we will likely discharge a client who is not interested in accountable treatment.

When you actually put pen to paper and write out the implications, this generates open discussion of often disparate ideologies and attitudes. When implications are made explicit -before confronting a “live” relapse crisis- this minimizes the inevitable conflicts which arise amongst people of different disciplines, personalities and life experiences. Remember, conflict is normal. There are policies and procedures that can make resolution more likely. See the February 2007 edition of TIPS and TOPICS for one example.

Tip 2

  • Work with team members in the same way you would with a client: i.e. challenge/ support one another in adhering to each team member’s development plan.

When a client presents for services, what drives the treatment planning process should be an alliance around what the client wants, and why they chose to walk in the door.

Here is the parallel process on the agency level. When a new Mission is written, it requires team members to re-commit to work in that agency. So each team member can ponder the following steps. Supervisors and Change leaders can facilitate the team member’s personal exploration by ensuring a strong, supportive, safe work environment:
–> What do you want that makes you choose to work here, especially with the new Mission? For example: being honest, do you just want a paycheck especially if you are close to retirement? Or are you getting ready to go to graduate school and want to be on the cutting edge of new directions? Or are you wanting a paycheck and not wanting to change what you are doing- in which case, your plan may be to transition out of the system if you are taking responsibility for your personal sanity and self-care.

–> Where are you at as regards the new directions the Mission promotes? What is your attitude, stage of change, comfort level and competence level? For example, if you see no reason to change the Mission, your personal development plan will require attention to some consciousness-raising. What information do I need to convince me of the need for change, before I am ready to focus on actually expanding knowledge and skills? If you are eager to be on the cutting edge of new technologies and methods, your development plan might have you lead the team in a journal club; or plan the in-service training curriculum; or be the local change agent champion.

–> How best would you acquire new skills necessary to promote the new Mission? Do you learn best by observation, trial and error, didactic presentations, individual supervision, group peer supervision, discussion of case examples, viewing videos, on the job coaching etc.? Your personal plan would include whatever methods will quickly and efficiently expand your knowledge and skills.

SOUL

I have not gotten on the Harry Potter bandwagon of incredibly successful books and spin-off films and merchandise. It’s not because I approve or disapprove; I just haven’t read JK Rowling’s works. Her fans may gasp at this point. What I do admire about her is how she pressed ahead when hardly anyone believed in what she had to offer.

In an interview recorded in TIME Magazine’s December 31, 2007 – January 7, 2008 edition, she was asked about her beginning fame. “It happened very, very quickly. I had written a book that I was told repeatedly was uncommercial, overlong, wouldn’t sell. So when it happened, it really was a profound shock.” That prediction about her book is right up there with “Who would want a computer in every house?” What successful author, musician, artist, entrepreneur, politician or athlete has not faced repeated failure, before eventually finding themselves contributing in a way they had set their sights on? And it is not just those professions. This is true for just about anything worth achieving.

Most of us are involved in work, leisure and community activities which do not require the kind of commitment and energy that it takes to run for the Presidency of the United States or to compete in the Super Bowl with a perfect win record of 18 straight games. But when you show up for work everyday, have you chosen to be there? Or are you just going through the motions? How cynical, burnt-out, compassion-fatigued, frustrated are you? When a flight gets cancelled due to weather, and I have to drive seven hours in freezing rain and snow to make sure the workshop goes on the next morning, the experience of frustrated, burnt- out and fatigued come to mind. All that melts though, when participants leave having gained a lot to help them in their work—and appreciatively feed that back to me.

Here’s what JK Rowling also said: “I hope my work sends the message that self-worth is about finding out what you do best and working hard at it.”

This won’t necessarily translate into instant fame and fortune. Who wants the paparazzi anyway? But it is a great formula for a meaningful way of being and contributing; and a potent antidote if you find yourself cynical, burnt-out, compassion-fatigued, and frustrated.

Until Next Time

Thanks for joining us for this first edition of 2008. See you in late February.

David