Vol. 14, No. 10
In this issue
Enduring principles as healthcare changes
Customer & team values
David Mee-Lee M.D.
Vol. 14, No. 10
In this issue
David Mee-Lee M.D.
Welcome to all new readers to the March edition of Tips and Topics. Thanks to all for reading this month.
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.
Howcan you tell if a person is just “doing time, not treatment”?
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?
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.
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?
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:
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,
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).
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.
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.
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.
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.
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.
Hope this helps.
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.
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.
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.
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.
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.
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.
* 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.
Welcome to the July edition of Tips and Topics. If you are in the northern hemisphere, I hope your summer is fun. If not, stay warm!
This month, there was a vigorous discussion amongst some members of a relatively new and small group of Addiction Medicine Physicians called “Like Minded Docs”.
“We Like Minded Docs are a group of compassionate physicians who support efforts to improve the quality of care for persons with addiction. We seek to put more “heart and soul” back into all aspects of the practice of addiction medicine. As we strive to achieve that shared goal, we will continue to work with the American Society of Addiction Medicine (ASAM) and other organizations toward a comprehensive, integrative approach to addiction treatment.”
We Like Minded Docs don’t actually walk lock step on a variety of issues in addiction treatment, as I discovered full well this month. A discussion began about people who use alcohol or other drugs while in residential or inpatient treatment, and what to do about that. It was fascinating to see how this group of committed physicians, all of whom firmly believe addiction is a disease needing chronic disease management, varied in their views on what to do when a patient has a flare-up of addiction and uses substances while in treatment.
In the 1980s, I established and directed an inpatient addiction treatment unit. There we had a zero tolerance policy and discharged patients who used while in treatment. I have long argued, since then, about a zero tolerance policy. It is not consistent with viewing addiction as a chronic disease characterized by loss of control of use, and prone to relapse or acute exacerbation of addiction illness.
I have written on this several times before. You can read more in the October 2012 and November 2012 editions of Tips and Topics.
Consider these steps when a person uses substances while in treatment.
1. View such a flare-up as a poor outcome, which needs assessment and a change in the treatment plan.
2. Collaborate with the patient to discover: What went wrong? What is s/he willing to do differently in their treatment plan that is in a positive direction?
3. Call a crisis patient community meeting. Highlight the dangers of use in the treatment community and address any triggering or even actual use by others.
4. Work with any patients affected by their fellow patient’s flare-up. Help them learn from this and change their treatment plan accordingly.
5. Discharge the person who used only if s/he is not interested in treatment and just wants to “do time” in a treatment program and continue using trying not to get caught.
Now not all my Like Minded Docs agree with these steps. It was interesting to note different approaches by some addiction medicine specialists. Here are some excerpts and my commentary on their approaches:
“I had a patient once who took meds brought in by another, and I did not ‘kick out’ the one who used in treatment who had been given the drugs by the ‘smuggler’. She was forever grateful that we let her stay and process her use. But the person who brings drugs in and violates the safety of the milieu, is a ‘vector of disease’ and this person must be removed, for his/her own good, and to protect the integrity of the environment….
If someone brings drugs into a residential environment, for WHATEVER reason, is that ‘enough’ of a ‘violation’ that even if it is ‘predictable addiction behavior’ we need to transfer them to another location? I argue that it is……and this isn’t ‘punitive’ to the person, but it’s necessary for the care of the OTHERS in treatment…bringing drugs into a residential setting is assaultive to the community….it’s one of the expellable offenses that makes the treatment environment unsafe and “untherapeutic.”
My Commentary #1
The patient you did not “kick out” is an example of good therapeutic action and results: retaining in treatment the patient who used and this becoming a learning experience for which she was eternally grateful.
The patient who was the “smuggler” should have been discharged if he did so because he was willfully not interested in treatment. If he figured he would just hang out in a program because he was mandated, continue to party, use substances and pull others down with him, then discharge fits the assessment of his not being”in treatment”. It is assaultive to the community and expellable if the person has no interest in looking at or working on his addictive behavior.
However- if your “smuggler” was a patient in crisis, whose addiction was acutely flaring up with use, then that patient is in need of the same assessment and process to change the treatment plan as the patient who was not “kicked out”. I would argue that the treatment environment is strengthened and made more therapeutic by embracing the crisis of this patient’s acute exacerbation of addiction, which is not willful misconduct. The community is strengthened by helping this patient who (there but for the grace of God) could be any one of the other patients. Furthermore it addresses the needs of anyone else who also used with him or her.
And why are we even using terminology like “kicked out” and “smuggler” anyway when we are talking about a chronic disease?
Comment # 2
“Patients come into treatment in a residential setting and are extremely vulnerable whether they are in detox, just finishing, or after detox. They come into residential treatment with the hope and expectation that the environment is safe and drug-free. I cannot allow someone to bring drugs into the community and not do anything. If their using jeopardizes the community, then they need to be removed from that community by going to a different level of care within the current system or transfer to another system. We move them to an increased structure.”
My Commentary # 2
A zero tolerance policy prioritizes keeping the treatment community safe.Equally important is the patient in crisis AND keeping the treatment community safe. “Doing something” is equated with discharging or transferring the patient. However it IS”doing something” to take the following actions:
When there is an acute exacerbation of addiction illness, it is not therapeutic action to discharge or transfer someone out of the milieu. Psychiatric patients also enter an inpatient unit very vulnerable. If we discharged every patient who cuts themselves, attempted suicide, became psychotic, angry, loud and violent in order to keep the inpatient community safe, we’d have no patients.
When someone physically attacks other patients, commits sexual predatory behavior, then that is behavior which “jeopardizes the community”. If the program is unable to help the patient contain those behaviors, a safer place may be needed. All addiction patients must learn how to deal with triggering situations. Addiction flare-ups create triggering situations. Treatment must address both the patient in crisis AND others in the therapeutic milieu. Good therapeutic results can occur for the patient in crisis in their hour of need; and the others affected by his addiction flare-up.
Comment # 3
“The bringing in of drugs should be assessed and if there is no “correctable cause” found then the risk of it happening again is too great to continue in the current level of care. If the cause is found but the patient won’t engage to correct it and decrease risk, same thing, transfer or discharge is needed.
However, like any other symptom of the illness, if a correctable cause is found and corrected so that one can say that risk of recurrence is no greater than someone else bringing in a drug, then there should be no contraindication to the patient staying.”
My Commentary # 3
This physician’s approach parallels what is done with other signs, symptoms and flare-ups of any illness or disease. Bringing in or using substances is a sign and symptom of a flare-up of addiction illness for which a correctable cause is assessed and treated.
For example: Did the person get into an argument with his partner, which triggered drug use? Were cravings to use overwhelming so all he could think of was to buy and use drugs? Did he attempt to self-medicate anxiety or depression by using? Is the patient still hanging out with using friends?
Once a correctable cause is discovered with the patient, treatment continues if the change in the treatment plan addresses the problem:
e.g., “OK I won’t hang out with those friends anymore. Help me know how to say “no” to them.”
Or “when I get upset, depressed or anxious, I’m now ready to practice reaching out to someone for support and practicing my progressive relaxation exercises.”
When/if the patient is not interested in addressing the correctable cause of their substance use, they have a right to choose no further treatment and leave.
Comment # 4
“In our setting we identify relapse as a symptom of addiction, and if the patient self- reports we would dissect his relapse as a community process, and so far we have not seen relapse occur as an epidemic….our patients will soon enough be in a real world setting where relapse is the experience of many peers, especially in opioid recovery. Helping patients, and the patient who relapsed, have a process for understanding the chronicity of addiction and how to return to recovery following relapse can save them from saying “F- -k it, I relapsed, I failed – I’ll just stay high” and then fatally overdosing.”
My Commentary # 4
The unintended negative effects of a zero tolerance policy include:
One of the Addiction Medicine physicians shared a case. It provided a great illustration on what taking action and doing something means…..other than the often-usual transfer or discharge of the person who used substances while in treatment. For confidentiality reasons, I have altered the case. As well, I have excerpted clinical case material and interspersed my comments and suggestions on how to take therapeutic action.
What does taking action look like when a person uses while in treatment?
“This week one of the patients admitted to the staff and other clients that he got some vodka at an Alcoholics Anonymous (AA) meeting and drank it.”
Andrea Barthwell, M.D., Founder, Two Dreams Outer Banks and Director, Encounter Medical Group approach referenced William E. McAuliffe in a National Institute on Drug Abuse (NIDA Research Monograph 72, 1986) about recovery training. According to Andrea, McAuliffe described treatment as complete when:
(a) the patient acknowledges addiction,
(b) commits to recovery, and
(c) reduces or eliminates inducements to use.
“When I apply that to where a patient is” Andrea said, “substance use is not “relapse” unless those three simple criteria have been met:
(a) acknowledge – knows the disease and understands he has it;
(b) commit- heartfelt acknowledgement and willingness to follow lead of peers and professionals without resistance;
(c) reduce/eliminate- follows assessment of untreated issues and takes care of them (risky peer group, drug dealing boyfriend, untreated bipolar disorder, etc.).”
Dr. Barthwell continues: “So, I look to keep building on the gains made in treatment until these three criteria are met and thus look at substance use as really just “continued” use and not ‘relapse’.”
The case continues:
“I wanted him out and transferred to a higher level of care, being a traditional inpatient program. He clearly needs a more structured program.”
“The problemis it was Friday at 5 pm before the weekend. We were not able to make it happen until Monday. If we streeted him he probably would immediately relapse and of course risk continued heavy drinking. If we kept him we worried about what the other clients would think: “I guess it is okay to drink and use in rehab and nothing happens“.
“The compromise we made was he can’t stay in our program but we will keep him until Monday. This was discussed with all the clients at a community meeting so theyknew we were taking action. Had he given or offered alcohol to any other client I probably would not have let him stay in the program until Monday.”
The Bottom Line
Even among Addiction Medicine physicians there are mixed feelings about:
1. Whether alcoholand other drug use in people with addiction is willful misconduct and a choice, which requires expulsion for being assaultive to the treatment community; or whether it is out-of-control addiction where “choice” is no more relevant than “choosing” a heart attack.
2. Whether the highest responsibility of providers in inpatient and residential settings is to the other patients to keep the community drug-free and therefore transferor discharge the person who used substances; or whether the milieu can be kept therapeutic by actually dealing openly with the patient whose addiction flared up and with those affected by the patient in crisis.
3. Whether zero tolerance policies are effective in keeping an environment safe and therapeutic; or whether the unintended negative effects are for substance use to go underground, encouraging dishonesty and non-confrontation of BUDDING and actual use.
Even criminal justice is coming around to the futility of just removing drug users from the community to keep the community safe from drugs.
July is Germany’s month…..if you were into the World Cup for soccer or “football” (depending what country you are in.) Germany won it all.
For me personally though, July was also my Germany month. “Das ist sehr gut” = that is very good. Not because I spent so much time traveling the country, but because I do love foreign travel. I had the opportunity to conduct a training in Mainz, not far from Frankfurt. No – I didn’t have to do the training in German,”Ich spricht nicht Deutsch” = I don’t speak German… or is it “Ich nicht spricht Deutsch”? It was for adolescent addiction counselors throughout the USA military bases and schools in Japan, Korea, Europe and Hawaii.
What was fun was simply noticing the differences in how other countries approach a variety of everyday things:
Then there was getting into and out of the country. No forms to fill out arriving or leaving. Nocustoms declaration of goods brought in or taken out. No inspection of bags. Passport control was over in about 30 seconds with a simple stamp in my passport.
The security checkpoint for boarding the plane in Frankfurt was very civilized. In the USA, you often have to search for the cart of plastic trays into which to place yourliquids, gels and toothpaste. (The Transportation Security Administration (TSA) personnel have not yet moved the empty trays stack back up to where the passengers are lining up.)
In Frankfurt, the trays arrive on a smooth-flowing conveyor belt exactly where you need them. It slots the next empty tray into place as soon as you remove one to use. If you happen to need two trays, you simply reach down and retrieve the next one. No frantic pushing and shoving to grab the last tray on anempty cart, or calling out to a TSA person to bring more trays.
One more thing: the stores were closed on Sunday to allow for a more relaxed weekend for people and their families. Not good for an American tourist who wanted to shop, but a reminder that consuming and shopping should take second place to life-work balance.
Now for August and mytrip to Australia. That is the opposite extreme and I don’t just mean driving on the left hand side of the road. There, you had better stick strictly to the speed limit or risk a camera-tracked speeding ticket of hundreds of dollars. No 5 to 10 miles/hour grace margin.
But at least the US dollar gets me a healthy Aussie dollar exchange rate compared with the dollar-busting exchange rate for the European Euro.
Thanks for joining us this month. See you in late August.
Welcome to the September edition of Tips and Topics (TNT). I’m glad that we have many new subscribers to join our longtime TNT community.
It is difficult to work in the mental health and addiction treatment field without interfacing with clients involved in the criminal justice system. Some addiction treatment programs receive 90% or more of their clients from the criminal justice system.
“In a 2006 Special Report, the Bureau of Justice Statistics (BJS) estimated that 705,600 mentally ill adults were incarcerated in State prisons, 78,800 in Federal prisons and 479,900 in local jails. In addition, research suggests that “people with mental illnesses are overrepresented in probation and parole populations at estimated rates ranging from two to four time the general population” (Prins and Draper, 2009). Growing numbers of mentally ill offenders have strained correctional systems.”
Here’s another headline from the Bureau of Justice:
STUDY FINDS MORE THAN HALF OF ALL PRISON AND JAIL INMATES HAVE MENTAL HEALTH PROBLEMS
“More than half of all prison and jail inmates, including 56 percent of state prisoners, 45 percent of federal prisoners and 64 percent of local jail inmates, were found to have a mental health problem”. This was according to the 2006 study published by the Justice Department’s Bureau of Justice Statistics (BJS).
And now, note this headline on addiction and criminal justice:
NEW CASA REPORT FINDS: 65% OF ALL U.S. INMATES MEET MEDICAL CRITERIA FOR SUBSTANCE ABUSE ADDICTION, ONLY 11% RECEIVE ANY TREATMENT
NEW YORK, N.Y., FEBRUARY 26, 2010
The National Center on Addiction and Substance Abuse at Columbia University, a
drug policy organization, found that “of the 2.3 million inmates crowding our nation’s prisons and jails, 1.5 million meet the DSM-IV medical criteria for substance abuse or addiction, and another 458,000, while not meeting the strict DSM-IV criteria, had histories of substance abuse; were under the influence of alcohol or other drugs at the time of their crime; committed their offense to get money to buy drugs; were incarcerated for an alcohol or drug law violation;or shared some combination of these characteristics, according to Behind Bars II: Substance Abuse and America’s Prison Population. Combined, these two groups constitute 85% of the U.S. prison population.”
Any way you cut it, in clinical work it is increasingly important to understand Drug Courts, Mental Health/Behavioral Health Courts, other Problem-Solving Courts, and how to interface with Probation and Parole officers, Judges and their court teams.
What Are Problem-Solving Courts?
Here’s how the Center for Program Evaluation and Performance Measurement explains these courts:
“Problem-solving courts began in the 1990s to accommodate offenders with specific needs and problems that were not, or could not be adequately addressed in traditional courts. Problem-solving courts seek to promote outcomes that will benefit not only the offender, but the victim and society as well. Thus problem-solving courts were developed as an innovative response to deal with offenders’ problems, including drug abuse, mental illness, and domestic violence. Although most problem-solving court models are relatively new, early results from studies show that these types of courts are having a positive impact on the lives of offenders and victims and, in some instances, are saving jail and prison costs.
In general, problem-solving courts share some common elements:
Access “A Technical Assistance Guide For Drug Court Judges on Drug Court Treatment Services“
The Justice Programs Office, School of Public Affairs at American University, Washington D.C. http://www.american.edu/justice has published a very useful guide that helps judges understand what is addiction treatment. It helps treatment providers understand Drug Courts. You can Google the guide (paste in “A Technical Assistance Guide For Drug Court Judges on Drug Court Treatment Services“)and it should come right up.
There is even a small section on The ASAM Criteria (2013) which I was privileged to contribute.
In May this year, I gave a presentation on The ASAM Criteria at the National Association of DrugCourt Professionals in Anaheim, California. It was such a learning experience for me to be around so many judges, attorneys, court team professionals and treatment providers. In a session I attended on Judicial Leadership principles, I was struck by something one of the judge panelists said when speaking of client outcomes (sorry, I didn’t note which judge it was):
“People don’t failDrug Court, Drug Court fails them by not meeting their needs.”
Problem-Solving courts are focused on outcomes. But knowing how easy it is to blame the offender and participant in Drug and other Problem-Solving Courts for any poor outcome, that statement really got my attention………and got me thinking:
Some judges are rightly concerned that treatment providers are not watching public safety closely enough. Not sure that they trust treatment providers’ reports, judges sometimes take treatment into their own hands. This can result in judges working outside their scope of practice and issuing sanctions or mandates that are not clinically assessment based. Here are some examples:
Consider these thoughts on how to deal with sanctions and incentives in Drug Court (and other Problem Saving Courts)
Drug court participants are varied and can present with addiction, mental health and physical health complexity. These diverse clinical presentations highlight the need for individualized approaches to sanctions that are:
1. Based on assessment of each client’s multidimensional needs as per The ASAM Criteria six dimensions (I’m biased of course, and there are other assessment tools and parameters that address high risk and high need). So assessing if a person is developmentally disabled and suffers from an intellectual developmental disorder (previously called Mental Retardation) is important compared with a person who has antisocial personality disorder or lifestyle and is very institutionalized and used to incarceration. The intellectually developmental disordered person has deficits in reasoning, problem solving, abstract thinking, judgment, learning from instruction and experience etc. The institutionalized antisocial person experiences sanctions like water on a duck’s back.
2. Based on treatment engagement and good faith effort of the client in treatment. Participants with co-occurring mental and addiction issues will have more difficulty with engagement and have needs that require awareness of their multiple vulnerabilities. Treatment plans need to be assessment-based and person-centered not program and compliance based. Because of different client learning styles and their array of needs, any manualized and evidence-based curriculum may require adaptation to fit each client’s problems and progress/outcomes.
This calls for a level of clinical sophistication to use Evidence-Based Practices (EBPs) in a person-centered and outcomes driven manner rather than a compliance and one-size-fits-all manner. Interactive Journaling is an evidence-based method to facilitate self-change using Motivational Interviewing, stages of change work and CBT. The Change Companies has a Drug Court journal that can be used along with other journals designed for criminal justice populations used by Federal Bureau of Prisons and many others.
3. Based on outcomes in treatment. Is the client making progress in real accountable change? Are they demonstrating improved functioning that will increase public safety, decrease legal recidivism and crime and increase safety for children and families? Active credible treatment is not just about compliance with attendance and negative drug screens. Is the client invested in a change process at a pace that fits their assessed abilities and vulnerabilities? Or is the client merely passively complying, which does not translate into lasting change and increased safety? How do we impact the revolving door of repeated episodes of treatment and incarceration, which wastes resources and does not produce the outcomes we all want?
What is the “bottom line” on how to move from punishment to accountability for lasting change – implications for sanctions and incentives?
A. Sanction for lack of good faith effort andadherence in treatment based on the clinical assessment of the person’s needs, strengths, skills and resources. Don’t sanction for signs and symptoms of their addiction and/or mental illness in a formulaic manner that is one-size-fits-all.
B. The treatment provider is responsible for careful assessment and person-centered services and to keep the court apprised of any risk to public safety. The court should be informed about the client’s level of good faith effort in treatment; and whether the client is improving in function at a pace consistent with their assessed needs, strengths, skills and resources. The provider should not just report on passive compliance with attendance and production of positive or negative drug screens….passive compliance is not functional change.
C. If the client is not changing their treatment plan in a positive direction when outcomes are poor e.g., positive drug screens, attendance problems, passive participation, no change in peer group activities and support groups like AA etc., then the client is “doing time” not “doing treatment and change.” Providers need to then inform the judge that the client is out of compliance with the court order todo treatment. The client consented to do treatment not just do time and should be held accountable for their individualized treatment plan. If the client is substantively modifying their treatment plan in a positive direction in response to poor outcomes; and adhering to the new direction in the treatment plan, then the client should continue in treatment and not be sanctioned for signs and symptoms of their illness(es).
D. Incentives for clients can be explored and matched to what is most meaningful to them. For example, incentives that allow a client to choose a gift certificate or coupon for a restaurant may be meaningful for some clients. But others may find assistance in seeing their children; or receiving help with housing; or advocacy to change group attendance times to fit better their work schedule to be more meaningful incentives to be used. This requires an individualized approach recommended to the court by providers who should know their client’s needs, skills, strengths and resources. It is too much to expect the judge can work all this out in a busy schedule of court appearances.
E. A close working relationship between the client, judge, court team and treatment providers is needed to actualize this approach.
These ideas come from my clinical bias and experience, but they are offered with awareness:
Recently a colleague was to meet up for dinner but had to cancel because he strained his back and was in a lot of pain. I know what that is like. Over 20 years ago, I reached up to place my roll aboard suitcase in the overhead bin on the plane only to be shocked by a sharp back pain that left me walking like a 120 year old.
Hopping out of a car is a quick turn to the side, swinging your legs to the outside and rising out of the car seat….right? Not when you have back pain. Even in slow motion, each of those maneuvers can be excruciating. If you think back pain is mind over matter, let me know after you get your first attack.
On the other hand, it is true that people can milk back pain for all kinds of advantages: “I’d help you move those tissue boxes, but I have a bad back.” “Sorry I can’t come to the volunteer community park cleanup, I have a bad back (and by the way, the game is on TV).” I’d help with the dishes, but you know my back is bad today.”
Twenty years ago, I had almost crippling back pain in Greece on vacation, in Australia on vacation and when I moved to California. But I haven’t had an acute episode in nearly 18 years!
Lucky streak of good health? I don’t think so. On that bad back attack in Australia, I saw a musculo-skeletal physician who was quick to prescribe not narcotic analgesics,but rather muscle strengthening exercises. They take less than five minutes a day and I swear by this preventive remedy.
Here’s the three sets of exercises the Aussie doctor taught me:
1. Modified windshield wipers – I lie on my back with knees bent and feet flat on the floor. Arms are by my side and I sway my legs back and forth like windshield wipers. This seems to loosen up the back and spinal muscles.
If you want to do the real thing, you can check out:
How to do Windshield Wipers
2. Next, do Pelvic tilt exercises. Same position on my back, feet flat on the floor, arms by my side. Then I tilt my pelvis up and down repetitively.
If you want to see a professional teach this, go to:
How to Do Pelvic TiltExercises -YouTube
3. The third exerciseinvolves abdominal crunches. Same position on my back, but this time, I raise my legs and rest my feet on a stool or chair. Keeping the neck in line with your spine, not bent forward with chin touching your chest, do some crunches to strengthen abdominal muscles. I cross my arms across my chest butyou can check out a couple of ways here:
How to Do Crunches
How many repetitions of these are necessary? I don’t know what works for you, but at first, if the back pain is still acute, just do a few to get the idea…maybe five each. But I have worked up to do 3 sets of 20 windshield wipers and pelvic tilts and 2 sets of 20 crunches in sequence: wipers, tilts, crunches to tilts,wipers and crunches and ending with tilts and wipers.
I talked to another colleague today. He is going for an MRI in preparation for back surgery, hopefully to fix his chronic back pain.
I feel bad for him and I know I don’t want to get anywhere near that. I better do my wipers, tilts and crunches.
Thanks for joining us this month. See you in late October.
Welcome to the July edition of Tips and Topics. I hope your summer is going well for our northern hemisphere readers. Stay warm Down Under.
Earlier this month, I received a question prompting this combined SAVVY and STUMP THE SHRINK. This is especially relevant if you work in a program that focuses on rules and regulations, consequences for breaking the rules, and behavior contracts.
Even if it is the treatment plan that focuses your work with the client, it is easy to become distracted by behavior which disrupts the group and treatment milieu. Here is what Bob Fox of St. Paul, Minnesota wrote:
“I work in Level 2.1 Intensive Outpatient, mixed gender group. What is your view on policies about treatment peers forming exclusive, romantic relationships, or plain old sexual intimacy (hooking up) in treatment?”
Bob gave me three multiple choice options, but as you can see further below, I waxed eloquent and expanded way beyond the offered choices:
“a. Should the relationship be prohibited and one or both clients be discharged (referred to another program?)
b. Should the relationship be allowed, but the involved clients be separated into different groups? And then a focus of treatment is learning about healthy relationships, boundaries, etc.?
c. Or some other option?”
Think about how you deal with emotional, behavioral and cognitive issues that are potentially disruptive to the group and treatment milieu.
In general, my view is to see all emotional, behavioral and cognitive problems as treatment issues needing to be dealt with in the context of an individualized treatment plan. That plan should be frequently and collaboratively changed depending on what is working well (or not working well) in the client’s progress in treatment.
So in this case…. if peers are forming relationships and hooking up, that is behavior which is going to happen while a person is in treatment and certainly occurs when people are not in treatment. I suspect that for many clients in treatment the relationships and sexual behavior they engage in has created problems in their lives previously – both substance-related and non-substance-related.
In outpatient and residential treatment, we have an opportunity to create:
In addiction treatment and sometimes in mental health as well, we have had a tradition of creating a safe environment by having rules, policies and consequences if clients break the rules: like behavioral contracts; set back a level or phase in residential settings; loss of privileges; writing tasks; separating people into different groups; discharge etc.
We need to rethink our attitudes about what treatment is meant to do:
Help clients assess and evaluate the “differential diagnosis” of their emotional, behavioral and cognitive issues and the effect on their lives.
The answer to the STUMP THE SHRINK question centers around having a talk with the clients in the exclusive relationship. In addition, talk with all their peers in group regarding the dangers of becoming distracted by exclusive relationships and sexual behavior. Explore with all the clients about how this type of situation has distracted them in the past, how it distracts now in the present setting. Converse about how it can ‘de-focus’ people from recovery, from attending to their “work” of embracing new ways of being and doing.
1. Engage the group in talking. Where has this been an issue in other peers’ lives? What have they learnt from those experiences?
2. You can also discuss the dangers of forming intense new relationships early in recovery, especially if the new “love of my life” is also new in recovery and may even be less interested in recovery than I am.
3. How easy it is to turn to relationships and sex as a way to deal with pain e.g., regrets of past mistakes, lost relationships and jobs, mental health issues? Discuss this angle.
4. Pose this question for discussion: How can sex or a new relationship avoid the hard work of recovery? Can people avoid taking “a searching and fearless moral inventory of ourselves” (Alcoholics Anonymous 4th Step)? Looking at your life, whether in addiction or mental health treatment, can be a very hard thing to do.
5. Identify if certain mental health issues are contributing to such behavior e.g., unresolved issues with parents; or trauma or sexual abuse.
In other words, there is a whole “differential diagnosis” of what forming relationships and sexual behavior can mean. These are assessment and treatment issues to be opened up for the clients involved. There is also a rich opportunity for the other peers in the group to explore these issues for themselves for “there but for the grace of God go I.”
Consider what happens to treatment if the focus is on rules, consequences and discharge.
You can “prohibit” the exclusive relationship and sex, but are you also going to “prohibit”:
Treatment is not about us making people behave. It is about helping them make the right decisions in the dark of night when nobody is watching. If people do the right thing only when in our program, have we helped them to help themselves when we are not around? Have we facilitated a self-change process which enhances sustainable recovery? Or have we externally imposed compliant behavior that too easily falls away after “graduating” from treatment?
When is it appropriate to discharge people for their behavior?
A. There may be mandated clients who say they want treatment, but end up just “doing time”. They occupy and distract themselves by forming relationships and hooking up. They are not, in good faith, looking at the meaning of their behavior, the negative effects on their life and on others. Just sitting in a chair is not doing treatment. They are not choosing the work of treatment. At that point, you can talk about discharge.
B. If you ascertain someone is a sexual predator focused on disrupting treatment for themselves and others through forming relationships and hooking up, then discharge is appropriate. Why? Because you run a treatment place, not a dating place.
A friend and colleague recently said this:
“My mantra is, ‘this is the place where you don’t have to be at your best.’ If people are out of sorts or have a bad hair day, all the more material for the staff to work with.”
Andrea G. Barthwell, MD, FASAM
Oak Park, Illinois
If we expect people to behave and be at their best, then they probably don’t need treatment and have nothing important to change.
In June 2003, the 3rd edition ever of Tips and Topics, I wrote about “Discovery, Dropout” (D/D) prevention plans for people in early stages of change, those not yet interested in recovery. I also wrote about “Recovery, Relapse” (R/R) prevention plans for people at Preparation and Action for recovery. In 2015, you still find most treatment providers in general health, mental health and addiction treatment creating treatment plans which assume the client/patient is committed to recovery and relapse prevention.
(Aurel O Iuga and Maura J McGuire: “Adherence and health care costs”. Risk Management Health Policy. 2014; 7: 35-44. Published online 2014 Feb 20. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3934668)
What patients and clients actually need is a Discovery, drop-out prevention:
Consider these Sample Strategies for Treatment Plans
For more on Discovery plans, see SKILLS in the March 2006 edition.
Related past editions explain aspects of this too if you want to take a look:
Treatment Plan Strategies for Working on Relationships and Hooking Up
Referring back to Bob’s question: if the clients are interested in treatment, they will be willing to change their treatment plan in a positive direction using such strategies as:
Once you have done more assessment, there would be many other strategies that might fit better for this client. If they are willing to do this work, treatment continues. Don’t separate them or discharge them. Use the power of the group to implement these strategies.
Note of Caution:
You’ll notice that I define good faith working in treatment as “being open and willing to change their treatment plan in a positive direction.” Or as they say in AA “progress, not perfection”. We would like every person from Day 1, to be:
But if our clients and patients could do all that, they wouldn’t need our help in the first place! So if you have a notion to change their treatment plans by inserting: “Bob and Jane will end this inappropriate relationship and sexual behavior and focus on recovery” and then discharge Bob and Jane when they break their treatment plan, that is “perfection” not “progress”. It is not changing their treatment plan in a “positive direction”, it is expecting perfection and the final outcome immediately.
I just have to tell you my Medicare story. (So now you know I’m a senior citizen.) Last year when I joined Medicare, I was looking forward to that much lower monthly premium for health insurance…and yes, it was quite a bit lower. But then new notices came informing me that the bill was going to be higher because of my income. (So now you know I’m not a minimum wage senior citizen.)
I was OK with that, because I don’t mind contributing to the greater good if I can afford it. But then the amount I owed kept changing and I dutifully paid what the monthly invoice said. Here’s where the story gets interesting (or is a better word “frustrating”).
Time to call and talk to someone at Medicare. I called on a whim one night to see what hours they were open and amazingly you can talk to a “live” person- they are open 24 hours a day, 7 days a week. And it is not someone in the Philippines or India. Sounded like a regular ole American.
“Is there no way that I can go to a website, see my payments and what I owe, just like I do with my credit card, electric and phone bill etc.?”
“No, I’m sorry, we can’t even see that. I have to send a request to another department and they will call you to let you know where your account stands.”
“Could they not send me an email, because what if I miss their call?”
“Oh, well if they don’t reach you, they will send information in the mail.”
“You mean, regular snail-mail, not email?”
You get my drift. Now I think it is great that Medicare is open 24/7 and the hold time was very reasonable. BUT I spent at least a half an hour or more with people who receive more than minimum wage and nice government benefits only to find out that they can’t help me. The information I need will take much more time being spent by more government workers who will use last century’s methods to communicate with me.
I better stop here and recite the Serenity Prayer. But if any of you have the courage and wisdom to make government more efficient, please step forward. This old guy feels a bit hopeless.
Glad you could join us this month. See you in late August.
Vol. #13, No. 12
In this issue
David Mee-Lee M.D.
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
Hope to see you there.
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.”
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:
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.
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.
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.
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:
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.
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
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.
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
Email address: firstname.lastname@example.org
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.
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.
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
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
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.
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
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:
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.
Thanks for joining us this month . See you in late November with President Clinton or President Trump.
Welcome everyone to the July edition of Tips & Topics (TNT). Glad you could join us.
Thanks for joining us this month. See you in late August.