Vol. 13 , No. 4

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.

David Mee-Lee M.D.

SAVVY & STUMP THE SHRINK

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:

 

Question

Dr. Mee-Lee:

“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?”

 

TIP 1

Think about how you deal with emotional, behavioral and cognitive issues that are potentially disruptive to the group and treatment milieu.

 

My response

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:

  • A safe, therapeutic environment.
  • A therapeutic milieu which seeks to engage and attract people into an exploration of what has worked well for them before and what has not worked well.
  • An opportunity allowing clients to develop and practice new and healthier ways to deal with their behavioral health problems.  

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:

  • Meet people at the stage of change they are at. (What is the person at Action for? Identify their issues. Are they possibly still in a Precontemplation, Contemplation or Preparation stage of change?).
  • Help them self-identify and own the issues that keep “shooting themselves in the foot.” What behaviors are counterproductive to recovery and getting them what they want? Is it health and wellness? Maybe getting their children back? Getting off probation? Keeping a job? Retaining a relationship? Keeping their housing? Being sober and embracing recovery? Whatever it is that brought them to treatment- find it out.
  • Work compassionately with them to facilitate a self-change process using a collaborative, accountable treatment plan.
  • Fashion with them an updated treatment plan whenever progress stalls or new issues arise e.g., exclusive relationships and sexual behavior. The new strategies should move in a positive direction.

TIP 2

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.”  

 

TIP 3

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”:

  • Substance use and relapses (we still do this often and I have written before about discharging people for having the symptoms and signs of their addiction illness).
  • Angry outbursts.
  • Cravings to use with irritability and isolating behavior.
  • Disrespectful talking and interactions with peers and staff.
  • Hanging out with drug-using friends.
  • Telling war stories about drugs etc. etc.

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?

 

TIP 4

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.  

  • So you would be discharging them not because of bad behavior or breaking rules, but because they are not being open and willing to change their treatment plan in a positive direction. They have a right not to do treatment. As the clinician, you have a right to keep the treatment milieu therapeutic and “discovery” and “recovery”-focused.

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.  

  • Let’s say you determine a client’s behavior is part of their biopsychosocial-spiritual illness with implications for addiction, mental health and physical well-being. Then these are important treatment issues to pursue with further assessment and treatment. Do not discharge and hope you can just prohibit human behavior. If the person is willing to deal head on with this behavior and attitudes, then treatment is what they need. To discharge them for having problems to work on doesn’t fit my vision for treatment.

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

708-613-4750

www.twodreams.com

 

If we expect people to behave and be at their best, then they probably don’t need treatment and have nothing important to change.

SKILLS

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.

  • The doctor or nurse writes a prescription for the patient expecting adherence and healthy living. Actually medication non-adherence is widespread with rates ranging from 25% to 50%. Between $100 and $300 billion annually of avoidable health care costs in the US have been attributed to non-adherence.

(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)

  • Psychiatrists and mental health clinicians document problem #1 as “Psychosis” and problem #2 as “Medication Compliance” in the treatment plan.  However the patient thinks they are not mentally ill, it’s a conspiracy and the medication is poison and part of the plot. No wonder the patient doesn’t take their medication nor show up for sessions.
  • The addiction counselor documents strategies of abstinence, AA meetings and changing drug-using friends when the client simply just wants to cut back, hates AA and sees nothing wrong with his friends. No wonder he drops out of treatment.

What patients and clients actually need is a Discovery, drop-out prevention:

  • To discover for themselves (with our help) that what they are doing with their emotions, behavior and thinking is not getting them what they want.
  • We need to do all we can to prevent them from dropping out of services, so we have a chance to attract them into recovery.

TIP 1

Consider these Sample Strategies for Treatment Plans

  1. List three reasons the court sent you to treatment (D/D).
  2. Write down the most recent incidents involving alcohol and other drugs (D/D).
  3. Identify what happens if you don’t comply with probation requirements and report to group (D/D).
  4. List the positive and negative aspects of substance use (D/D).
  5. Attend at least one AA meeting and see if you can identify with anyone’s story (D/D).
  6. In group, verbalize what things need to change in your life or not (D/D).
  7. Discuss the positive and negative consequences of continued substance use (D/D).
  8. Explore early childhood history of violence through individual therapy once per week. Focus on what kind of role models the client had then, and how this affects relationships now (R/R).
  9. For the next incident of rage and anger, track it. Fill in the date, trigger, physiological signs and your behavior. Then discuss how you could have de-escalated the incident (R/R).
  10. In group, share what has been working to prevent relapse and obtain other suggestions (R/R).

For more on Discovery plans, see SKILLS in the March 2006 edition.

https://www.changecompanies.net/blogs/tipsntopics/2006/03 

 

Related past editions explain aspects of this too if you want to take a look:

February 2013

https://www.changecompanies.net/blogs/tipsntopics/2013/02 

 

November 2012

https://www.changecompanies.net/blogs/tipsntopics/2012/11 

  

TIP 2

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:

  1. Talk with a counselor about where relationships and hooking up has affected their life and addiction in the past. Share that in group to receive feedback.
  2. In group, explain what is so great about the new, exclusive relationship. Obtain feedback on whether this relationship will help, hinder or jeopardize recovery.
  3. Have a trial of staying away from the other person for a week. Then have each person in the relationship talk in group about what that experience was like.
  4. In group, talk about examples of past relationships and sexual behavior they got into quickly. Examine how that contributed to problems in their life, both addiction-related or not.  

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:

  • perfectly sober, with no cravings or impulses to use and no actual use
  • perfectly delaying gratification for relationships and hooking up and totally focused on recovery
  • perfectly non-depressed, non-psychotic; non-anxious; non-manic
  • perfectly non-angry, irritable and isolating
  • perfectly non self-mutilating, suicidal or impulsive etc. etc.

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.

SOUL

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”).

  • Invoices would come late with a due date that had already passed; or were so close to the date I received the bill, that it was bound to be delinquent.
  • You can’t pay online, so by the time snail-mail arrived, it was surely late, plus the three weeks it takes for their department to process the payment.
  • So now, each monthly invoice was showing either delinquent amounts owed and/or unprocessed payments I had already made.
  • Then I didn’t receive any invoices for two months. Had I already paid too much in advance, so they didn’t send me a bill? Or did it get lost in the mail? Or had I lost my Medicare? Who knows, because you can’t check your account and payments online – like every other business.

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.

  • Nice helpful man, but after 7 PM he can’t check the computer records to see what I owe or not. I could call back the next morning and then find out what I owed. But he did tell me I could sign up for Medicare Easy Pay where the payments would come directly out of my bank account. That sounds more like it in the 21st century.
  • But not so fast. He would have to mail me the form to fill out, and that could take 3 weeks; then it could take up to 8 weeks to process my application for Easy (or not so Easy) Pay. Faster, he said, to sign up with my bank for online payment directly.
  • Went to my bank website and in 5 minutes I had signed up and paid a couple months’ premium just to be sure I wasn’t behind. “I’ll check in the morning to see where my account stands”, I said to myself.
  • Next morning at the Medicare call center, there was a nice helpful lady and not a long wait to get to her either. However, she can see what premium I am being charged, but has to send a special request to another department to tell me whether my account is ahead or behind and what has happened to my monthly bills.

“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.

Until next time

Glad you could join us this month. See you in late August.

                           

David

Vol. 13, No. 8

To all in the USA, I hope you had a thankful and happy Thanksgiving and welcome everyone to the November edition of Tips and Topics. I’m glad you could join us this month.

 

David Mee-Lee M.D.

SAVVY

I have known Dr. Norman Hoffmann for over 30 years as a friend and colleague. Over the years of many presentations I have enjoyed and appreciated, Norm has shared quotes and quips that provide bits of wisdom as well as humor. Recently, as I listened again, I thought it was time to get some of those into print. So here a few of Norm’s favorites and what they mean.

 

TIP 1

Ponder these quotes and the wisdom they hold as told by Dr. Hoffmann.

 

1. “For every complex problem, there is a simple answer; and it’s wrong.” Attributed to H. L. Mencken.

  • So often people look for a simple answer, or fix, to complicated issues instead of a more comprehensive approach.

 

2. “The truth is rarely pure and never simple.” A line from the play, “The Importance of Being Ernest” by Oscar Wilde.

  • This is similar to the Mencken quote in that things are often more complex than we would like them to be.

 

3. “If your theory conflicts with folklore, recheck your theory.” This is a comment made by Paul Meehl during a graduate school seminar at the University of Minnesota.

  • Folklore is often based on observed associations. The folk explanation for the association might be fanciful, but the association is quite real.

 

4. “For the great enemy of truth is very often not the lie – deliberate, contrived, and dishonest; but the myth – persistent, persuasive, and unrealistic.” By John F. Kennedy in a commencement address at Yale.

  • Myths and misconceptions can often be more damaging than deliberate falsifications.

“Then there are a few for whom I do not know the originator or ones that I have adapted from some recollection.” Here they are:

 

5. “Left unchallenged our beliefs become our truths.”

  • All too often we may have a tendency to go with the myth that is comfortable rather than to consider the truth, which may be disquieting.

 

6. “If you torture a statistic long enough, you can get it to confess to anything.”

  • As one who reads the literature on addiction, I am often disturbed that the numbers underlying the conclusions do not seem to support the contentions of the authors.

 

7. “Beware of a theory that explains everything, but predicts nothing.”

  • One can often come up with any far-fetched idea to explain something, but it is not replicable or predictive.

 

8. Finally, there is my own favorite contribution: “A computer program can make a diagnosis when it is licensed for independent practice in your state.”

  • Too often I find people who want computers to do their thinking for them instead of examining the evidence and thinking for themselves.

 

TIP 2

Enjoy some vague terms often used in addiction and some fanciful definitions of Dr. Hoffmann.

 

1. “Heavy drinker”

  • Someone who weighs 250 lbs. and drinks.

 

2. “Problem drinkers”

  • People who spill more than they swallow.

 

3. “alcohol abuse”

  • Pouring water into good Scotch.

 

4. “Data is not the plural of anecdotes”

  • This addresses the issue of using memorable examples to support a position rather than actual statistics that might be quite different. (David Mee-Lee: Just because you have lots of examples and stories that support your views and perspectives, doesn’t mean you have valid research data.)

 

Norman Hoffmann, Ph.D.

President, Evince Clinical Assessments

E-mail: evinceassessment@aol.com

www.evinceassessment.com

 

Bio:

Dr. Hoffmann is a clinical psychologist who has evaluated behavioral health programs, provided consultations, and conducted trainings for over 35 years. He has worked with private organizations and governmental agencies in a variety of countries. Dr. Hoffmann has developed a number of assessments instruments used throughout the United States, as well as in Canada, Sweden, Norway, and the United Kingdom and authored or co-authored more than 190 publications. Take a look at some of Dr. Hoffmann’s work:

https://www.changecompanies.net/products/?servicearea=12

His faculty appointments include the University of Minnesota and Brown University. Currently he is President of Evince Clinical Assessments and adjunct professor of psychology at Western Carolina University.

SKILLS & STUMP THE SHRINK

Earlier this month, Ian Evans sent me the following message:

 

I was curious about slips when a client is in residential. Recently some programs we deal with have discharged clients who have drunk or used while on their pass. To me, it seems that residential treatment is the perfect place to deal with this issue. The client is in a structured environment, counselors they are familiar with, and in a treatment facility that can help them figure out what happened, why it happened, coping skills for the future, etc.

            I have heard various reasons why: it being unsafe for other clients, there being state guidelines that someone must be discharged if they use while in treatment, etc. I was curious not only your thoughts on this in general, but also if you are aware of any guidelines for residential facilities in these instances.

            I have reached out to the Department of Health Care Services as well, but to me it seems to make the most sense to allow someone to get treated in treatment rather than discharging and creating policies such as the client needs to check in and go to meetings every day for 2 weeks before they can come back to treatment.

Thanks,

Ian Evans MFTI #78016

Clinician I, Adult Forensic Care Team

Yolo County Department of Health Services, California

Work Cell: (530) 681-8165

Voicemail: (530) 666-8099 ext 1803

E-mail: Ian.Evans@yolocounty.org

 

TIP 1

Note how our attitudes and actions about substance use while in treatment does not fit with treating addiction as a disease.

 

Hi Ian:

Your concerns are what I have written and spoken about a lot. Here are some links to what I have written before. You should also look at Appendix B in the latest edition of The ASAM Criteria (2013) pp. 401-410 where we suggest an approach and policy and procedure on use while in treatment. If you don’t have the latest book, I suggest you get it. See www.ASAMCriteria.org for more information.

 

Here are some links. If the links don’t work, go to www.tipsntopics.com and click on the edition on the right hand side Archives:

 

A. Tips and Topics, July 2014:

  • In SAVVY of this edition, I wrote about the steps to consider when a person uses substances while in treatment.
  • In SKILLS, note what taking action means when a person uses while in treatment. It isn’t about discharging a person or transferring to a more intensive level of care.

https://www.changecompanies.net/blogs/tipsntopics/2014/07

B. Tips and Topics, October 2012:

  • In SAVVY of this edition, I wrote about how we don’t treat addiction flare-ups the same way we treat flare-ups of other illnesses like depression, schizophrenia, hypertension, bipolar or panic disorder.
  • I also referenced an interview with William Miller (Motivational Interviewing) who raises the question whether “relapse” is even a useful clinical term.

https://www.changecompanies.net/blogs/tipsntopics/2012/10/31/october-2012-tips-topics

 

 

C. Tips and Topics, November 2012:

  • In SAVVY, look at some alternative terms for “relapse” and try those on for size.
  • In SKILLS in this edition, here’s what to do when a client uses in residential treatment; when discharge is clinically reasonable and when it is not.

https://www.changecompanies.net/blogs/tipsntopics/2012/11/29/november-2012-tips-topics

 

 

D. Tips and Topics, June 2009:

  • In SKILLS, look at what to do when concerned that letting substance-using clients stay in treatment will trigger others and send a message that it is OK to use if there are no “consequences” for use.
  • Also see what to do when you get a poor outcome like a flare-up of use in an addicted client – assess and change the treatment plan like we do with other illnesses.

https://www.changecompanies.net/blogs/tipsntopics/2009/06

 

 

E. Tips and Topics, October 2004:

  • In SAVVY, I reference the constructs in ASAM Criteria Dimension 5, Relapse, Continued Use or Continued Problem Potential which first appeared in ASAM PPC-2R (2001) but is available in The ASAM Criteria (2013), Appendix B, pp. 401-410. These help you assess and treat flare-ups of addiction instead of discharging people.
  • Also in SAVVY, understand the difference between ASAM Criteria Dimension 4, Readiness to Change and Dimension 5.
  • In SKILLS, suggestions on what to do when a person arrives to a group having used alcohol or some other drug; and what to do if there is a positive drug screen.
  • Do clients in early stages of change, need relapse prevention strategies? See the answer in SKILLS.

https://www.changecompanies.net/blogs/tipsntopics/2004/10

 

 

F. Tips and Topics, September 2006 SKILLS section:

  • In SKILLS, look at “Things That Don’t Make Sense” and what to do about them. It will reinforce the suggestions of the previous editions above.

https://www.changecompanies.net/blogs/tipsntopics/2006/09

 

Hope this helps, but let me know if not.

David

 

TIP 2

In a follow up message, Ian raised a common State policy preventing clinicians from treating relapse and flare-ups as assessment and treatment issues.

 

BARCLAYS OFFICIAL CALIFORNIA CODE OF REGULATIONS

Health-Related Services.

Title 9 Section 10572 (e) that states:

 

“(e) No person, who, within the previous 24 hours, has consumed, used, or is still otherwise under the influence of alcohol or drugs as specified in section 10501(a), shall be permitted on the premises except for individuals admitted for detoxification or withdrawal. The licensee shall have specific written rules and policies and procedures to enforce this provision.”

https://govt.westlaw.com/calregs/Document/I49471470D45411DEB97CF67CD0B99467?viewType=FullText&originationContext=documenttoc&transitionType=CategoryPageItem&contextData=(sc.Default)

 

http://www.apartment-manager-law.com/data11/10572-Health.htm

 

Ian’s message:

It may be a huge question I am asking here, but do you see any way of working with the State to amend this so that if a client has a slip while on a weekend pass that they are not told they are discharged and must come back in 72 hours or 2 weeks like some programs do? There’s just something about discharging someone from residential treatment for slipping on a weekend pass and having them go back to the very environment they were using in before treatment that doesn’t sit well with me.

 

Thanks for your time,

Ian Evans

 

Perhaps you have similar regulations in your State or county. I have pledged to Ian that I will do what I can to raise this sticky regulation with the powers that be to start a conversation for change:

  • How can we combat the discrimination and stigma that addiction attracts even in our treatment system?
  • How we can we start treating addiction and flare-ups and poor outcomes the same way we treat other chronic conditions, instead of marginalizing clients and patients – discharging them and contributing to already high dropout and premature discharge rates?
  • What would it take to change attitudes of the general public, criminal justice and especially treatment providers in general health, mental health and addiction treatment to take addiction seriously as an illness needing care, not punishment, rejection, incarceration and discharge?
  • How can we begin to change policies, procedures and regulations to fit the disease of addiction rather concepts of willful misconduct and need for punishment?

Let’s start the conversation.

SOUL

I’m not really an avid sports fan (except maybe for the New England Patriots National Football League, NFL, team). I am much more interested in the psychology of sports than the actual mechanics of why a person or a team wins. So when I heard that the Golden State Warriors (the San Francisco Bay area National Basketball Association, NBA, team) were about to make history, it sparked my interest. Golden State was about to have the best regular season start (16 wins in a row) in the NBA’s 70-year history.

 

As I listened to the sports pundits and commentators opining on why Golden State was so successful, I was intrigued by their explanation and analysis, heard on San Francisco public radio station KQED’s Forum with Michael Krasny. If you are into sports and want to listen, here’s the link: http://www.kqed.org/a/forum/R201511230930

  • Often, when a team wins the NBA championship as Golden State did last year, players start getting inflated egos and entourages. Humility goes out the window. On this team, players have stayed humble and are “just having fun”.
  • A number of the players had been written off in the past as too small to be an effective player; or clearly not a top tier prospect; or late to the game and inexperienced. They all had something to prove and worked hard to debunk the critics. Even with their proven success, they are still “hungry” to win and while confident, are not complacent.
  • “Unselfishness” – Golden State, like other teams, have created success by unselfish play consisting of many “assists” and moving the ball around to all players on the floor. The goal was to score a basket: get the points as a team rather than each player trying to be the star, drive to the basket to get the points on their scorecard.

Humility, fun, hard work, confidence but not complacence, unselfishness and team work – sounds to me like a winning formula for life, not just basketball history.

 

You might be interested to know that the Patriots are one of only two teams out of 32 in the NFL to have a winning start to the season, unbeaten in 10 games so far. I wonder if that is because of humility, fun, hard work, confidence but not complacence, unselfishness and team work too? Some other teams accuse the Patriots of being arrogant and cheaters, but they’re just jealous.

 

Go Pats!

Until next time

Thank-you for joining us this month. See you in late December.

                              

David

Vol. 13, No. 8

To all in the USA, I hope you had a thankful and happy Thanksgiving and welcome everyone to the November edition of Tips and Topics. I’m glad you could join us this month.

 

David Mee-Lee M.D.

SAVVY

I have known Dr. Norman Hoffmann for over 30 years as a friend and colleague. Over the years of many presentations I have enjoyed and appreciated, Norm has shared quotes and quips that provide bits of wisdom as well as humor. Recently, as I listened again, I thought it was time to get some of those into print. So here a few of Norm’s favorites and what they mean.

 

TIP 1

Ponder these quotes and the wisdom they hold as told by Dr. Hoffmann.

 

1. “For every complex problem, there is a simple answer; and it’s wrong.” Attributed to H. L. Mencken.

  • So often people look for a simple answer, or fix, to complicated issues instead of a more comprehensive approach.

 

2. “The truth is rarely pure and never simple.” A line from the play, “The Importance of Being Ernest” by Oscar Wilde.

  • This is similar to the Mencken quote in that things are often more complex than we would like them to be.

 

3. “If your theory conflicts with folklore, recheck your theory.” This is a comment made by Paul Meehl during a graduate school seminar at the University of Minnesota.

  • Folklore is often based on observed associations. The folk explanation for the association might be fanciful, but the association is quite real.

 

4. “For the great enemy of truth is very often not the lie – deliberate, contrived, and dishonest; but the myth – persistent, persuasive, and unrealistic.” By John F. Kennedy in a commencement address at Yale.

  • Myths and misconceptions can often be more damaging than deliberate falsifications.

“Then there are a few for whom I do not know the originator or ones that I have adapted from some recollection.” Here they are:

 

5. “Left unchallenged our beliefs become our truths.”

  • All too often we may have a tendency to go with the myth that is comfortable rather than to consider the truth, which may be disquieting.

 

6. “If you torture a statistic long enough, you can get it to confess to anything.”

  • As one who reads the literature on addiction, I am often disturbed that the numbers underlying the conclusions do not seem to support the contentions of the authors.

 

7. “Beware of a theory that explains everything, but predicts nothing.”

  • One can often come up with any far-fetched idea to explain something, but it is not replicable or predictive.

 

8. Finally, there is my own favorite contribution: “A computer program can make a diagnosis when it is licensed for independent practice in your state.”

  • Too often I find people who want computers to do their thinking for them instead of examining the evidence and thinking for themselves.

 

TIP 2

Enjoy some vague terms often used in addiction and some fanciful definitions of Dr. Hoffmann.

 

1. “Heavy drinker”

  • Someone who weighs 250 lbs. and drinks.

 

2. “Problem drinkers”

  • People who spill more than they swallow.

 

3. “alcohol abuse”

  • Pouring water into good Scotch.

 

4. “Data is not the plural of anecdotes”

  • This addresses the issue of using memorable examples to support a position rather than actual statistics that might be quite different. (David Mee-Lee: Just because you have lots of examples and stories that support your views and perspectives, doesn’t mean you have valid research data.)

 

Norman Hoffmann, Ph.D.

President, Evince Clinical Assessments

E-mail: evinceassessment@aol.com

www.evinceassessment.com

 

Bio:

Dr. Hoffmann is a clinical psychologist who has evaluated behavioral health programs, provided consultations, and conducted trainings for over 35 years. He has worked with private organizations and governmental agencies in a variety of countries. Dr. Hoffmann has developed a number of assessments instruments used throughout the United States, as well as in Canada, Sweden, Norway, and the United Kingdom and authored or co-authored more than 190 publications. Take a look at some of Dr. Hoffmann’s work:

https://www.changecompanies.net/products/?servicearea=12

His faculty appointments include the University of Minnesota and Brown University. Currently he is President of Evince Clinical Assessments and adjunct professor of psychology at Western Carolina University.

SKILLS & STUMP THE SHRINK

Earlier this month, Ian Evans sent me the following message:

 

I was curious about slips when a client is in residential. Recently some programs we deal with have discharged clients who have drunk or used while on their pass. To me, it seems that residential treatment is the perfect place to deal with this issue. The client is in a structured environment, counselors they are familiar with, and in a treatment facility that can help them figure out what happened, why it happened, coping skills for the future, etc.

            I have heard various reasons why: it being unsafe for other clients, there being state guidelines that someone must be discharged if they use while in treatment, etc. I was curious not only your thoughts on this in general, but also if you are aware of any guidelines for residential facilities in these instances.

            I have reached out to the Department of Health Care Services as well, but to me it seems to make the most sense to allow someone to get treated in treatment rather than discharging and creating policies such as the client needs to check in and go to meetings every day for 2 weeks before they can come back to treatment.

Thanks,

Ian Evans MFTI #78016

Clinician I, Adult Forensic Care Team

Yolo County Department of Health Services, California

Work Cell: (530) 681-8165

Voicemail: (530) 666-8099 ext 1803

E-mail: Ian.Evans@yolocounty.org

 

TIP 1

Note how our attitudes and actions about substance use while in treatment does not fit with treating addiction as a disease.

 

Hi Ian:

Your concerns are what I have written and spoken about a lot. Here are some links to what I have written before. You should also look at Appendix B in the latest edition of The ASAM Criteria (2013) pp. 401-410 where we suggest an approach and policy and procedure on use while in treatment. If you don’t have the latest book, I suggest you get it. See www.ASAMCriteria.org for more information.

 

Here are some links. If the links don’t work, go to www.tipsntopics.com and click on the edition on the right hand side Archives:

 

A. Tips and Topics, July 2014:

  • In SAVVY of this edition, I wrote about the steps to consider when a person uses substances while in treatment.
  • In SKILLS, note what taking action means when a person uses while in treatment. It isn’t about discharging a person or transferring to a more intensive level of care.

https://www.changecompanies.net/blogs/tipsntopics/2014/07

B. Tips and Topics, October 2012:

  • In SAVVY of this edition, I wrote about how we don’t treat addiction flare-ups the same way we treat flare-ups of other illnesses like depression, schizophrenia, hypertension, bipolar or panic disorder.
  • I also referenced an interview with William Miller (Motivational Interviewing) who raises the question whether “relapse” is even a useful clinical term.

https://www.changecompanies.net/blogs/tipsntopics/2012/10/31/october-2012-tips-topics

 

 

C. Tips and Topics, November 2012:

  • In SAVVY, look at some alternative terms for “relapse” and try those on for size.
  • In SKILLS in this edition, here’s what to do when a client uses in residential treatment; when discharge is clinically reasonable and when it is not.

https://www.changecompanies.net/blogs/tipsntopics/2012/11/29/november-2012-tips-topics

 

 

D. Tips and Topics, June 2009:

  • In SKILLS, look at what to do when concerned that letting substance-using clients stay in treatment will trigger others and send a message that it is OK to use if there are no “consequences” for use.
  • Also see what to do when you get a poor outcome like a flare-up of use in an addicted client – assess and change the treatment plan like we do with other illnesses.

https://www.changecompanies.net/blogs/tipsntopics/2009/06

 

 

E. Tips and Topics, October 2004:

  • In SAVVY, I reference the constructs in ASAM Criteria Dimension 5, Relapse, Continued Use or Continued Problem Potential which first appeared in ASAM PPC-2R (2001) but is available in The ASAM Criteria (2013), Appendix B, pp. 401-410. These help you assess and treat flare-ups of addiction instead of discharging people.
  • Also in SAVVY, understand the difference between ASAM Criteria Dimension 4, Readiness to Change and Dimension 5.
  • In SKILLS, suggestions on what to do when a person arrives to a group having used alcohol or some other drug; and what to do if there is a positive drug screen.
  • Do clients in early stages of change, need relapse prevention strategies? See the answer in SKILLS.

https://www.changecompanies.net/blogs/tipsntopics/2004/10

 

 

F. Tips and Topics, September 2006 SKILLS section:

  • In SKILLS, look at “Things That Don’t Make Sense” and what to do about them. It will reinforce the suggestions of the previous editions above.

https://www.changecompanies.net/blogs/tipsntopics/2006/09

 

Hope this helps, but let me know if not.

David

 

TIP 2

In a follow up message, Ian raised a common State policy preventing clinicians from treating relapse and flare-ups as assessment and treatment issues.

 

BARCLAYS OFFICIAL CALIFORNIA CODE OF REGULATIONS

Health-Related Services.

Title 9 Section 10572 (e) that states:

 

“(e) No person, who, within the previous 24 hours, has consumed, used, or is still otherwise under the influence of alcohol or drugs as specified in section 10501(a), shall be permitted on the premises except for individuals admitted for detoxification or withdrawal. The licensee shall have specific written rules and policies and procedures to enforce this provision.”

https://govt.westlaw.com/calregs/Document/I49471470D45411DEB97CF67CD0B99467?viewType=FullText&originationContext=documenttoc&transitionType=CategoryPageItem&contextData=(sc.Default)

 

http://www.apartment-manager-law.com/data11/10572-Health.htm

 

Ian’s message:

It may be a huge question I am asking here, but do you see any way of working with the State to amend this so that if a client has a slip while on a weekend pass that they are not told they are discharged and must come back in 72 hours or 2 weeks like some programs do? There’s just something about discharging someone from residential treatment for slipping on a weekend pass and having them go back to the very environment they were using in before treatment that doesn’t sit well with me.

 

Thanks for your time,

Ian Evans

 

Perhaps you have similar regulations in your State or county. I have pledged to Ian that I will do what I can to raise this sticky regulation with the powers that be to start a conversation for change:

  • How can we combat the discrimination and stigma that addiction attracts even in our treatment system?
  • How we can we start treating addiction and flare-ups and poor outcomes the same way we treat other chronic conditions, instead of marginalizing clients and patients – discharging them and contributing to already high dropout and premature discharge rates?
  • What would it take to change attitudes of the general public, criminal justice and especially treatment providers in general health, mental health and addiction treatment to take addiction seriously as an illness needing care, not punishment, rejection, incarceration and discharge?
  • How can we begin to change policies, procedures and regulations to fit the disease of addiction rather concepts of willful misconduct and need for punishment?

Let’s start the conversation.

SOUL

I’m not really an avid sports fan (except maybe for the New England Patriots National Football League, NFL, team). I am much more interested in the psychology of sports than the actual mechanics of why a person or a team wins. So when I heard that the Golden State Warriors (the San Francisco Bay area National Basketball Association, NBA, team) were about to make history, it sparked my interest. Golden State was about to have the best regular season start (16 wins in a row) in the NBA’s 70-year history.

 

As I listened to the sports pundits and commentators opining on why Golden State was so successful, I was intrigued by their explanation and analysis, heard on San Francisco public radio station KQED’s Forum with Michael Krasny. If you are into sports and want to listen, here’s the link: http://www.kqed.org/a/forum/R201511230930

  • Often, when a team wins the NBA championship as Golden State did last year, players start getting inflated egos and entourages. Humility goes out the window. On this team, players have stayed humble and are “just having fun”.
  • A number of the players had been written off in the past as too small to be an effective player; or clearly not a top tier prospect; or late to the game and inexperienced. They all had something to prove and worked hard to debunk the critics. Even with their proven success, they are still “hungry” to win and while confident, are not complacent.
  • “Unselfishness” – Golden State, like other teams, have created success by unselfish play consisting of many “assists” and moving the ball around to all players on the floor. The goal was to score a basket: get the points as a team rather than each player trying to be the star, drive to the basket to get the points on their scorecard.

Humility, fun, hard work, confidence but not complacence, unselfishness and team work – sounds to me like a winning formula for life, not just basketball history.

 

You might be interested to know that the Patriots are one of only two teams out of 32 in the NFL to have a winning start to the season, unbeaten in 10 games so far. I wonder if that is because of humility, fun, hard work, confidence but not complacence, unselfishness and team work too? Some other teams accuse the Patriots of being arrogant and cheaters, but they’re just jealous.

 

Go Pats!

Until next time

Thank-you for joining us this month. See you in late December.

                              

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…)

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…)

July 2012 – Tips & Topics – july-2012-tips-topics

Vol. 10, No. 4 July 2012

Thank-you for joining us for the July edition of Tips and Topics (TNT). For all our readers in the Northern Hemisphere, hope you are having some summer fun. For our readers way further south….stay warm.

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…)

March 2011 – Tips & Topics – march-2011-tips-topics

TIPS & TOPICS
David Mee-Lee, M.D.

Volume 8, No. 11
March 2011

In this issue
— SAVVY – The METHODS method for discharge planning
— SKILLS – RCA ceremonies – The new treatment completion Graduation?
— SOUL – Always the right answer

— STUMP THE SHRINK – Medical necessity, ASAM PPC and what levels of care?
— Until Next Time

Welcome and thanks for joining us for the March edition of TIPS and TOPICS (TNT).

(more…)

April 2007 – Tips & Topics – april-2007-2

TIPS & TOPICS
Volume 5, No.1
April 2007

In this issue
— SAVVY
— SKILLS
— SOUL
— STUMP THE SHRINK
— Until Next Time

Welcome to the start of the fifth year of publishing TIPS and TOPICS. The first edition hit cyberspace in April 2003. You can see all previous editions and print them out from the website.

(more…)

June 2003

Vol 1, No.3 | June, 2003
In this issue


SAVVY | SKILLS | SOUL | SUCCESS STORIES

David Mee-Lee M.D.


SAVVY

There is one assessment dimension of the Revised Second Edition of the Patient Placement Criteria of the American Society of Addiction Medicine (ASAM PPC-2R) that potentially has the greatest impact on how we assess, refer and treat people with substance use and mental health problems. It is Dimension 4 – Readiness to Change. In our field, there is increasing interest in strength-based, client-centered, consumer-driven, customer-focused services that empower clients who come to us to use their own (and community) resources to enhance recovery.

Despite the rhetoric of person-centered services, unfortunately clinicians’ attitudes, knowledge and skills too often create services that are clinician-centered, not client-centered. Many programs and services are designed and dominated by program ideology, referral-source mandates, and funding guidelines. What the client, patient, person, consumer or customer wants- and even needs- are a long second, third or even sixth place concern.

Tips:

  • Many of you are already well versed in Stages of Change models and motivational enhancement strategies. But in case you are not, Procahska and DiClemente’s Transtheoretical Model would be a good place to start.

Here are a few references for that:

Prochaska, JO; Norcross, JC; DiClemente, CC (1994): “Changing For Good” Avon Books, New York.

Prochaska, JO (2003): “Enhancing Motivation to Change”, Chapter 1 in Section 7, Behavioral Interventions in “Principles of Addiction Medicine” Eds Graham AW, Schultz TK, Mayo-Smith MF, Ries RK, Wilford BB, Third Edition. American Society of Addiction Medicine Inc., Chevy Chase, MD.

Prochaska, JO; DiClemente, CC and Norcross, JC (1992): “In Search of How People Change: Applications to Addictive Behaviors” American Psychologist, 47, 1102-1114.

  • People in the Preparation or Action stage are ready to change and are actively doing something about it. They really want to be free of the power of substance and mental health problems over their life. They seek recovery. They also want to prevent relapse into drinking or drugging. They want to stop behaviors like cutting himself/herself, or be free of depression or psychosis. By all means, help them develop a recovery, relapse prevention plan.

However, if the person presents for assessment because they want to stay out of jail, keep their job or their family, treatment is definitely warranted. But, the individual may first need to discover that s/he has a substance use and/or mental health problem before ever being interested in preventing relapse or getting into recovery. In other words, he/she needs a “discovery”, dropout prevention plan; not a recovery, relapse prevention plan! And there is a big difference between the two plans.

  • If you want to educate yourself on the science and skills behind the importance of more person-centered services, check the work of Scott Miller, Ph.D. and his colleagues at The Institute for the Study of Therapeutic Change, www.talkingcure.com. They review decades of outcomes research on how people change. You may be disturbed, yet illuminated on what they find. William Miller, Ph.D. of Motivational Interviewing is the other Miller you will want to read more about.

SKILLS

Every day we face pressures for efficiency, accountability, documentation and performance. It can feel like we do not have the luxury to assess and treat a person’s readiness to change. The courts, child protective services, employers and welfare-to-work can only give so much time for a chance at treatment.

There is a lot of pressure from referral sources to assign a person to a set program that expects quick results in a 30 day, 60 day or 12 month program. Is it really practical to ask a client what they want? Is it feasible to provide services individualized around a participatory treatment plan matched to their particular stage of change? These are dilemmas and hard questions. However the outcomes research data and our clinical “gut” tell us that unless the individual is an active participant in treatment, we are unlikely to really help them to change. We want them to do treatment, not time. We want them to have lasting results in public safety, good parenting, productive employment and social independence.

Tips:

  • If you ask a person “How can I help you? What do you want help with?”- do you really mean it? They may say something like “I want to be clean and sober”, but were just referred by the probation officer or employer. What they really want may be a letter and to stay out of jail or to keep their job; not serenity and sobriety one day at a time. Dig more deeply. Create a therapeutic alliance around what the person really wants, not what they think you want to hear or what you think they should want. Again, they may first need a “discovery”, dropout prevention plan; not a recovery, relapse prevention plan. If you already have a set program and treatment agenda that you are unwilling to adjust, better not to ask them what they want. If you do ask, they might actually want you to listen to what they say!
  • 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”.

A recovery, relapse prevention plan may have strategies like:
>>”Go to an AA meeting to get two names and numbers and to find a sponsor”. or
>> “Develop your plan on how not to be late. Ask your group for feedback on how to improve the plan”.

Can you can see the distinction between “discovery” and “recovery” strategies?

  • A treatment plan in which a client participates actively solicits the clients’ ideas on the problem and the solution. People often have strong ideas about what they think will work, or what they will or won’t do.
  • For example: “I don’t want to be in groups, or go to AA, or take medication, or go to residential”.

You can respond several ways.

Response #1: “Do it or else you won’t get your letter”. Or “That’s the program” (and I have a bigger stick than you).
Response #2: You can educate them on the wisdom of your recommendations. If they understand and accept your views, fine. If they remain ambivalent or unconvinced, you may need to start with their plan. If their plan is imminently dangerous, this society allows us to override a person’s opinions and rights.

If dangerousness is not a concern, I’d recommend you start with a treatment plan that only includes strategies the person wholeheartedly agrees to do. This will increase both personal effort and accountability.

A SPECIAL NOTE:

I am pleased to announce the release of a Training Album on this topic I have been discussing.
The training module is titled “Enhancing Motivation: How to Engage People into Addictions Treatment”. This album contains a CD, Videotape and Companion Guide. Read more about it at the link below.

Click here for a time-limited, special introductory offer!

SOUL

Last summer, my family had the privilege of traveling in France, Spain and Italy. Everywhere we went, we continued to be surprised again at how widespread cigarette smoking still is in Europe. As a California resident, (where smoking is not allowed in bars, restaurants and many public places) I was reminded how different cultures and attitudes can be.

A couple of weeks ago, I was in Washington, DC., invited to address a joint European Union/USA meeting on treating the difficult patient at the Office of National Drug Control Policy. The night before, I walked into the hotel sports bar for a light dinner. The place was filled with smoke. I had to quickly move to the less atmospheric, but smoke-free lobby lounge. I was surprised to see how different the culture and attitudes can be – even in the USA.

In the meeting, we compared and contrasted the Europeans’ approach to demand reduction with that of the United States. I was struck again how different we are in culture, attitudes, perspectives and solutions. (Have you ever visited an injection clinic where you can shoot up so long as you bring your own drugs? Clean needles and hygienic clinic supplied!)

It is easy to argue and fight with righteous indignation for the causes and concepts we firmly believe. We should not shrink from standing for what we believe is right. But you don’t even have to travel to Europe, or from California to Washington, DC to face attitude and culture differences. Just notice if the next client or team member agrees with everything you assess or recommend.

What I want and what “the other” wants can often be as different as a smoke-filled room and a crisp, clean morning in Yosemite. Increasingly I want to find effective and efficient ways to achieve results together. Counselor to client. Team member to team member. Care provider to care manager. Administrator to advocate.

It starts with me. Was it Gandhi who said: “Be the change you wish to see in the world”?

SUCCESS STORIES

In the “Skills” section of the first edition of TIPS and TOPICS, I discussed how to organize and present assessment data using the structure of the six ASAM PPC-2R assessment dimensions. One workshop attendee and unofficial supervisee has persevered to discipline himself to stay focused on the client and the assessment.

About his presentations to managed care, he writes this: “My denials from Managed Care Organizations have dropped to almost none. I am able to present myself more cogently, briefly and to properly present the criteria to ensure proper treatment. I have been complimented on my presentation by insurance company reps.” – Paul Herman, M.Ed., Evaluation Therapist, for a large treatment program with multiple levels of care.

Maybe there’s hope we could end the game-playing between providers and managed care companies. Maybe providers can prevent the impulse to exaggerate severity to get authorization of care – e.g., the patient is suicidal. Maybe care managers can resist the reaction to minimize severity; or resort to blanket statements like “it doesn’t meet medical necessity”. I wonder if we could ever start managing care- all of us? It could start with how we organize and present the assessment data.

Until next time

Send us any comments or Success Stories on implementing any of the TIPS and TOPICS. Send any questions to Stump the Shrink. (Tell me how much identifying data you are comfortable with my sharing here.)

All the best…

David

P.S. Time is running out to be part of a select group in a 3 day “Supervisor Intensive”, train-the-trainers workshop in Davis, CA July 30-August 1, 2003.

Learn more about the Supervisor Intensive. Click here.

July 2003 – Tips & Topics – july-2003

TIPS and TOPICS
Vol 1, No.3
June 2003

In this issue
– SAVVY
– SKILLS
– SOUL
– SUCCESS STORIES
– Until next time……

WELCOME!

Thank-you for taking the time to read this third edition of TIPS and TOPICS. If you are receiving this for the first time, the April and May editions are on my website. Certainly feel free to forward TIPS and TOPICS to others who may be interested.

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October 2004 – Tips & Topics – october-2004

TIPS & TOPICS 
Volume 2, No. 6
October 2004

In this issue
– SAVVY
– SKILLS
– SOUL
– STUMP THE SHRINK
– Until Next Time

Welcome readers!

I want to welcome the very large number of new subscribers to TIPS and TOPICS in September- October! You’ll quickly get the gist of the “S” format. When ever any of you have a question or comment, email me. It may be included in “Stump the Shrink.”

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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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