December 2004

Volume 2, No. 8
In this issue


SAVVY | SKILLS | SOUL | SUCCESS STORIES

David Mee-Lee M.D.


SAVVY

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

Tips:

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

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

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

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

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

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

Question checks:

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

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

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

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

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

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

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

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

SKILLS

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

Tips:

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

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

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

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

Question Checks:

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

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

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

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

Question Checks:

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

SOUL

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

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

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

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

SUCCESS STORIES

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

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

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

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

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

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

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

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

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

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

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

Thanks again,

John Gonzalez
Washtenaw Community Health Organization
Ypsilanti, Michigan

Until Next Time

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

David

What are therapeutic communities (TC) today?

Vol. 10, No. 11

In This Issue
  • SAVVY : What are therapeutic communities (TC) today?
  • SKILLS : How to individualize treatment in TCs
  • SOUL : Celebrating ten years
  • SHARING SOLUTIONS : See the movie and read the book

Welcome to the February edition of Tips and Topics. We are approaching the tenth anniversary of Tips and Topics in April, so check out SOUL of this edition for a special request I have of you.

David Mee-Lee M.D.

SAVVY

In 1976, I was still in my specialty psychiatric training in the Boston area. I completed two rotations, which had a long-lasting impact on me.

–> One was a weekly visit to a traditional Synanon-style therapeutic community (TC) with its attacking, confrontive peer group therapy. The “no language barred” style seemed like every second sentence was “f… you this” and “f…you that.” There was the belief that personal humiliation was needed in order to receive the well-meaning feedback from ones’ peers. Clients in the TC were made to wear signs around their neck saying such things as “I’m stupid” or “I’m arrogant”. People were sometimes made to clean the floor with a toothbrush, or shave their head for some infraction of the rules.

Perhaps back then, I was naïve about the ravages of heroin use and other drug street addiction and its effects on hardening the defenses of the addicted. However I still believe the attacking counseling style was abusive, guilt-enhancing, and an affront to each client’s personal dignity.

–> My second training opportunity was on the Behavior Therapy Unit (BTU). Here there was no confrontive yelling or humiliating techniques, just the initial defining Behavioral Analysis. This determined what rewards and reinforcers would be constructed to modify the client’s specified target behaviors in the BTU’s token economy system of behavior modification.

So what has this got to do with treatment programs in 2013? 1976 was last century!

We’ve come a long way from the attacking, “no language barred,” confrontive Therapeutic Community model. There are not many pure behavior therapy token economies left either. However… many modified strands of those original models shape current residential programs, especially in adolescent and criminal justice treatment.

In therapeutic communities, especially in criminal justice treatment settings, a predominant belief is: The way to arrest addiction is through retraining the individual’s thinking, to make better decisions on using drugs. This approach relies almost exclusively upon behavioral theories and techniques, versus any other theoretical model.

 

TIP 1

Of those earlier models, note what features have been modified and are being used in today’s therapeutic communities.

Then
Milieu therapy: “Patients are encouraged to take responsibility for themselves and the others within the unit.” (Wikipedia) This typifies therapeutic communities, where trust is built through an attitude of ‘we are all in this together ‘to help each other. Peer support and confrontation are central to milieu therapy.
Now
This milieu therapy approach still seems to apply today in most programs.

Then
Heavy confrontation and verbal attacks, with a good dose of profanity and humiliation, were not uncommon in the old TC model.
Now
Counselors and peers no longer verbally attack and humiliate clients. Usually there is a “no profanity allowed” and no “drug talk” war stories approach. However a central part of the treatment culture is for peers and counselors to issue corrective reminders of rule violations or unacceptable behavior, sometimes called “pull-ups” or “write ups”. There are various consequences, which affect a client’s movement through phases of the program. These write-ups can delay “graduation” and treatment completion. Confrontation and Encounter groups still continue in some therapeutic communities.

Then
In the past in some programs, clients were expected to do significant unpaid work for the program.
Now
Unpaid work for the program is no longer allowed. However there is still a value put on physical health, activity and work. There is still an emphasis on sharing chores and maintaining clean, tidy, and orderly living spaces.

Then
Traditional therapeutic communities emphasized separation from clients’ old lives and environment and entering into the safe community of the program for long periods.
Now
Today there is less of that in terms of length of stay and degree of isolation from the “outside” world. Some elements of previous methods still do remain though: limited phone calls, limited contact with friends and family; earning of privileges for passes and outings based on behavior and compliance with rules and regulations; restriction of family visits.

Both Then & Now
Compliance with program goals, rules and norms remains a major focus of treatment. Clients’ status, level or phase in the program is based upon their accomplishments within the therapeutic community.

  • They must complete various therapeutic tasks and assignments common to all clients.
  • They must demonstrate a quality and degree of participation in the groups and therapeutic milieu.
  • They must show changes in attitudes and behaviors. Movement through treatment is based on compliance with program tasks and responsibilities and the individual’s adherence to rules and norms.
  • This is reinforced by the use of contingencies (privileges, learning experiences, earned incentives, and sanctions.)

Both Then & Now
The tradition of peer role models remains part of the therapeutic process. Clients are expected to demonstrate consistent compliance with rules; supportiveness to peers and staff; leadership skills and a positive, no “drug talk” war stories attitude. Self-help and mutual-help group sessions remain central to a “people helping people,” “all in this together” culture of healing and wellness.

There is much from the past to be valued. Effective, relevant elements from past models should be continued but modified for today’s programs. Even so, some unintended negative consequences work against change that is positive, lasting and accountable.

Overemphasis on compliance to program rules, norms and assignments overshadows a person-centered, assessment-based, outcomes-driven approach. Lasting change is then compromised.

*The challenge*
How do we integrate individualized and tailored treatment plans into a therapeutic community, preserving all that is good, but modifying elements of past models?

SKILLS will begin to address this challenge.

Reference:
Warren K, Hiance D, Doogan N, De Leon G, Phillips G (2013): “Verbal feedback in therapeutic communities: pull-ups and reciprocated pull-ups as predictors of graduation”Journal of Substance Abuse Treatment Vol. 44, Issue 4 , Pages 361-368, April 2013.

SKILLS

So if the research on integrated and collaborative care is compelling, why are some -perhaps many- physicians, clinicians and counselors suspicious and even antagonistic to these changes in health care?

There are aspects of modified Therapeutic Communities that work against outcomes-driven individualized treatment:

—> Because a therapeutic community approach relies almost exclusively upon behavioral and social learning models and techniques, other evidence-based practices do not mesh well.

  • How does a program integrate Motivational Interviewing and Stages of change work if all clients are expected to do the same clinical assignments regardless of their stage and readiness to embrace recovery?
  • How do you use Integrated Dual Disorders Treatment for a person with a mood disorder, if there are sanctions or write-ups when there is an emotional outburst?
  • How do you decide if one client gets psychotropic medication for their mood swings and behavior, while another peer is confronted and gets a write-up?

—> A client may not be progressing well. Mental health issues with more complex treatment needs may not be responsive to behavioral methods.

  • In a therapeutic community, all clients are expected to comply with certain universal tasks and meet behavioral expectations. How does a program deal with more complex clients incapable of doing these at the same pace as others, or who may even be incapable of compliance?
  • How do counselors individualize expectations for particular clients in a treatment culture that relies on peer confrontation where everyone is expected to comply?
  • How do you individualize treatment without peers feeling that “if he doesn’t have to do it, why do I?” and upset that a peer is receiving special treatment and exceptions from the rules and norms?

TIP 1

Review these dilemmas in Therapeutic Communities. Consider these solutions to move to individualized treatment.

1. Early Phase/Level Expectation
In order to achieve and maintain the first level in the program, one task to complete is to list 10 costs and benefits of substance use in your life.

Clinical Dilemma:
What if a client is at Action for completing probation, but at Precontemplation about substance use and sees nothing wrong with his/her use? In order to get through the program and get off probation s/he will comply with the task- to talk about the costs of substance use. But how is this promoting honesty?

A Solution to Individualize Treatment:
Ask your client to share: “What brings you here? ” “What do you want to get from the program?” This could be done in an individual session or in a “What do I want?” group where the group leader helps each client state honestly why they came to treatment. “I want to get off probation, but I don’t have a drug problem, it wasn’t even my stuff.” Or “I just want to get my kids back and don’t have a parenting or alcohol problem.”

2. Behavioral Infractions
Because of an angry exchange with staff, the client was written up with an LOP (Loss of Privileges); and required to write a 1,000 word essay on managing anger.

Clinical Dilemma:
When there are structured policies and procedures for certain behavioral infractions -e.g. LOP and 1,000-word essay, it is easy to avoid an individual assessment of the outburst and to tailor the treatment response. Yet a more tailored treatment response may actually be needed and clinically indicated. For example, a client may learn better by role-playing in group an angry situation rather than writing an essay. Another example: A client may be angry after an upsetting phone call with his wife. Counseling on how to plan for a family meeting is what is needed, not writing an essay. Another example: If the patient’s medication is not stabilized, that may be the priority, not an essay.

A Solution to Individualize Treatment:
Train staff on how to de-escalate behavior. Train them how to assess, with the client (at the time of the behavior) what is going on and what the communication difficulty is about. Focus then on helping the client to express negative emotions in ways that are effective in getting their needs met. This can involve cognitive behavioral therapy (CBT) and TC methods of “learning experiences”. Thus the emphasis is on treatment and change, not on write-ups and consequences for behavioral infractions.

3. Evaluating Progress in Treatment
With a levels system, movement through the program is measured by compliance with program tasks. By contrast, individualized treatment evaluates progress by how well the client improves in the problems identified in the assessment. In some systems, clients even wear color labels to indicate what level they are at. Such a culture and mindset is too focused on levels and tasks, not on each person’s specific treatment plan.

Clinical Dilemma:
A “levels” system directs the client’s attention to compliance to tasks. But we want their energy directed toward resolving their unique combination of obstacles to their recovery. We work with them to apply their personal strengths, skills and resources to advance recovery.

Check where your client’s attention is by asking: “Tell me about your treatment plan and what you want to get out of group today to advance your treatment plan? I am asking about your treatment plan, not what level you are in the program, nor what you have to do to avoid loss of privileges or to move to the next level.”

A Solution to Individualize Treatment:
Consider eliminating color tags or other labeling mechanisms used to identify the phase a client is at in the program. Develop new clinical skills to gradually replace any old methods of a TC model that no longer promote individualized, outcomes-driven treatment. Focus clients and staff on evaluating client function, stages of change, and progress of assessment-based goals, not program-driven tasks and goals.

4. Late Phase/Level Expectation
In order to achieve and maintain a more advanced level in the program, a client generally must demonstrate certain skills: leadership in groups, show leadership by following rules, helping staff voluntarily, aiding in maintaining order in group, and providing honest feedback.

Clinical Dilemma:
Clinical example: The client is the oldest of three children of alcoholic parents. He was always the “hero” who rescued his younger siblings, putting aside his own needs. In the program he takes on a role almost like junior assistant counselor, more focused on giving feedback to others than on getting in touch with his own needs. What if his individualized treatment plan needs for him to NOT be a leader; NOT be always helping others and giving them feedback?

A Solution to Individualize Treatment:
Consider changing the program culture to one where:

  • Each client is the one most familiar with, and responsible for the success of their treatment plan.
  • Each person then shares that plan with peers. He/she uses the therapeutic community as a safe and supportive place to take responsibility for trying out new ways of thinking, being, behaving and relating.
  • Each person indicates what help they need each day, perhaps a role play to handle anger better, or feedback on how to ask for help- whatever is in their particular treatment plan.
  • Progress through treatment is based on outcomes of the tailored treatment plan rather than compliance with program milestones and levels.

Bottom Line
Perhaps you are someone involved in a TC model. What is your level of interest in changing your program…or not?!

If you are not involved in a TC model, what can you do to raise consciousness about these issues for your colleagues in such programs? Many have been set on the road to recovery in therapeutic communities, so how do we preserve all that is good? How do we modify what would make them even better?

“No single treatment is appropriate for everyone. Matching treatment settings, interventions, and services to an individual’s particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace and society.”– Principle No. 2 in National Institute on Drug Abuse: Principles of drug addiction treatment: a research-based guide (NIH Publ No 09-4180). Rockville, MD: National Institute on Drug Abuse, 2009.

 

SOUL

In April, Tips and Topics (TNT) is having a birthday, turning ten years old. I’m not usually one for big anniversary celebrations. But ten years of monthly newsletters emailed to over 8,000 addresses is no small feat. And those addresses didn’t come from some purchased mailing list either. Workshop attendees, colleagues and friends of participants signed up voluntarily over the past decade.

But this is February, so why am I talking about an April edition tenth anniversary?

Tips and Topics has been my gift to you. To help celebrate, I thought I would ask a gift of you.
No, I’m not asking for money donations or an engraved plaque. It would be fun (and informative to me) to hear what you appreciate about Tips and Topics. You can even slip in a suggestion or two on what you would like to see more of, less of, or different from what we have presented to you each month.

In the tenth anniversary edition, we’ll publish some of your “appreciation gifts” to celebrate together. Now maybe all you have time to do is shoot back an e-mail that says “Great job!” or “Love getting TNT every month” (I am assuming you’ll spare me any hate mail for the April edition). On the other hand, if you can take a little more time and effort to express appreciation, check out SKILLS in the March 2010 edition where you are guided through a more powerful way to express appreciation in your life.
http://www.changecompanies.net/tipsntopics/2010/03/

Perhaps there was a particular edition of a SAVVY, SKILLS, SOUL or STUMP THE SHRINK section especially meaningful or memorable for you. Please tell me what it was and in which edition. (You can see all ten years of TNT at The Change Companies www.changecompanies.net and click on Blogs.)

Thank-you for reading TNT. And to the many of you who have already taken the time to write and express appreciation over the years, thanks. Over the next month, I look forward to hearing from you, if you are moved to write something for the 10 year celebration of Tips and Topics.

P.S. Let me know how you want to be identified or not.

SHARING SOLUTIONS

Motivational Interviewing DVD

If you haven’t yet read the new third edition of Motivational Interviewing (2013), you can get the “movie” first. It didn’t win an Academy Award, but maybe next year!

Drs. William R. Miller, Theresa B. Moyers and Stephen Rollnick walk you through the concepts and practice of Motivational Interviewing.

It is based on the revised and updated Motivational Interviewing, 3rd Edition (2013) by Drs. William R. Miller and Stephen Rollnick. The video provides over 6 hours of material, introduces the new four-process method of Motivational Interviewing, and includes downloadable resources. (Available in 2-DVD set, streaming Web version, or a bundle that includes both formats).

Features:

  • Discussion with the authors
  • Interview demonstrations with annotated transcripts
  • Detailed menu of topics
  • Interview commentary

Learn More athttp://www.changecompanies.net/motivational_interviewing.php

Until next time

I am glad you could join us this month. See you in late March.
David

Vol. 11, No. 4

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

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

David Mee-Lee M.D.

SAVVY

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

I promised to share readers’ suggestions.

Here are three and some editorial comments:

 

Reader #1
Hi Dr. Mee-Lee:

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

 

Regards,

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

 

–> Comment from David Mee-Lee

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

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

 

Joan Zweben, Ph.D.

Berkeley, CA

 

–> Comment from David Mee-Lee

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

 

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

 

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

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

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

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

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

 

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

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

SKILLS

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

 

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

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

 

 

TIP 1

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Client: Sure, go ahead.

 

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

 

Client: I guess I could do that.

 

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

 

 

And for the depressed client:

 

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

 

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

 

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

 

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

 

Clinician: Have you taken medication before? (Following)

 

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

 

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

 

Client: What do you mean?

 

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

 

Client: I’d rather take medication.

 

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

 

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

 

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

 

 

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

 

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

 

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

SOUL

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

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

 

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

 

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

 

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

 

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

We ask: “Where should we go next?”

Well where would you like to go?”

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

“Well they are both interesting.”

“So what would you recommend?”

“You want me to decide for you?”

 

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

 

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

 

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

Until next time

Thanks for reading. See you in late August.

David

Vol. 11, No. 7

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

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

David Mee-Lee M.D.

SAVVY

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

 

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

 

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


TIP 1

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

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

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

Common Case Scenario

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

 

 

*Level 1, Outpatient Services

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

 

*Level 3, Residential Services

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

Level 3.1. Clinically Managed Low Intensity Residential

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

 

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

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

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

 

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

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

TIP 2

Broaden your perspectives on addiction treatment

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

Tobacco Use Disorder

Gambling Disorder

 

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

 

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

 

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

 

 

TIP 3

Apply the criteria to special populations

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

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

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

—-clients in criminal justice settings.

 

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

 

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

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

SKILLS

TIP 1

Cultivate interdisciplinary relationships with other health systems

Here are the facts:

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

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

 

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

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


TIP 2

Learn how to manage care yourself

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

 

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

 

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

2. Which ASAM Criteria dimensions do they belong to?

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

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Learning to manage care yourself means:

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

SOUL

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

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

 

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

 

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

 

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

 

Then I think of Malala Yousafzai.

SHARING SOLUTIONS

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

Until next time

See you again in late November.  Thanks for reading.

David

Vol. 11, No. 9

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

David Mee-Lee M.D.

SAVVY

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

 

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

 

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

 

TIP 1

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

 

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

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

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

 

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

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

 

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

 

TIP 2

Review the DSM-5 criteria for Tobacco Use Disorder.

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

 

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

References:

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

 

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

SKILLS

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

 

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

 

TIP 1

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

 

Case 6 (page 391) 

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

 

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

 

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

 

 

TIP 2

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

 

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

 

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

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

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

Reference:

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

SOUL

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

 

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

 

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

 

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

 

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

 

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

 

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

SHARING SOLUTIONS

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

 

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

 

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

 

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

 

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

Until next time

Happy New Year and see you again in late January.

 

David

Vol. 12, No. 5

Welcome to all the new readers of Tips and Topics and to all our longtime readers as well. Thanks for joining us for the August edition.

David Mee-Lee M.D.

SAVVY

I recently was in a rush and jumped in the car to get to an appointment. Once on the road, I reached down to my cell phone belt holder and realized I had left my cellphone on my desk at home. I noticed a little twinge of panic…..somewhat like when you suddenly realize your wallet, with all your money and credit cards, is not in your pocket. Have I dropped it? Did I leave it on the store counter?

 

But this is just my mobile phone. I know where it is. If I miss a call or a text, my voice mail and the message will still be there. So no big issue…right? Well it is worth taking a look at your own reactions if you find yourselves without your mobile device or smartphone. Or, even if you have it with you, what is your usual behavior?

  • Can you sit alone at a restaurant, bus stop or airport departure gate without picking up your phone to check messages or email?
  • For that matter, can you sit anywhere even with friends, partners and loved ones and not look at your phone’s screen?
  • Even if you don’t look at your phone, look around. Observe how many people have heads down, fingers tappingthe little screens on the device cupped in their hand.

A group of young, passionate, mission-driven young adults has recently been challenging the relationship we have with our digital devices.  Take a look at what “digital detox” is all about at http://thedigitaldetox.org. They’ve been getting a lot of attention in the mainstream press. There’s a shift in the culture…a little shift. They don’t just blog about it; they’ve been introducing people to the experience of digital detox at what they call Camp Grounded (and other such device-free events.) Take a look at http://blog.thedigitaldetox.org/camp-grounded-official-video/

By the way, catch a glimpse of my son, Taylor in the box titled “Talent Show. ” It is one of a collage of images halfway down the page, with the main title- “CAMP GROUNDED IS.”  At Camp, he leads singing, songwriting and a capella groups (proud father speaking).

 

TIP 1

What’s So Bad About Being Alone With Your Thoughts?

 

This is the title of a July 11, 2014, segment on Public Radio International’s Science Friday radio program. “Researchers at the University of Virginia were recently amazed to discover that many people would rather self-administer painful shocks than sit quietly with their own thoughts for 15 minutes. They also found that men were significantly more likely to shock themselves than women. So what’s so bad about sitting alone and thinking? One of the study authors, Erin Westgate, talked about a fascinating experiment you can hear more about at:

http://www.sciencefriday.com/segment/07/11/2014/what-s-so-bad-about-being-alone-with-your-thoughts.html

 

It is worth the 10 minutes to listen to. If you don’t have the time right now, here are a few excerpts from that program and other news items about this study:

 

Excerpts and Tidbits

In the year 1654, scientist and philosopher Blaise Pascal said “All of humanities problems stem from man’s inability to sit quietly in a room alone.” This age long premise was tested in experiments that were published in the journal Science. Here is the Abstract of that published paper:

 

“In 11 studies, we found that participants typically did not enjoy spending 6 to 15 minutes in a room by themselves with nothing to do but think, that they enjoyed doing mundane external activities much more, and that many preferred to administer electric shocks to themselves instead of being left alone with their thoughts. Most people seem to prefer to be doing something rather than nothing, even if that something is negative.”

 

“Now the big question is, ‘Why would someone do this?’” Erin says. “Why is it so hard to entertain ourselves with our thoughts that we’re willing to turn to almost anything, it seems, to avoid it?”

 

College Students in a study

Studies at universities often start with college students. College volunteers were asked to sit alone in a bare laboratory room and spend six to 15 minutes doing nothing but thinking or daydreaming. They were not allowed to have a cellphone, music player, reading material or writing implements and were asked to remain in their seats and stay awake. Most reported they did not enjoy the task and found it hard to concentrate.

 

The researchers experimented to see if the student volunteers would even do an unpleasant task rather than just sit and think:

  • In one of the studies they offered students a chance to rate various stimuli:ranging from seeing attractive photographs to the feeling of being given an electric shock about as strong as one that might come from dragging one’s feet on a carpet.
  • After the participants felt the shock (which Westgate described as a mild shock of the intensity of static electricity) some even said they would prefer to pay $5 rather than feel it again.
  • Volunteers were asked whether, if given $5, they would spend some of it to avoid getting shocked again. The ones who said they would be willing to pay to avoid another shock became a subject in the experiment.
  • Each subject went into a room for 15 minutes of thinking time alone. They were told they had the opportunity to shock themselves, if desired, by simply pushing a button.

College Students- The Results

  • Two-thirds of the male subjects — 12 out of 18 — gave themselves at least one shock while they were alone.
  • Most of the men shocked themselves between one and four times. However, one “outlier” shocked himself 190 times.
  • A quarter of the women, six out of 24, decided to shock themselves, each between one and nine times.
  • All of those who shocked themselves had previously said they would have paid to avoid it.

Next: Different subjects- not college students

The researchers wondered: were the young college subjects just overly fidgety, not being allowed to tweet or text or check their e-mail? So they reached out to the wider community for non-college volunteers. New subjects ranged in age from 18 -77, recruited from a church and farmers’ market.

  • Researchers asked them to sit alone in an unadorned room in their home – without the shock, since “we weren’t there to supervise them.” They were asked to do the same thing: just sit there at a time of their own choosing, with no mobile phone, reading or writing materials. They were to report back on what it was like to entertain themselves with their thoughts for between six and 15 minutes.   The researchers got pretty much the same results.
    “These were adults,far past college age,” Westgate says, “and again they were terrible at it!”
  • 57percent found it hard to concentrate; 89 percent said their minds wandered.
  • Over half of the participants confessed to cheating. They weren’t supposed to get on their phones or talk to other people, but over half said they had. “And those were just the ones who were honest with us,” Westgate says.
  • About half found the experience was unpleasant.

Thoughts from the researchers- Westgate & Wilson 

Erin Westgate said she is still astounded by those findings.
“I think we just vastly underestimated both how hard it is to purposely engage in pleasant thoughts and how strongly we desire external stimulation from the world around us, even when that stimulation is actively unpleasant.”

 

She added that the research showed, by and large, that people prefer some positive stimulation, like reading a book or playing a video game.

“Many people find it difficult to use their own minds to entertain themselves, at least when asked to do it on the spot,” said University of Virginia psychology professor Timothy Wilson, who led the study. “In this modern age, with all the gadgets we have, people seem to fill up every moment with some external activity.”

 

“I think they just wanted to shock themselves out of the boredom,” Wilson said. “Sometimes negative stimulation is preferable to no stimulation.”

 

Whether the effects seen in the experiment are a product of today’s digital culture or not is a matter of debate.

 

So try this experiment at home!
All you need is a timer and an empty room.  Tell your friends and loved ones how you did. You could lie (if you want) that you sat perfectly calm and serenely.

 

Reference:

Timothy D. Wilson, David A. Reinhard, Erin C. Westgate, Daniel T. Gilbert, Nicole Ellerbeck, Cheryl Hahn, Casey L. Brown, Adi Shaked: “Just think: The challenges of the disengaged mind” Science 4 July 2014: Vol. 345 no. 6192 pp. 75-77

SKILLS & STUMP THE SHRINK

Here is a combined Stump the Shrink question and Skills section this month.

 

Kurt Snyder, Executive Director of Heartview Foundation in Bismarck, North Dakota asked about treatment planning and The ASAM Criteria assessment dimensions.

 

Question:

“We are wanting to list random drug and alcohol screens as a method and strategy on the treatment plan. Our treatment plans are organized using the structure of the ASAM Criteria six Dimensions. We develop goals and objectives for the high severity dimensions. So as people progress through treatment the severity risk scores tend to fall in Dimensions 1, 2, and 3. Would you suggest we list the random tests in Dimension 1 or Dimension 5?”

 

Kurt

 

Now for readers unfamiliar with The ASAM Criteria six assessment dimensions, here is a brief overview (The ASAM Criteria 2013, pp 43-53):

 

Assessment Dimensions

Assessment and Treatment Planning Focus

1. Acute Intoxication and/or Withdrawal Potential  Assessment for intoxication and/or withdrawal management. Withdrawal management in a variety of levels of care and preparation for continued addiction services 
2. Biomedical Conditions and Complications Assess and treat co-occurring physical health conditions or complications. Treatment provided within the level of care or through coordination of physical health services 
3. Emotional, Behavioral or Cognitive Conditions and Complications Assess and treat co-occurring diagnostic or sub-diagnostic mental health conditions or complications. Treatment provided within the level of care or through coordination of mental health services 
4. Readiness to Change Assess stage of readiness to change. If not ready to commit to full recovery, engage into treatment using motivational enhancement strategies. If ready for recovery, consolidate and expand action for change 
5. Relapse, Continued Use or Continued Problem Potential Assess readiness for relapse prevention services and teach where appropriate. If still at early stages of change, focus on raising consciousness of consequences of continued use or problems with motivational strategies. 
6. Recovery Environment

 

Assess need for specific individualized family or significant other, housing, financial, vocational, educational, legal, transportation, childcare services

 

You can obtain a great working knowledge of The ASAM Criteria dimensions by doing the eTraining module for continuing credit “Multidimensional Assessment”. See http://www.ASAMcriteria.org and click on Resources & Training.

 

TIP 1

Determine why the drug and alcohol testing is needed. Then decide which ASAM Criteria dimension the random testing strategy relates to.

 

As regards your question, Kurt: Let’s look at all the possibilities when random drug and alcohol testing might be used.

 

Dimension 1, Acute Intoxication and/or Withdrawal Potential
If you want to verify what drugs a person may be intoxicated with, or go into withdrawal from, then the random testing would be under Dimension 1.

If you want to be sure a client is taking their maintenance medication to prevent going into withdrawal (methadone or buprenorphine), then random testing can check and monitor that. These are 2 examples of Dimension 1 strategies.

 

Dimension 2, Biomedical Conditions and Complications

Perhaps you have concerns about the drug interaction with a client’s physical health medications- e.g. drinking while taking anti-hypertensive or diabetes medication. Or you have concern about a person using heroin while also on chronic pain narcotics. This would put the random testing under Dimension 2.

 

Dimension 3, Emotional, Behavioral or Cognitive Conditions and Complications

As with Dimension 2, you might have concerns with the person drinking and drugging along with their psychotropic medication. In assessing whether a patient’s psychosis or depression is substance-induced, random testing would be a diagnostic strategy under Dimension 3.

 

Dimension 4, Readiness to Change

Clients will often say: “I can stop anytime, I don’t have an addiction problem.” In trying to engage the person, you might try a motivational “Discovery” plan. Such an approach would have the client try the “I can stop any time” plan. Random testing would track and monitor the client’s success or not.

 

Dimension 5, Relapse, Continued Use or Continued Problem Potential

In a Relapse Prevention plan, random testing would track how well a person’s coping skills are working. Are they maintaining abstinence or not?

 

Dimension 6, Recovery Environment

The Department of Transportation (DOT) and other employers require everyone to be drug-free. Random testing in this situation would be a Dimension 6 example.

Perhaps someone is enrolled in a Drug Court program where random testing is part of the Court expectations.

Some parents have children who are playing high-level sports with costly equipment and travel expenses. As a condition for ongoing financial and emotional support, they require their child to be drug-free. Using random home-testing kits would be another Dimension 6 example. This is the same expectation as in professional and college sports.

 

So drug and alcohol screening has many purposes. It is a lab test to help track the effectiveness of treatment. It is not a “gotcha” spying activity as part of an adversarial relationship based on mistrust and suspicion.

SOUL

What a tragedy that Robin Williams is dead. This month he killed himself in his home about two hours from my home. It is a grim reminder that celebrities, so talented and creative, are nevertheless people who can suffer the same addiction and mental health problems, of which we are all vulnerable. But their very celebrity status can be a curse, aggravating their vulnerabilities and even inhibiting reaching out for help.

 

I have gotten a glimpse of how celebrity can be a blessing and a curse, not because I consider myself a celebrity, but because I travel a lot. I have been on planes for over 18 years due to my full-time training and consulting work.

 

Here’s what I get just because I travel a lot:

  • Priority boarding at the front of the line because I am approaching 3 million lifetime miles on United Airlines.  I have flown over 100,000 miles every year with them for 20 years.
  • Free upgrades to first class domestically and business class internationally – oh it is such a let down to be on another airline and be up the back with all the “common” people! (LOL)
  • Even the Transportation Security Administration (TSA) often lets me skip the long lines and zip through TSA PreCheck. I can keep my shoes, belt and coat on and just show them my computer, wallet and cellphone. No stripping down and going through those big fancy security machines.
  • When I hit 2 million miles with United Airlines, I received an engraved 160 gigabyte Apple iPod and lifetime membership in the United Clubs at airports around the world. I wonder what I’ll get when I hit 3 million miles next year….a new BMW car?
  • On some trips, the pilot has even come to greet me by name. On occasion I have received a personalized note from the pilot thanking me for my loyalty. All I’ve done is buy airline tickets, not entertained millions of people like Robin Williams.

Anyway, you get the picture.

 

The problem with all this ‘special treatment’ is it’s easy to start thinking you arespecial and deserve this all the time.   You can see why celebrities start acting like entitled celebrities. (My wife quickly reminds me I am not a celebrity, so there isn’t too much danger.)

 

This is so insidious for real celebrities who are always in the public eye, with fans and swooning groupies paying homage to them. And their money can buy almost any material desire or best seat in the restaurant……

 

Reality starts to become very distorted. So have some sympathy for celebrities. For many it is a curse that can kill you. Who knows, for Robin Williams, it just may have.

SAVVY

In the February 2015 edition of Tips and Topics, I outlined a case presentation of a client who had already been in Level 3.5 Residential addiction treatment service for over four months when she was discharged to outpatient services. The client used alcohol within a day of discharge. The treatment program readmitted her for more weeks in their residential program. It was as if the treatment agency felt several more weeks of the same level of care would produce a better outcome.

https://www.changecompanies.net/blogs/tipsntopics/2015/02/

Joe Gerstein, MD, FACP, is the Founding President of SMART Recovery Self-Help Network is an internist and pain management consultant. He wrote and shared perspectives and information worth passing onto you this month.

 

Here’s some of what he said:

“In the 2nd case presented, the woman who had been over 4 months in residential care and relapsed immediately on discharge, there seems to be more than just a failure to observe a rational and patient-centered interpretation of criteria. There seems to be total obliviousness to the likelihood that the therapeutic approach being used may be entirely incorrect for this patient’s temperament and worldview and that “more of the same” will be unlikely to achieve any benefit.”

 

Dr. Gerstein went on to correctly suggest that there be a re-assessment of the type and style of therapy rather than the “assumption that the fault always lies with the patient’s obstinacy and lack of cooperation and denial.” He then shared the following link as an example of how a change in treatment approach can yield dramatic results.

See https://www.youtube.com/watch?v=o4S70dPBSIM by Leigh who is now Regional Coordinator for Wales, UK SMART Recovery Trust.

 

Many are familiar with Alcoholics Anonymous, Narcotics Anonymous and other 12-Step recovery groups; and I always try to mainstream people into AA or NA since these groups are so readily available. But too few fully understand SMART Recovery as an adjunct or alternative to AA and NA for those who may need a different approach to improve outcomes. Since Joe has facilitated over 3,000 SMART Recovery meetings in communities and prisons around the world; and has written about and lectured at a number of symposia on alternatives to the 12-Step approach, I asked him to explain more about SMART Recovery.

 

TIP 1

Take a look at what you know or do not know about SMART Recovery

 

Here’s what Dr. Gerstein explained about SMART.  His comments are indicated with quotation marks:

 

Some history:

“I certainly would like to clarify things about the origin of SMART Recovery. This was definitely a group endeavor. SMART started out as the non-profit arm of Rational Recovery. As I recall, there were 8 professionals [all except myself from the mental health profession] and 2 lay people who had used the program to achieve sobriety at the first organizational meeting of the Rational Recovery Self-Help Network. The detailed history is capsulized in several sources, which I will note below.

 

It became clear in the next few years that there were irresolvable differences between the non-profit and the for-profit elements, so the non-profit broke away and renamed itself SMART Recovery (Self-Management And Recovery Training) in 1994. Originally only a 2-Point program, Coping With Urges and Dealing More Rationally With Problems, it rapidly evolved into a 4 Point Program by adding Motivational Enhancement and Lifestyle Balance components. By now there are 13 Tools. Our Correctional Version of SMART Recovery, InsideOut, funded by the National Institute on Drug Abuse (NIDA), contains an additional module, Criminal Thinking Errors.”

 

SMART in the Prisons and Criminal Justice:

Dr. Gerstein again: “My own particular areas of involvement in the program have been here in Massachusetts where we have had over 25,000 meetings, prison applications of SMART [I have facilitated almost 800 prison meetings and introduced the program into Australian and UK prisons, where it has flourished] and the formation of SMART Australia, SMART UK and SMART South Africa. The Kingdom of Denmark has provided almost $2,000,000 to translate SMART materials and support startup of 24 SMART groups. A recent study from New South Wales (Australia) prisons involved 3,000 inmates exposed to SMART and 3,000 controls matched in 7 parameters. Those inmates attending at least 9 SMART sessions had a 53% reduction in reconviction rate for violent crimes.”

 

SMART and Science:

  • “The scientific underpinnings of the program are Rational Emotive Behavioral Therapy (REBT)/Cognitive Behavior Therapy (CBT), Motivational Interviewing, Solution-Focused Therapy, Stages of Change and Motivational Enhancement Theory.”
  • “Incidentally, a number of surveys have demonstrated that about 30% of participants who attend SMART meetings fairly regularly and consider SMART their primary recovery modality also attend AA/NA meetings at least occasionally. We have absolutely no problem with this approach. SMART has no objection to use of appropriately-prescribed medication for either the addiction or underlying mental health problems, or both.”
  • “A study by the Walsh Group several years ago demonstrated that progress in recovery via SMART was about the same for people with varying degrees of religiosity or the non-religious.”
  • “A study by Reid Hester funded by NIDA was a randomized control trial (RCT) with 183 new SMART attendees. They were divided into 3 cohorts receiving different types of access to the SMART program and/or to Hester’s interactive online program, “Overcoming Addictions: Introduction to SMART Recovery. All had alcohol as their addictive substance. All had a corroborative person available. We have the 3- month results (6-month results due soon). There was about a 70% reduction in all groups in drinking days, drinks per drinking day and negative social/legal/medical events.”

SMART online and internationally:

“The online experience has been quite a phenomenon. Except for a webmaster (in Uruguay!) and an intermittent web designer, virtually the entire enterprise is run by volunteers. Thousands have had their entire recovery on the website and develop incredible bonds amongst themselves.

 

SMART Recovery now has 1500 meetings in 17 countries and is in use in a number of treatment facilities. About 150 trainees per month take the interactive online training program, about 2/3 professionals or students training to become professionals. At our 20th Anniversary Conference in Washington last Fall, we were gratified to have Michael Botticelli, Director of National Drug Control Policy, give the welcoming address and bring along a Presidential Proclamation honoring SMART’s contribution to the recovery community.”

 

Joe Gerstein. MD, FACP

508 733 6469

jgerstein@hotmail.com

 

 

References:

Atkins, Randolph G., Hawdon James E (2007): “Religiosity and Participation in Mutual-Aid Support Groups for Addiction” J Subst Abuse Treat. 2007 Oct; 33(3): 321-331.

The Walsh Group Study: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2095128/

 

Blatch, C., et al. Efficacy of SMART Recovery Program in New South Wales Prisons. Submitted for publication.

 

A Chronology of SMART Recovery®

Compiled by Shari Allwood and William White

 http://www.williamwhitepapers.com/pr/Chronology%20of%20SMART%20Recovery.pdf 

 

Hester, Reid K, Lenberg, Kathryn L, Campbell, William, Delaney, Harold D. (2013): “Overcoming Addictions, a Web-Based Application, and SMART Recovery, an Online and In-Person Mutual Help Group for Problem Drinkers, Part 1: Three-Month Outcomes of a Randomized Controlled Trial” Journal of Medical Internet Research. Vol 15, No 7 (2013): July. The Hester Study: http://www.jmir.org/2013/7/e134/

SKILLS

Last month I introduced some information on Transgender individuals and an article by Beck Gee.

 

Beck wrote to me and I’ll share some of the dialogue we exchanged as I learned something new. This led to this month’s SKILLS section:

 

Dear Dr. Mee-Lee,

“I wanted to thank you for your Tips & Topics discussion this month. One of my friends forwarded it to me as he noticed I was referenced. This topic is very dear to my heart and it is my passion and calling to work with trans-individuals and substance use….. I just wanted to make a small remark. You referenced me with male pronouns. I identify on the spectrum of trans, as gender nonconforming and use them/they/their pronouns. I was assigned female at birth. It’s totally okay that you identified me as male, probably due to my name… these are the things that I continue to work on and help treatment centers and addiction professionals be more aware of. It’s an amazing opportunity, and relevant, and timely. I think if I would have started talking about this 2 years ago, it would not be having the same effect as it is now.”

 

All the best,

 

Beck Gee MA LADC ADCR-MN

Assistant Director of Clinical Services

Pride Institute

2101 Hennepin Ave #202

Minneapolis, MN 55405

612-825-8714 (main)

rebecca.gee@uhsinc.com

  

My response:

Thank-you, Beck, for writing and for your original article which was informative for me. I am relatively new to the whole subject of transgender people and appreciate your pointing out who I assumed you were -male- and referred to you that way. Yes, your name did lead me to make that assumption, although, as I think about it now, I’m not sure if Beck is a male or female name and so is perfect for gender nonconforming people. This goes to show how I still have more to learn.

 

So if I had referred to you correctly, how should I have said that: “In their article, Beck Gee emphasizes…..” Would readers understand that “their” was used instead of “his” or “her” because you are a gender nonconforming person? Is this an issue you teach clinicians about – how to refer to each person by asking them do you want to be referred to as “he”, “she” or “they”?

 

Thanks for writing and helping raise my consciousness about trans people.

David

 

TIP 1

Raise your consciousness about gender nonconforming individuals who identify on the spectrum of transgender. Note terminology on how to address them.

 

Here’s what Beck taught me:

  • You would be correct in using “In their
    article…” When I train clinicians we can sometimes battle on the grammar piece, when someone comes in who is gender non conforming and uses the pronouns them/they/theirs. In lectures/sessions, I’ve experienced battles with clinicians on grammar. It would be easier if we lived in Sweden, where they use a third gender pronoun

http://www.washingtonpost.com/blogs/worldviews/wp/2015/04/01/sweden-is-about-to-add-a-gender-neutral-pronoun-to-its-official-dictionary/

  • Beck pointed to the following article:

http://feministing.com/2015/02/03/how-using-they-as-a-singular-pronoun-can-change-the-world/

  • “I also tell them that in clinical notes, I make a note at the beginning that states “The client uses them/they/their pronouns, therefore all clinical notes will refer to the client with those pronouns”.   I also make note that therapeutic alliance relies heavily on affirmation and respect. If we are not affirming of a client’s identity then we are doing a disservice. And respect must come from the institution as a whole, if someone is misgendering a client, we must correct them. Even where I work, when a client comes in, and someone may misgender them in staffing or report, I instantly correct them. Because even behind closed doors we must be respectful and aware.
  • We also have done away with “What pronouns do you prefer?” question. We ask “What are your pronouns, or what pronouns do you use?” Because it’s not a preference, it just is.”

So was your consciousness raised? Or did you already know all about this and it was just me who was oblivious to these issues?

 

SOUL

I don’t know what your high school teachers were like and whether they were as confrontive as some of mine. (Of course this was last century). But I remember one teacher almost yelling at a fellow student who was an unmotivated learner and kind of pouty and negative: “Change your attitude!”

   

“Change your attitude” indeed.  Not so easy to do.  But then, maybe it is easier than I would have thought.  Society in the USA – even more so in some other countries-  is changing attitudes and cultural norms at a more rapid pace than you would have thought possible even a decade ago:

  • Same-sex marriage is legal in 37 states and the District of Columbia.  I’m no math wiz, but that seems like a pretty substantial majority.
  • Medical marijuana is legal in 23 states and the District of Columbia with nine more states pending.
  • Four states have already legalized recreational use of marijuana and the District of Columbia has legalized possession of small amounts of marijuana. Seven more states are getting ready to legalize it too.
  • Transgender individuals are increasingly being recognized and accepted and will likely get a boost with Bruce Jenner’s recent interview on his transition seen by 17 million people and counting. (Bruce asked to be referred to with male pronouns for the time being.)

When it comes to addiction treatment providers though, it is interesting to see how slowly attitudes are changing in regards to one of the most difficult forms of addiction – nicotine addiction or tobacco use disorder. Ever since the new edition of The ASAM Criteria (2013) published a new chapter on Tobacco Use Disorder, I’ve been quoting a statistic that surprises people:

 

  • More people die in the USA every year from smoking tobacco and nicotine addiction than from alcohol, heroin and cocaine combined.

Recently, I thought I better check this statistic to make sure this is accurate. I found out I was wrong – or at least only partially correct. Actually…..

 

  • More people die in the USA every year from smoking tobacco and nicotine addiction than from alcohol, heroin and cocaine; AND from AIDS, car accidents, murders and suicides; AND in World War II… all combined.

http://www.politifact.com/truth-o-meter/statements/2009/jun/29/george-will/claims-smoking-kills-more-people-annually-other-da/ 

 

Now that is some statistic that you think would change the attitude of addiction treatment providers to make treatment programs smoke and tobacco-free. And in fact, more and more treatment providers are taking nicotine addiction seriously.  But there are still many programs that don’t allow smoking in treatment groups or in the building, but have a smoking gazebo on the grounds where clients and staff can have a cigarette before group treatment.

 

Well, I’m looking for the beer and wine gazebo where clients and staff can bond and have a beer or glass of wine before group.  What’s the difference?

 

“Change your attitude” indeed.  It’s harder than you think……or is it?

SHARING SOLUTIONS

The ASAM Criteria Software was released on April 25, 2015 at the Annual ASAM Meeting in Austin, Texas. Now branded as Continuum ™, The ASAM Criteria Decision Engine.

 

Continuum ™ provides counselors, clinicians and other treatment team members with a computer-guided, structured interview for assessing and caring for patients with addictive, substance-related and co-occurring conditions. By branding the software as “Continuum” it means The ASAM Criteria isn’t just about assessment at the front intake part of treatment in order to make a placement decision. It means that The ASAM Criteria is about ongoing chronic disease management across a whole continuum of care.

 

The book and Continuum ™ are companion text and application. The text delineates the dimensions, levels of care, and decision rules that comprise The ASAM Criteria. The software provides an approved structured interview to guide adult assessment and calculate the complex decision tree to yield suggested levels of care, which are verified through the text.

For more information, go to the website www.asamcontinuum.org 

Until next time

For the May edition, I have asked a special guest-writer to share his experience.  My son,

Taylor, will share with you his observations on what it is like to set aside alcohol for Quarter 1 of the year.  I know you’ll enjoy hearing about his experience.    

David

Vol.13, No. 3

Welcome to the many new readers of Tips and Topics. Thanks for joining the long time readers for the June edition.

David Mee-Lee M.D.

SAVVY

Remember the 1970’s and 1980’s TV series MASH. I’ve always appreciated Alan Alda for making me laugh. However I have come to appreciate Alda even more but for the different contribution he has made today – with the Alan Alda Center for Communicating Science at Stony Brook University, New York. When he started the Flame Challenge, the goal was for scientists to communicate, succinctly and effectively, to explain science to an 11-year-old.

 

The 2015 challenge focused on something we all do everyday, for every day of our life. You might think that would mean we’d be both familiar and knowledgeable about something we do everyday. But for most of us, that’s not true. I’m talking about sleep.

 

It was illuminating to read the top-ranked written answer by Brandon Aldinger, Ph.D and watch the top-ranked video explanation by Eric C. Galicia. These were the winning entries in the 2015 Flame Challenge question: “What is Sleep?”

 

You can listen to their interviews in the June 5, 2015 edition of Science Friday

http://www.sciencefriday.com/segment/06/05/2015/what-is-sleep-a-superpower-a-power-cleanse.html 

 

TIP 1

Note these tidbits about sleep and dreams written for 11 year olds and the 11 year old in all of us.

 

Here are excerpts from the winners’ succinct, creative and informative explanations about sleep. Entries were judged by more than 20,000 11 year-olds in schools around the world. Firstly from Brandon Aldinger’s written entry:

  • “If you don’t sleep, you’ll die! Like us, almost all animals need to sleep-everything from fish, to horses, to birds. Even butterflies and worms sleep!”

First Function of Sleep

  • “Our body takes care of two big things while we’re sleeping. First, our brain organizes what it learned while we were awake. Your brain is made up of billions of cells called neurons. These neurons are connected in a huge network.”
  • “While we sleep, our brain strengthens and rearranges these connections to help us remember things more quickly and easily when we are awake.

Second Function of Sleep

  • “The second thing that happens during sleep is our body heals itself. Sleep is a little bit like a superpower.” 
  • “If you want to get over a cold quickly, make sure you sleep a lot. You might also have noticed that adults in your home don’t sleep as much as you do. That’s because your body needs more sleep to manage the stuff that happens while your body and brain are still growing.” 

Dreams

  • “But what about dreams? Well, as your brain is calming down from being awake, parts of it shoot out random signals, like a TV station with too much static.”
  • “Another part of your brain does its best to make sense of these signals, but the story it puts together can be pretty weird!”

http://www.centerforcommunicatingscience.org/the-flame-challenge-2/flame-challenge-2015-finalists/ 

 

 

TIP 2

Enjoy the video winner’s short film about sleep and dreams. But here are some excerpts before you see the video.

 

Eric C. Galicia is a candidate in the Master of Health Physics program at Illinois Institute of Technology. He produced the top-ranked video explanation about sleep, and he did that in just under five minutes. To watch it, click on this link and scroll down the page a bit:

http://www.centerforcommunicatingscience.org/the-flame-challenge-2/flame-challenge-2015-finalists/ 

  • “Your brain categorizes things that you learn during the day and generates a lot of cellular waste while doing it. One kind of waste is Amyloid beta, a gummy plaque of brain.”
  • “Cerebral spinal fluid cleans the brain. This fluid is essential and helps the brain re-learn the lessons it learned during the day.”
  • “When you sleep, your body and mind are hard at work replenishing crucial brain functions.”
  • We spend 36% of our life sleeping.

Good sleep

  • With good sleep, we remember lessons from the day before.
  • Good sleep is when the brain cleans itself – get increased concentration, creativity, decreased stress and moodiness.

Bad sleep

  • “When you don’t get enough sleep, it’s hard to remember things; or you can become moody.” Risks for Alzheimer’s disease, depression, anxiety and other emotional disorders.
  • Poor memory, judgment, increased stress and impulsivity with not good sleep.

Dreams

We still don’t understand a lot about dreaming:

  • Dreams are important and contribute to creativity and learning.
  • A part of the brain is dedicated to incapacitating the body while dreaming. It releases serotonin, which inhibits your muscles from moving when intensely dreaming. This disarms movement when dreaming and stops physical movement.
    (My comment: This explains to me how I can never run fast enough or fight back and defend myself when having that bad dream.)

SKILLS

Sleep hygiene has been defined in different ways. Here are elements of those definitions along with points about the importance of sleep hygiene:

  • “habits and practices that are conducive to sleeping well on a regular basis.” “sleep hygiene is the key to sweet dreams(Google sleep hygiene)
  • “a variety of different practices that are necessary to have normal, quality nighttime sleep and full daytime alertness.”  http://sleepfoundation.org/ask-the-expert/sleep-hygiene
  • “The promotion of regular sleep” (Centers for Disease Control and Prevention, CDC.  http://www.cdc.gov/sleep/about_sleep/sleep_hygiene.htm 
  • Sleep hygiene is important for everyone, from childhood through adulthood. A good sleep hygiene routine promotes healthy sleep and daytime alertness.
  • Good sleep hygiene practices can prevent the development of sleep problems and disorders.
  • Sleep disturbances and daytime sleepiness are the most telling signs of poor sleep hygiene.
  • If one is experiencing a sleep problem, he or she should evaluate their sleep routine. It may take some time for the changes to have a positive effect. (Michael Thorpy, MD.)  http://sleepfoundation.org/ask-the-expert/sleep-hygiene

 

TIP 1

How do you measure up with these good sleep hygiene tips?

 

I merged and rearranged into categories the following tips which are excerpts from The National Sleep Foundation  http://sleepfoundation.org/ask-the-expert/sleep-hygiene

Centers for Disease Control and Prevention (CDC) http://www.cdc.gov/sleep/about_sleep/sleep_hygiene.htm, and

American Sleep Association (ASA)

https://www.sleepassociation.org/patients-general-public/insomnia/sleep-hygiene-tips/ 

 

A. Regular wake and sleep pattern

  • Maintain a regular wake and sleep pattern; go to bed at the same time each night and rise at the same time each morning. Ideally, your schedule will remain the same (+/- 20 minutes) every night of the week.
  • Establish a regular relaxing bedtime routine. Have a comfortable pre-bedtime routine: a warm bath, shower, meditation, or quiet time.
  • Spend an appropriate amount of time in bed, not too little, or too excessive. This may vary by individual; for example, if someone has a problem with daytime sleepiness, they should spend a minimum of eight hours in bed. If they have difficulty sleeping at night, they should limit themselves to 7 hours in bed in order to keep the sleep pattern consolidated.
  • Avoid napping during the day. It can disturb the normal pattern of sleep and wakefulness and naps decrease the ‘Sleep Debt’ so necessary for easy sleep onset. Each of us needs a certain amount of sleep per 24-hour period. We need that amount, and we don’t need more than that. When we take naps, it decreases the amount of sleep we need the next night – which may cause sleep fragmentation and difficulty initiating sleep, and may lead to insomnia.
  • Try to avoid emotionally upsetting conversations and activities before trying to go to sleep. Don’t dwell on, or bring your problems to bed.
  • Don’t stay in bed awake for more than 5-10 minutes. If you find your mind racing, or worrying about not being able to sleep during the middle of the night, get out of bed, and sit in a chair in the dark. Do your mind-racing in the chair until you are sleepy, then return to bed. No TV or internet during these periods! That will just stimulate you more than desired.
  • If this happens several times during the night, that is OK. Just maintain your regular wake time, and try to avoid naps.
  • If you’re taking too long to fall asleep, or awakening during the night, you should consider revising your bedtime habits. Most important for everyone is to maintain a regular sleep-wake schedule throughout the week and consider how much time you spend in bed, which could be too much or too little.

B. Food, caffeine, nicotine and alcohol

  • Avoid stimulants such as caffeine, nicotine, and alcohol too close to bedtime. The effects of caffeine may last for several hours after ingestion. Caffeine can fragment sleep, and cause difficulty initiating sleep. If you drink caffeine, use it only before noon. Remember soda and tea contain caffeine as well.
  • While alcohol is well known to speed the onset of sleep, it disrupts sleep in the second half as the body begins to metabolize the alcohol, causing arousal.
  • Food can be disruptive right before sleep. Stay away from large meals close to bedtime.
  • Dietary changes can cause sleep problems. If struggling with a sleep problem, it’s not a good time to start experimenting with spicy dishes. And, remember, chocolate has caffeine. 

C. Exercise

  • Exercise can promote good sleep. Vigorous exercise should be done in the morning or late afternoon.
  • A relaxing exercise, like yoga, can be done before bed to help initiate a restful night’s sleep.
  • Exercise regularly as exercise promotes continuous sleep. Avoid rigorous exercise before bedtime. Rigorous exercise circulates endorphins into the body, which may make initiating sleep difficult. 

D. Sleeping and Bedroom Environment

  • Ensure adequate exposure to natural light. This is particularly important for older people who may not venture outside as frequently as children and adults. Light exposure helps maintain a healthy sleep-wake cycle.
  • Make sure your bed is comfortable and associate your bed with sleep. It’s not a good idea to use your bed to watch TV, listen to the radio or music, or read. Remove all TVs, computers, and other “gadgets” from the bedroom. When you watch TV or read in bed, you associate the bed with wakefulness. The bed is reserved for two things – sleep and hanky panky.
  • Have a quiet, comfortable bedroom with a sleep environment which is pleasant and relaxing. The room should not be too hot or cold, or too bright. Set your bedroom thermostat at a comfortable temperature. Generally, a little cooler is better than a little warmer.
  • Turn off the TV and other extraneous noise that may disrupt sleep. Background ‘white noise’ like a fan is OK.
  • If your pets awaken you, keep them outside the bedroom.
  • If you are a ‘clock watcher’ at night, hide the clock.

 

TIP 2

Consider your digital devices and their effect on your sleep

 

In its “Sleepless in America” special series, NBC Nightly News of June 24 reported, “The CDC has called lack of sleep a public health epidemic, and most sleep experts say all our digital devices we’re taking into the bedroom are taking a toll on getting a good night’s rest.”

  • NBC News correspondent Hallie Jackson explained: “Experts say it’s no coincidence 95 percent of us look at some kind of screen within an hour of bedtime and 85 percent have trouble falling asleep.”
  • Blue light emitted from “screens send[s] a signal it’s still daylight, triggering a surge of energy and blocking the melatonin that makes us sleepy.” Therefore, it’s “no wonder then that with the device on nearly every nightstand, one in three people sleeps less than six hours a day, raising the risk for diabetes, heart disease, obesity and depression.” (American Psychiatric Association Headlines, June 25, 2015)

 

TIP 3

What you can do to boost your chances of getting a good night’s rest

http://www.nbcnews.com/nightly-news/sleepless-america-how-digital-devices-keep-us-all-night-n381251 

  • “Create a charging station in another room to power your devices overnight. Don’t keep them on the bedside table.”
  • “Buy a real alarm clock – don’t use your phone. “It’s better to have an alarm clock that is not interrupting your sleep in the middle of the night,” said Czeisler, “than to have a [phone-based] alarm clock that is waking you up at all hours.”
  • “Turn off all your screens – televisions, phones, computers – an hour before bed. Read from a printed book instead of a tablet, for example.”
  • “If that’s not realistic for you, try an app that flips your screen’s background. Instead of black letters on a white background (like you’re reading right now), it will show white letters on a black background, helping to cut down on how much light is emitted.”

For your children:

“Start good habits early, especially with your kids. A startling 75 percent of children have at least one electronic device in the bedroom when they sleep, according to the National Sleep Foundation. Create a bedtime routine for that does not involve electronics.”

SOUL

One of the most gratifying joys of working to attract people into recovery is when they come back and thank you for helping them change their lives. That’s what happened this week as I had lunch with Todd (not his real name). Todd had come back to thank his counselor and care coordinator and tell his story.

 

Todd is 25. About 14 months ago he was doing $1,500 worth of drugs a day supported by drug dealing and “selling my girlfriend for sex”. When he presented for treatment, he was homeless, penniless and was done with drugs. It was addiction treatment, supportive living in a halfway house and Todd’s daily commitment and active participation in Narcotics and Alcoholics Anonymous (NA & AA) meetings which brought him a new start to life. With over a year of recovery, he is now:

  • Working full time, supporting himself in legal work and paying off all his court debts and obligations.
  • Living in a stable environment; and trusted to baby-sit an 8 and 11 year old while their mother works the night shift.
  • Taking addiction seriously. He has quit not only alcohol and heroin, but also nicotine and caffeine (two drugs many addiction programs are still very ambivalent about).

If you’ve ever been to an AA or NA meeting, you’ll notice it can be a great training environment – for public speaking, humorous and pithy nuggets of wisdom, and inspiring, motivational encouragement for newcomers and long time attendees alike.

 

Todd, at such a young age and relatively early in his recovery, demonstrated the impact of that “training,” projecting his passion for recovery, which is what AA and NA is all about. As he told his story, Todd shared some nuggets of wisdom I’ll share with you:

  • You can’t be No. 1 unless you are odd,” he said. I was impressed with how ready he was to break away from negative peer influences, quit nicotine and caffeine – “odd” for someone so young in age and recovery.
  • Go early and you’ll never be late” was something his Dad taught him. This spoke to Todd’s level of responsibility and accountability.
  • We live in a world where we’re always noticing the bad things. Keep looking at the peaks instead of dwelling on the valleys.” He joked about whether you ever hear the police thanking you for going nicely through a green light. They only notice when you go through a red light. We all do the same thing and dwell on the bad things in the valleys of life.
  • You need to struggle to succeed.” It was reassuring to me that Todd was not “pink-clouding” thinking recovery was easy, even though he was so positive and made it look easy.
  • Using drugs is not a family event.” When Todd said this, he was not saying addiction doesn’t affect families. In fact, he now has a growing positive relationship with his mother and brother. He is also resolving the death of his father from addiction. The idea he was expressing is that drugs isolate you and he is recovering from the alienation his addiction caused.

What an inspiration Todd was to us! He reinvigorated and re-motivated us to keep attracting people into recovery. Nobody fell asleep listening to this young and grateful man.

Until next time

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

David

Borneo, Malaysia; Nature nuggets; Addiction in SE Asia; Travel tips; Culture

Vol. #14, No. 6

Welcome to the September edition of Tips and Topics… or what I did on my summer vacation.

David Mee-Lee M.D.

SAVVY

Last week, I returned from my first trip to Borneo and Malaysia. I was fortunate to be invited to participate in a keynote, workshop and panel discussion at the 4th Asia Pacific Behavioural and Addiction Medicine Conference (APBAM 2016) at the University of Malaysia Sabah in Kota Kinabalu. 

If you are like me, Kota Kinabalu is not a travel destination at the top of one’s bucket list.

Yet it was the starting point for a fun and meaningful work/vacation experience I’ll share with you this month.  And unless you are a student of international affairs, your first thought about Malaysia might be the fateful 2014 flight of Malaysia Airlines Flight 370 which mysteriously disappeared from radar and still has not been located.

As you might expect, there is much more to Malaysia than missing planes and the “Wild Man of Borneo.”

TIP 1

A brief primer on Borneo and Malaysia

 map
  • Borneo is the world’s third largest island and is home to three countries: Malaysian Borneo, Brunei, and Indonesia.
  • Malaysia is located in Southeast Asia and is made up of 13 states and 3 federal territories. It is a country with two regions separated by the South China Sea: Peninsular Malaysia (West Malaysia) and Malaysian Borneo (East Malaysia).
  • Peninsular Malaysia shares a land and maritime border with Thailand and maritime borders with Singapore, Vietnam and Indonesia.
  • Malaysian Borneo is made up of two states: Sarawak and Sabah.
  • The capital of Sabah is Kota Kinabalu, the international gateway to Sabah.
  • Sabah and its main city, Sandakan, is where you can experience some of the richest wildlife areas found anywhere in Southeast Asia. 

Sandakan is where the wildlife, tourist part of my trip began.  It was hot and muggy, being just 6 degrees north of the Equator.

TIP 2

Nature nuggets from the Wild Animal Borneo tour

Here a few highlight anecdotes that stood out for me:

Orangutans

To watch the young babies and others up to age 4 or 5 years swing from rope to rope in the “nursery” of the Sepilok Orangutan Rehabilitation Centre was fascinating.  As they feel more adventurous there is nothing stopping them from venturing over to where the grown-ups hang out.

 ape-1

Lunch time for the big guy 

 

 ape-2

A family affair

  • We had an unusual and spontaneous treat. A 5 year old orangutan curiously explored contact with tourists and come out to the Sepilok entrance to take a look at all of us who were looking at him! Then he scurried up a tree right near the entrance.  We witnessed something that can’t be planned.
 ape-3

Our curious young guy came to watch us watch him

  • The Centre’s keepers teach the young ones many of the skills they need to survive in the jungle on their own. But what we saw was something keepers can’t teach; he must have learned from watching an adult.
  • Once he reached a comfortable height in the tree, he bent a branch into a semicircle arc. Then he started breaking off other branches, laying them in the leafy bent branches building himself a little temporary bed.
  • My guide said he would relax there for a few hours until it got cooler.  Then he would hunt for food.  Sure enough when we returned he was gone, having had a nice afternoon snooze.
 ape-4

Finished making his relaxation bed  and peered out to see what the tourists were doing 

 

Proboscis monkeys

“Proboscis” means long nose and you can only see this monkey in the wild, in Borneo. So of course I was curious: Why the long nose?   I was told that proboscis monkeys are like dogs; they don’t sweat, so have to dissipate heat through their long nose. I’m not sure that is correct, having checked in Google. I did see that idea mentioned, but mostly different explanations for the long nose. (Perhaps my guide’s explanation is an example of that joke which goes around in travel circles- that guides have a lot of information but only sometimes is it true!).

 monkey-1

The daddy Proboscis monkey with his harem 

  • The long nose seems to be more of a sex symbol – males who have the longer nose are more attractive to females.
 monkey-2

The male leader of the family with his big nose

  • Males have longer noses than females; and adult males have longer noses than young guys.
 monkey-3

Mother proboscis monkey with her shorter nose and baby

  • In times of danger, blood rushes to the nose and alters the resonance of the monkey’s calls of danger, which makes the warning calls more effective and more attractive to female proboscis monkeys.
  • Proboscis monkeys can swim and are pretty good at it. So a long nose helps breathing when jumping in the river to escape predators like the Clouded Leopard.
  • On our jungle river rides searching for birds, monkeys and crocodiles in the evening, we saw scores of proboscis monkeys finding their ideal sleeping spot high up in the trees nearest to the river.  This gives them an escape route should a leopard climb the tree in hot pursuit. The proboscis monkeys just jump into the river and swim away.

 

Night jungle walks – I was ready for almost anything: dressed head to toe in clothing infused with odorless and invisible insect protection to keep out mosquitoes; wearing knee-high rubber boots and even higher cotton socks you tie tight around your leg to discourage leeches jumping on your ankles; and topped off with generous sprays of insect repellent.

  • The high rubber boots were a must in the muddy jungle floor of rain forests where it can rain at a minute’s notice. In fact we had to cut one walk short as our guides could hear the spray of rain increasingly and quickly moving in our direction.
  • As the sound of rain grew stronger, they said: “That’s it. We have to go.” We had to run ahead of the sound to make it back just before being totally drenched.
  • But when we weren’t slipping and sliding or dodging torrential downpours, we were seeing multicolored, beautiful birds sleeping on tree branches just a few inches from our eyes and camera.  Keep quiet -and they’ll continue sleeping while you watch.
  • Four-legged animals are easier to spot at night. Just swing a flashlight around and look for glistening eyes.

 

Turtle Islands Park

A 45 minute speedboat ride from Sandakan whisked us to one of three turtle islands, Selingan Turtle Island. There, mother green turtles come ashore at night to lay their eggs and we tourists observe them up close and personal.

  • Upon arrival on the island, you see a field of little green circle mini-fences protecting each mother turtle’s 80-90 eggs which have been replanted here. This gives the hatchlings a chance to survive predators.
 turtle-1

Little green mesh towers protect the transplanted eggs from predators as they await to hatch

  • The reservation rangers are dedicated to protecting the turtles.  At night, they check the beach for the first arrival onshore.  This can be anything from 9 PM to midnight or later depending on how bright the moon is, and how high the tide is.
  • We all waited with anticipation for the first call of “Turtle time!” We then rushed to see the first mother lying in a big sandy pit she had dug out; she was ready to start dropping ping pong ball- sized eggs in the deep hole she had prepared.
 turtle-2

Ping pong size eggs – 90 eggs about to be transplanted

  • Watching her lay her eggs is the first of three parts of the turtle island experience.
  • We were lucky- the conditions were ideal to come ashore- a dim moon and a high tide.  The female turtle came in early so we didn’t have to wait up until midnight.
  • The second part of the experience was to see the 90 eggs we just saw laid transplanted into a new deep, man-made sand “nest”
 turtle-3

Soon these eggs will be inside a green mesh hole ready to hatch

 

The hatchlings

In the afternoon when it cools, you keep your eyes on the inside of those little green mesh towers. A stirring in the sand suddenly reveals a little baby turtle.  More and more appear; the rangers collect these in a basket to prepare for the third phase of our turtle adventure.    

 turtle-4

Newly hatched baby turtles about to experience the big sea 

  • As we all scurry to the water’s edge, the ranger passes around the basket

 

of newly hatched baby turtles. We marvel as he gently tips the basket to release them to the sea.

 turtle-5
  • You’ve probably seen video of  of hatchlings race as fast as they can to splash for the first time into the water.
  • Sadly, only about I in 1,000 will survive to adulthood.

 

A disappointment

Despite several river excursions, scouring the riverbanks to see crocodiles, I glimpsed -for just a few seconds -the head of one as he slipped below the surface. (Or was it a she?) All those floating logs though gave plenty of fodder for my imagination: “I think that was a crocodile I just saw.”

I did see relatively fresh tracks of where elephants had crossed the river, but no actual elephants on the move. Oh well, back to the zoo.

 

TIP 3

Addiction and mental health in Southeast Asian countries

 

The working part of my trip to Borneo centered on Kota Kinabalu or KK as it is popularly known. (Much easier to say). It is the state capital of Sabah and home to the University of Malaysia Sabah.  Attitudes about addiction as a treatable disease have years (and maybe a decade) to go before there is the will to expand treatment. Drug use and certainly trafficking are crimes taken very seriously.  Here are just a few bullet points about complex problems in Southeast Asia.

  • Several tourist brochures carried this Advisory in a bold red text box:
    “In Malaysia, the Possession and Trafficking of Illegal Drugs carry the Death Penalty.”
  • Psychiatric patients, I was told, suffer almost equal discrimination and in treatment settings are called “inmates” and are “released” from hospital – not “patients” to be “discharged” or “transferred”.
  • Addiction “patients” do two years or longer in residential treatment – first offense, six months; second 6 – 24 months; third offense – years and maybe the key is thrown away.
  • We in the USA may think we face a workforce problem, but these Southeast Asian countries have very few counselors or “allied health professionals” as they call them. The need is great, but helpers are few.
  • We still struggle here with parity for addiction and mental health treatment, but addiction treatment is hardly on the healthcare menu screen of services in many places.
  • I met many dedicated local and ex-pat professionals from the USA, UK, and Australia doing their best to influence attitudes, raise consciousness, educate about addiction and mental health and develop staff and services.
  • My admiration goes to them acting as “missionaries” in the best sense of the word, not literally in the jungles, but certainly in the jungles of sparse healthcare resources and negative and cultural attitudes about addiction and mental health.

SKILLS

Perhaps you are happy to enjoy a “staycation” at home – no planes to catch (or pay for); no rental cars, hotel rooms or expensive restaurants to drain your bank account; no worries about who will look after your pets, plants and valuables. You’re at home taking it easy.

However if you are like me and find traveling to foreign countries fascinating and fun, then here are a few tips on foreign travel.

TIP 1

Travel tips for an overseas vacation

Foreign currency

You’ll need cash immediately you exit Immigration and Customs formalities – for taxi, train fare or a quick snack.  You can probably use a credit card for many things, however, if at all possible, I avoid using credit cards in foreign countries.  It’s bad enough -at home- to discover your credit card information has been hacked, and has been charged a flow of expenses you don’t recognize at all.  I feel even more vulnerable in a foreign country. You do not want to be waiting for a new credit card to be sent to you from all that distance.

  • Find a bank or investment institution that allows you to draw out cash in local currency from most bank ATMs , ones using the current currency exchange rates with no commission or bank ATM fees. I have successfully used a Schwab High Yield Investor Checking Account. (This is not a paid endorsement; there probably are other competitors I haven’t researched.)
  • Figure out ahead of time the money conversion math so you are prepared to do quick arithmetic and roughly know what something costs.  I had it easy in Borneo;  a quick division by 4 converted 100 Malaysian Ringgits into 25 US dollars equivalent. 1 Ringgit equaled about 25 US cents.
  • You can avoid the mental math method by simply using a currency conversion app on your smartphone. But that leads to my next tip:

SIM Cards

One of my first purchases is to switch out my iPhone SIM card for a local SIM card. This gives me gigabytes to check email on my phone, make phone calls and use apps or directions guides like Google Maps.

  • Use a reputable digital network company so your phone will likely work even in more remote areas of the country.
  • Having a local SIM card means you avoid the roaming feature of your home mobile phone network, which is much more expensive than a local SIM card and network.
  • Do you have the Skype app on your phone?  It is an inexpensive way to make international calls to family and work back home.
  • Better still for calling home, check if your hotel has free Wi-Fi service (most do these days); then call home using Skype on your laptop computer.  That makes communication (computer-to-computer) free, rather than incurring expensive roaming fees or long distance telephone charges. 

Tipping

Google the local customs about tipping. Do the math and research what tip percentage is customary.

  • Don’t assume you should use the same percentage formulas you use in the USA. Many countries don’t even have tipping as a general custom; or expect tips only in certain situations.
  • If you obtain foreign currency from a local bank ATM, they will be in large denomination bills. Change that into smaller coins or notes to be prepared with tip money, if needed.
  • Keep some tip money loose in your pocket or outer pocket of your handbag.  Avoid pulling out your wallet or purse displaying a wad of big denomination bills. Locals, especially unsavory characters looking to relieve you of your wallet, know what color notes are worth what amounts. At first you are oblivious just acquainting yourself with the coins and notes.  You may not initially realize the wad of green or blue notes represents quite a lot of money.

Electrical outlets

Before you leave home, check  the voltage and electrical outlet plug style used in your foreign destination country.

  • You can buy an adapter plug at airport shops before you leave or when you get there.  But I like to be prepared and buy ahead of time – and it’s less expensive on the internet.
  • Remember that whatever adapter plug you insert into the electrical outlet in the foreign country is not an electrical transformer that can convert your 110 volt hairdryer into the 220 or 240 volt system in the new country. All you’ll end up with is a fried hairdryer if it doesn’t say that your hairdryer works for a range of voltage systems from 110-240 volts.
  • If you are using a computer or other device that clearly indicates that it has a range from 110 to 240 volts, then you can safely just use the electrical outlet plug adaptor without concern of harming your laptop or another device.

TIP 2

From the USA to Southeast Asia – learning from our mistakes and experience

At the conference in KK, many of the countries represented are still quite early in developing addiction and mental health services.  Simply because we, in the USA, have been providing services for decades, doesn’t necessarily mean that longer means better than another country earlier in the developmental process.  I do happen to believe many things we do in the USA are indeed better.  But they better be better, because we’ve had more resources and more years to learn from our mistakes and celebrate our successes.

An old Chinese proverb says something like: “The foolish man learns from his own mistakes. But the wise man learns from the mistakes of others.”

Recognizing the many needs for services, but still early in their process, they are eager to learn.  I shared a few recommendations to help them learn from our mistakes:

1. In many countries there is a tendency to think the gold standard of addiction treatment is residential treatment. I  recommended they put greater emphasis on developing a broad range of community-based outpatient and supportive living services, in addition to residential and inpatient levels of care.

  • The USA also still thinks of residential levels first. As States react to the opioid crisis in the USA, the cry goes out for more beds, when we really need more community outreach, recovery supports, living environments, intensive care management and assertive community treatment for addiction just as is available more for severe mental illness.
  • Still too often, residential treatment is considered primary care and outpatient services just aftercare or continuing maintenance care.  As these countries design services from the ground up, I recommended they consider all levels of care important but if anything, put more emphasis on building community supports and services than large residential facilities. 

2. In a punishment-oriented culture, there is already a focus on long lengths of stay in residential and controlled environments for those caught using and dealing drugs. While it is true that longer lengths of stay help achieve good outcomes, that length of stay doesn’t need to be all in the one level of care e.g., residential. 

  • Just as we have historically had long lengths of stay (LOS) in residential levels in the USA, these countries would do well to not repeat our mistakes.
  • I encouraged them to focus on a broad, flexible continuum of outpatient and residential levels of care and to move clients through that disease management according to progress and outcomes.
  • Unlike our USA history of treatment, I recommended they plan for no fixed lengths of stay in any one level of care; and manage people in a broad continuum of services with variable LOS.

3. The USA at the Federal agency level still seems to not embrace addiction as a diseasethat manifests for some as alcohol and for others with drugs such as methamphetamine, heroin, nicotine etc.; and for still others, as gambling disorder. There is still in the USA a distinction between alcohol and other drugs. Hence the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA) exist as separate entities as if people come with just a drug problem or just an alcohol problem.

  • I recommended they notice how they already are predisposed to keep alcohol and other drug problems separate. In China, for example, people with alcohol problems are treated under the Department of Health. But those with other drug problems are treated under the jurisdiction of the police and criminal justice.
  • Decreasing stigma and discrimination about addiction has been hard enough in the USA. However in Malaysia, Singapore, Vietnam and other Southeast Asia countries, reducing stigma and discrimination has even a greater uphill battle when drug use alone has such severe legal and incarceration “treatment” consequences.

SOUL

You don’t have to travel overseas to understand different cultures.  But if you do have the opportunity to travel and see firsthand different people, customs, houses, joys and challenges, it sure comes alive.  Walking myself through some of the villages of Malaysia allowed me to really grasp what conference presenters face as they described their outreach projects to the villages.  What did I learn?  

  • In the villages, the main activity at the end of the day is a gathering of the families and friends to enjoy music on their guitars; and drink alcohol served from large jars on the ground circling the happy group.
  • Just about everyone in the village learns early on how to distill their own alcohol (e.g., home-made rice wine) so they are not dependent on spending huge sums of money, or having to travel to the local liquor store, which is not local anyway.
  • Alcohol is embedded in the social fabric of daily life. That can happen in our culture too, but when there aren’t a lot of options for activities in the village, music and alcohol rise to the top.
  • Conference presenters explained that teaching and expecting abstinence in the village is futile and naïve. They had to think what would be first steps that would work to start to change the culture and practices of everyone.
  • They started engaging the mothers and other women in an educational and change process. Women are the ones who traditionally draw from the large jars of alcohol and keep everyone’s cup full.
  • Once the women were engaged to make some changes, the first strategy was to move the jars away from the circle of music, laughter and drinking. The alcohol was then placed on a table away from the socializing, which meant, no more refills right where you sat. Want a refill? Sorry, you have to get up and go get it.
  • This small but significant change has started to shift the culture of drinking. 

One more anecdote on culture:

Singapore is up there for sophisticated, cosmopolitan and expensive living – nothing like the Malaysian villages. Singapore, however, is not advanced in their attitudes and treatment of their people with addiction. (How many strokes of the cane do you think you should get for your second flare-up of addiction?) There is still a very punitive and incarceration approach, thanks (I was told) to some expert psychologists from the USA. Some years ago they came, by request, to consult to government officials about what to do about addiction.  They declared that treatment for addiction doesn’t work; and this has been the “scientific” advice driving “treatment” ever since.

More enlightened addiction treatment specialists in Singapore recognized the importance of developing better community resources and mutual help groups for those trying to establish recovery in this cosmopolitan society. There are Alcoholics Anonymous and Narcotics Anonymous meetings.  But local people in recovery don’t relate well to meetings attended mostly by white ex-pats from the USA, Canada, Australia and the United Kingdom. What to do?

  • Harnessing the passion of the Chinese, Malay, Indian and other diverse ethnicities in the recovery community, they started mutual help groups much more inviting to local people.
  • Building on that growing community, more outpatient resources have blossomed to balance the government’s predominantly punitive and “lock them up” approach in Singapore and in the other Southeast Asian countries.

It was humbling to meet dedicated people running Non-Government Organizations (NGOs) and faith-based treatment programs who were countering the widespread negative attitudes about addiction and mental health.  Often on very limited resources and support, they respond courageously to the increasing need for services.

This is a time, in our current culture of fear, when some would respond by building walls, demonizing certain people and oversimplifying complex issues.  I am in awe of the people and the work they do in NGOs, humanitarian aid agencies and other outreach projects not only in Southeast Asia, but the Middle East, Africa and all around the world where it is not so safe and comfy as California or your neck of the woods.

October 2012 – Tips & Topics – october-2012-tips-topics

Vol. 10, No. 7 October 2012
In This Issue

SAVVY – “Relapse” revisited and reconsidered
SKILLS – Dealing with substance use in treatment and Deleting “resistance”?
SOUL – Who has influenced you and how did they get there?
SUCCESS STORY and SHARING SOLUTIONS: How one program is moving to individualized services

Welcome to the many new readers this month. Thank-you all for joining us for the October edition of Tips and Topics.

Senior Vice President
of The Change Companies®
(more…)

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…)

June 2007 – Tips & Topics – june-2007

TIPS & TOPICS
Volume 5, No.3
June 2007

In this issue
— SAVVY and SKILLS
— SOUL
— Until Next Time

Welcome to the June edition. Thank you to all who write expressing appreciation and offering your opinions. I read and appreciate them all, even if I can’t respond personally to each and every one.

(more…)

June 2005 – Tips & Topics – june-2005

TIPS & TOPICS
Volume 3, No.3
June 2005

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

Thanks for reading the June edition of TIPS and TOPICS. Welcome to all the new readers who signed up this month.

(more…)

November 2004 – Tips & Topics – november-2004

TIPS & TOPICS
Volume 2, No. 7
November 2004

In this issue
– SAVVY
– SKILLS
– SOUL
– Until Next Time

Welcome readers!

Since this is Thanksgiving time (at least for USA readers), I give thanks to you for reading TIPS and TOPICS, and to the many of you who have told me how much you appreciate receiving it. It is gratifying to me to know that TIPS and TOPICS has had a positive influence on many, and the ideas help improve treatment for the people we serve.

(more…)

December 2003 – Tips & Topics – december-2003


TIPS and TOPICS
Vol 1, No.8
December 2003

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

WELCOME!

Holiday greetings everyone! Thank you for reading this December edition of TIPS and TOPICS. I enjoy sharing some thoughts with you each month. I am glad that many of you find some tidbit to help you think about the work we do for the people we serve.

(more…)

June 2008 – Tips & Topics – 41

TIPS & TOPICS
Volume 6, No.3
June 2008

In this issue
— SAVVY
— SKILLS
— SOUL
— Until Next Time

Welcome to June’s edition of TIPS and TOPICS (TNT). Thanks for all your e-mail feedback and comments. I do appreciate them, even if I can’t respond to all personally. If you have a SUCCESS STORY to share, please send that along too.

(more…)

January 2008

Volume 5, No.9 | January 2008
In this issue


SAVVY | SKILLS | SOUL

David Mee-Lee M.D.


 

Happy New Year and may 2008 be a successful and productive year for you and your team.

January’s edition takes a fresh look at the Mission, Vision & Values of both your agency and your personal work. Similarly I also am taking a fresh look at my Mission, Vision & Values and -my website, www.DMLMD.com.

I am evaluating the website – what works, what doesn’t, what’s relevant, outdated, helpful, useless, unfriendly, missing, time-saving, cumbersome, easy, difficult. You name it —- the good and the bad! I want my website to be really useful to all the people I serve, including you, the readers of TIPS & TOPICS.

Many of you have given me helpful feedback about TNT. Now I’d like to harness your feedback to help me revamp the website. I want it to serve you better, and build on the community of TNT readers. So I’d like to meet you where you’re at: I need your opinion.

Look for a second email where you can express your opinions. There just might be some prizes for three randomly selected responders. We all love free stuff!

 

SAVVY

It seems there are hardly any cities, counties, states and health care systems NOT thinking about, planning for, or actively working on integrating services for people with co-occurring substance use and mental health problems. Administrators may decide to re- define their mission to better serve people with multiple needs. That doesn’t mean every frontline worker is ready and willing to suddenly shift focus. I have consulted with systems on this, and here are a few steps I suggest:

Tip 1

  • Assemble team members to take a fresh look at the Mission, Vision and Values of the agency or system involved in the change process.

Addiction counselors may not be interested in working with those “crazy” psychiatric patients, and mental health clinicians in working with “those people – those out of control alcoholics and addicts”. In fact these sentiments partly explain why clinicians may have chosen their ‘specialty’ in the first place. Suddenly they are now expected to work with clients with both problems (not that they weren’t actually working with them already.) The juices for working with co-occurring disorders don’t just automatically flow simply because administration declares a new direction.

Where does a system start in the change process? Team members will be challenged on their attitudes, perspectives and comfort zone of work competence. Include all important stakeholders to fashion the Mission. This meeting sets the context, and establishes the process of collaboration with all involved parties. It gives each person the opportunity to take responsibility for re-committing to his/her job. It is a time (if they are honest in their heart) when some may decide/declare they are not interested in, or committed to the new Mission.

When you arrive at discussing Values, the team identifies principles before policies, procedures and personalities. This discussion usually provokes the inevitable disagreements over “what to do” in a variety of clinical situations. What do we do if a client shows up to treatment having used alcohol or some other drug on the way? What do we do when a client refuses to take medication? What do we do when a client wants to stop methamphetamine or heroin, but keep drinking alcohol or smoking marijuana? When we discuss and name Values before a concrete clinical situation arises, this creates an anchor, a solid reference point to guide what to do in the heat of the moment.

–> For example, suppose your team agreed on this Value:
“Any relapse -whether in addiction or mental health – will be addressed as a crisis in a client’s treatment. This requires evaluation of the crisis and a revision of the service plan. We will not suspend, discharge from treatment, or have zero tolerance for relapse with any client – whether a substance use or mental health crisis.”

–> When the Value is discussed as a group, all team members have the chance to air their various points of view.

Tip 2

  • Develop individualized agency development plans and individualized staff development plans that recognize all agencies, program sites and team members are likely to be at different levels of preparedness to integrate co- occurring services.

Most clinicians are familiar with Stages of Change, and understand that clients seek help at different “stages of readiness.” Agencies (or program sites within an agency) are no different, just a larger organism. Staff also may be at different “stages” on being ready to adopt more integrated services. However, all would be expected to develop a formal plan that begins where they are comfortable, but also requires that they progress toward better integrated services.

–> Change leaders, technical assistance (TA) staff or consultants guide each agency/service site in the development of an “individualized agency development plan” matched to the stage of change and readiness for integrated services of that unit or provider.

–> They then monitor the progress of the individualized plans inside each agency in their service network.

–> Similarly each team member fashions an “individualized staff development plan.” This is done in collaboration with their supervisor, Change leader or TA consultant. The plan should honor each team member’s stage of readiness. It provides for training to increase awareness of the need for integrated services, as well as the skills to engage and treat people with co-occurring disorders.

–> Change leaders are personnel who have embraced the mission for integrated services. They are committed to improving services to the co- occurring population. To give Change leaders time to meaningfully participate in this mission, administrators and supervisors may need to adjust caseloads, job descriptions or duties.

SKILLS

It is fairly easy to stage training workshops, write up elaborate strategic plans and sketch out impressive timelines for goals/tasks to integrate services. The more challenging task is actually making change happen, the type of change which ends up making a difference on a daily basis to the people we serve in the trenches.

Tip 1

  • Develop specific implications for each Value raised in discussions of the new Mission and Vision.

Nearly every agency and company has a Mission Statement which very few team members can recall, let alone articulate, or explain concrete implications of the Mission.

–> Test yourself. Can you recite right now your agency’s Mission Statement without looking it up?
–> Have you always thought of it as being so generically lofty, “motherhood and apple pie,” so broad as to be of little practical use in the dilemmas and pressures of daily life on the job?

A good next step is to comprehensively explore and list all the implications for each Value you created. Let’s work with the example Value above.

It states: “Any relapse -whether in addiction or mental health – will be addressed as a crisis in a client’s treatment. This requires evaluation of the crisis and a revision of the service plan. We will not suspend, discharge from treatment, or have zero tolerance for relapse with any client – whether a substance use or mental health crisis.”

What would be the implications of such a Value? The list could include:

–> If a crisis of substance use, suicidal, violent or self-mutilation behavior, psychosis, mood instability should occur, all clients will receive timely assessment to address any immediate needs. We will revise the treatment plan to improve the client’s progress and outcome.

–>If a client’s relapse triggers reactions in other clients, this provides the opportunity to assist both the relapsing client, as well as helping other clients learn from their reactions to the relapse and crisis.

–> No client will be excluded from treatment because symptoms recur. But if a client deliberately undermines treatment by enticing others to use substances or violates boundaries with violence or impulsive behavior, we will likely discharge a client who is not interested in accountable treatment.

When you actually put pen to paper and write out the implications, this generates open discussion of often disparate ideologies and attitudes. When implications are made explicit -before confronting a “live” relapse crisis- this minimizes the inevitable conflicts which arise amongst people of different disciplines, personalities and life experiences. Remember, conflict is normal. There are policies and procedures that can make resolution more likely. See the February 2007 edition of TIPS and TOPICS for one example.

Tip 2

  • Work with team members in the same way you would with a client: i.e. challenge/ support one another in adhering to each team member’s development plan.

When a client presents for services, what drives the treatment planning process should be an alliance around what the client wants, and why they chose to walk in the door.

Here is the parallel process on the agency level. When a new Mission is written, it requires team members to re-commit to work in that agency. So each team member can ponder the following steps. Supervisors and Change leaders can facilitate the team member’s personal exploration by ensuring a strong, supportive, safe work environment:
–> What do you want that makes you choose to work here, especially with the new Mission? For example: being honest, do you just want a paycheck especially if you are close to retirement? Or are you getting ready to go to graduate school and want to be on the cutting edge of new directions? Or are you wanting a paycheck and not wanting to change what you are doing- in which case, your plan may be to transition out of the system if you are taking responsibility for your personal sanity and self-care.

–> Where are you at as regards the new directions the Mission promotes? What is your attitude, stage of change, comfort level and competence level? For example, if you see no reason to change the Mission, your personal development plan will require attention to some consciousness-raising. What information do I need to convince me of the need for change, before I am ready to focus on actually expanding knowledge and skills? If you are eager to be on the cutting edge of new technologies and methods, your development plan might have you lead the team in a journal club; or plan the in-service training curriculum; or be the local change agent champion.

–> How best would you acquire new skills necessary to promote the new Mission? Do you learn best by observation, trial and error, didactic presentations, individual supervision, group peer supervision, discussion of case examples, viewing videos, on the job coaching etc.? Your personal plan would include whatever methods will quickly and efficiently expand your knowledge and skills.

SOUL

I have not gotten on the Harry Potter bandwagon of incredibly successful books and spin-off films and merchandise. It’s not because I approve or disapprove; I just haven’t read JK Rowling’s works. Her fans may gasp at this point. What I do admire about her is how she pressed ahead when hardly anyone believed in what she had to offer.

In an interview recorded in TIME Magazine’s December 31, 2007 – January 7, 2008 edition, she was asked about her beginning fame. “It happened very, very quickly. I had written a book that I was told repeatedly was uncommercial, overlong, wouldn’t sell. So when it happened, it really was a profound shock.” That prediction about her book is right up there with “Who would want a computer in every house?” What successful author, musician, artist, entrepreneur, politician or athlete has not faced repeated failure, before eventually finding themselves contributing in a way they had set their sights on? And it is not just those professions. This is true for just about anything worth achieving.

Most of us are involved in work, leisure and community activities which do not require the kind of commitment and energy that it takes to run for the Presidency of the United States or to compete in the Super Bowl with a perfect win record of 18 straight games. But when you show up for work everyday, have you chosen to be there? Or are you just going through the motions? How cynical, burnt-out, compassion-fatigued, frustrated are you? When a flight gets cancelled due to weather, and I have to drive seven hours in freezing rain and snow to make sure the workshop goes on the next morning, the experience of frustrated, burnt- out and fatigued come to mind. All that melts though, when participants leave having gained a lot to help them in their work—and appreciatively feed that back to me.

Here’s what JK Rowling also said: “I hope my work sends the message that self-worth is about finding out what you do best and working hard at it.”

This won’t necessarily translate into instant fame and fortune. Who wants the paparazzi anyway? But it is a great formula for a meaningful way of being and contributing; and a potent antidote if you find yourself cynical, burnt-out, compassion-fatigued, and frustrated.

Until Next Time

Thanks for joining us for this first edition of 2008. See you in late February.

David