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.12, No. 9

Welcome to the December edition of Tips and Topics (TNT). Happy Holidays to everyone – chilly and cold for our Northern Hemisphere readers and sunny and warm for our Aussie and New Zealand readers.

David Mee-Lee M.D.

SAVVY

There is always a well-known solution to every human problem–neat, plausible, and wrong.” H. L. Mencken, Prejudices: Second Series, 1920. US editor (1880 – 1956) http://www.quotationspage.com/quote/282.html

 

Or I like the paraphrased version: “For every complex problem there is a simple and clear answer; and it is wrong.” When it comes to the conversation – or more accurately – the war of words and deeds currently raging on in the USA about race and alleged police brutality, there is not a simple answer. So I am adding my words on the subject for this edition; or more accurately I am adding my comments on a couple of other people’s perspectives on this important issue.

 

TIP 1

How do you view race relations in the USA and what solutions resonate with you?

 

Matt McDonell, a high school librarian in San Francisco, wrote in a Perspective he titled “The Conversation on Race – You can’t have a conversation on race if both sides aren’t prepared to listen.”

 

If you want to hear Matt speak what he has written below, here’s the link:

http://www.kqed.org/a/perspectives/R201412090735

 

“In college, I attended a Christian Men’s rally where two speakers, one white, one black, addressed racial reconciliation. Longtime friends, they had spent years working through these issues together.

 

When the white speaker addressed the white men present specifically, he exhorted us to pursue relationships with people different from ourselves, to acknowledge the privilege we are born into and not to hoard that privilege but use it for the good of all.

 

Then the black speaker exhorted the black men to not use racial oppression as an excuse to avoid responsibility for the example they set for their community.

 

The white men sitting in front of us seemed defensive and dismissive of the white speaker, but cheered loudly when the black speaker addressed the black audience.

 

I’ve been thinking about that rally while reading the responses to my Facebook posts during our latest supposed national conversation about race. I’ve noted who has more to say about the loss of black lives and who has more to say about violent protests and it tells me we have a lot to overcome if this conversation is going anywhere.

 

Nobody wants to be the first to blink and admit that not only is my perspective incomplete, but I also have a real and important part in the change we need. Admitting the other guy has a point doesn’t let him off the hook, and taking responsibility isn’t accepting blame.

 

In my experience, the reluctance to do either is a human condition that affects us equally. I see no group — racial or otherwise — more inclined to defensiveness or humility, blaming or repenting, being open-minded or willfully ignorant.

 

I am just as guilty of this as the next person, but I want things to change. I don’t have any pat answers, so for now I’m just going to try to listen better. Not just listen for holes in others’ arguments and jumping in whenever there’s a pause. I’ve been doing that for a long time, and it hasn’t resulted in any productive change for anyone. I want to really listen, and let myself be humbled,and let myself be changed.

 

With a Perspective, I’m Matt McDonell.”

 

My Comments on Matt’s Comments:

While driving in the Bay area December 9, I heard Matt McDonell’s views on San Francisco radio station KQED. It made me think about these points:

  • It’s natural to tune into people who think the same way we do. With the plethora of opinionated radio commentators and cable TV pundits,it is even easier to listen only to stations that reinforce our beliefs.
  • Notice how the white men were dismissive of the message they didn’t like even though exhorted by a man of their own race. It is hard not to be defensive when I hear a message that requires a change in attitude or behavior.
  • It’s also difficult, as Matt says, to “admit that that not only is my perspective incomplete, but I also have a real and important part in the change we need.”
  • It takes a real step of humility and open-mindedness to admit “the other guy has a point”, and to take responsibility to change one’s attitudes or behavior.
  • But I’m glad Matt also made the point that it doesn’t mean I am all to blame. The “other guy” might have to make some changes too.
  • Like Matt, “I don’t have any pat answers” either. But I remember a family therapist years ago teaching me how to look at a dispute between a couple or family member. The advice: the person who thinks they are most right should be the first person to reach out to the other “wrong” partner or family member.
  • If we all took that advice, we might all “really listen”, and might all “be humbled”, and let ourselves “be changed.”

 

Lisa Hendrickson is a Substance “Recovery” Counselor, from Utah who wrote an email to me with the Subject line: “Drugs NOT Race!!”

 

Dr Mee-Lee,

Please bring attention to a critical factor in the recent shooting stories. I’m a substance recovery counselor, and I’m scared there’s a wave of chemistry destroying our youth that everybody’s missing. Michael Brown (MB) had THC levels in his blood and urine consistent with current and past use of marijuana. He was either intoxicated, i.e., cognitively impaired, OR more likely, he was CRAVING – hence the strong-arm robbery of the cigarillos which are typically used to make “blunts.” People behave in irrational ways when they are in midst of very real biological “urges.” (Everyone can relate to speeding when in need of a toilet.) MB didn’t want to go jail; he wanted to go get high, and no one was going to stop him. THAT explains his bizarre response to being detained by Officer Wilson. It’s called “dope” for a reason – it turns off the “thinking” part of the brain!

 

Right after MB’s death, Dillon Taylor (white), was shot and killed in Salt Lake City while intoxicated on alcohol more than twice the legal limit. He had hinted that he would rather die than go back to jail. He ignored the cops’ orders and acted like he had a weapon. The Salt Lake cop (mixed race) who shot him was cleared because he was wearing a body camera that showed the alarming behavior of the suspect. Just last week another young man, Gil Collar (white), was shot in Mobile, Alabama while under the influence of LSD and engaging the police officer (black) in an erratic manner. I’m sure if we analyzed data nationwide we’d see a CLEAR pattern: People do stupid stuff while intoxicated regardless of their race or that of the cops!!

 

Lisa Hendrickson

Substance “Recovery” Counselor, (SUDC in the state of Utah)

E-mail: lhendrickson@sbhcutah.org

 

My Comments on Lisa’s E-mail:

I haven’t researched the facts in these cases to be aware of what Lisa raises as a possible common theme in these recent tragic situations. It made me think about these points:

  • There has been much focus on what the police did in the split-second decisions they have to make all the time to protect the lives of all involved.
  • But you don’t hear as much about what the victims were thinking and doing that brought them to the attention of the police in the first place: What were their attitudes and behavior when confronted by the police? How provocative or ambiguous were their physical gestures? How did they respond to questions that could have been interpreted as resisting arrest or endangering the police officer?
  • Lisa raises good points about how alcohol and other drugs is a common and even determining theme in all three cases. “Drugs NOT Race!!” is what she declares.
  • Emergency rooms, acute mental health facilities and other general health personnel too often fail to screen for, assess and treat addiction. Here too, Lisa is saying the focus, in her opinion, has been misguided: concentrated just on race and not drugs. She may have an important point that explains the victims’ attitude and behavior other than race as the assumed common factor.

SKILLS

I caught the tail end of a radio panel interviewed about race relations and exploring solutions.I heard a brief snippet from one woman who apparently does a lot of training of families and children about race and the interface with law enforcement personnel. I missed discovering who the wise panelist was, as I arrived at my destination and had to turn off the radio. This is what she tells parents to teach their children about how to avoid tragedies with police officers.

 

TIP 1

Teach your children to avoid being a RAT

I was taken aback at first when I heard Rat and children in the same sentence. But it soon all made perfect sense:

 

R – Don’t run from a police officer

A – Don’t argue with the police officer

T – Don’t touch a police officer

 

I tried a Google search to find the panelist and what she teaches. I didn’t find her, however I did find a related article “Teach Your Child How to Survive Being Arrested at School”. You can read the whole content here:

http://www.dailykos.com/story/2012/01/30/1059937/-Teach-Your-Child-How-to-Survive-Being-Arrested-at-School#

 

Listed below are a few of the tips the article advised. Michael Brown may well be alive today had he been taught this:

  • Teach your child to say “I want a lawyer” as soon as they see handcuffs. Include the “zip tie” cuffs as well as the metal cuffs.
  • Teach your child to put their hands on their head when a police officer talks to them.
  • Don’t run from the police.
  • Don’t argue with the police.
  • Say, “I want a lawyer.”
  • Don’t touch the police officer at all.
  • Don’t gesture towards the police: no finger waving, no flipping the finger, no waving arms, no shaking hands, no speaking in American Sign Language (ASL), nothing they can and will interpret as a hostile move.
  • Don’t talk other than giving your name and saying “I want a lawyer”: “My name is __ and I want lawyer.”
  • Ask “Am I under arrest?”
  • Keep your hands where the police can see them.
  • Do not consent to a search.
  • Don’t resist the arrest, innocent or not.
  • Remember the police officer’s name, badge number, and patrol car number.

Reference:

Originally posted to Practical Survivalism and Sustainable Living on Monday, January 30, 2012. Also republished by Education Alternatives and Community Spotlight.

SOUL

It’s hard to watch the video of how Eric Garner died on July 17, 2014, on Staten Island, New York, after a police officer used a chokehold or headlock to arrest this 43-year-old father of six. It seems baffling to understand why such violence was necessary. Even though Garner had a lengthy criminal history and was well known to the police, you wonder why such force was applied.

 

Just the other day on December 20, 2014, two New York City (NYPD) police officers were ambushed and killed by a 28-year-old man, Ismaaiyl Brinsley, in retaliation for the Eric Garner and Michael Brown deaths. Again, it is shocking to consider such venomous violence against two police officers who daily risk their lives to preserve law and order. One officer was married with two children. His colleague just got married two months ago.

 

I am allergic to violence. It never seems to solve anything: people beat up police and loot innocent people’s stores protesting police violence; police beat people who may have just beaten up someone else.

 

I know, it is not all protesters and not all police. I’m not taking sides because Marshall Rosenberg, Ph.D. taught me there are commonalities about violence that join all protesters and police together – in fact, that join all of us together.

 

I referenced Dr. Rosenberg and his leadership with Nonviolent Communication (NVC) in the February 2007 edition of Tips and Topics. See more detail in SKILLS of that edition:

http://www.tipsntopics.com/2007/02/february-2007/#more-83

 

Rosenberg said: “Violence in any form is the tragic expression of our unmet needs” (P.78)

  • The tragedy of verbal or physical violence is that it usually induces a violent reaction in the other person.
  • That victim of the violence is now sadly even less likely to want to resolve disagreements, let alone reach out to help fulfill the unmet universal human needs of the attacking person.
  • Yet it is these needs which fuels the violence in the first place. If those needs could only be acknowledged, appreciated and addressed, the power of the conflict would dissipate.

What might be the unmet universal human needs of protesters, police and all of us which is fueling the violence?

  • The need for: justice, safety, security, respect, acknowledgement, recognition

Rosenberg again: “When we listen for their feelings and needs, we no longer see people as monsters.”

  • The universal human experience is that we all have feelings and needs. Even the most obnoxious behavior and aggressive language arise from feelings and needs we have all experienced.
  • The recognition of these feelings and the fulfilling of these needs is what all people crave.
  • Can you see the “monstrous” behavior as if it comes from a helpless child crying out for help to get their needs met?

There is no vaccine for the virus of violence that feels like it is going “viral”. But despite my abhorrence of violence, I try to remember: “Violence in any form is the tragic expression of our unmet needs

 

Reference:

Rosenberg, Marshall B (1999): “Nonviolent Communication – A Language of Compassion”   PuddleDancer Press, P.O. Box 1204, Del Mar, CA 92014.

Until next time

Thanks for joining us this month. Happy Holidays and may you get the best gifts of all – love and health.  See you next year – in late January.

David

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

Readers’ Responses on Mainstreaming COD into AA/NA; the magic hotel elevator

Vol.14, No. 3

Welcome to the June edition of Tips and Topics. I’m glad you could join us this month.

David Mee-Lee M.D.

SAVVY

Last month I provided a few tips on “mainstreaming” people with co-occurring addiction and mental disorders (COD) into Alcoholics Anonymous (AA) and Narcotic Anonymous (NA) as support groups. If you missed it, you can check out the May 2016 edition: May 2016 Tips and Topics

 

There were a number of readers who took the time to write and give feedback, corrections and further suggestions. Here is their wisdom and perspectives as a follow-up.

  

TIP 1

Readers in long-term recovery share about their experience and advice

 

Reader #1

Hi, My name is Lynda and I have 31 years clean. I also am an LCSW and CADC. (Social Worker). I am very active in NA as well as AA. I agree with your article except how NA/AA may tell people not to take medication. That is an outside issue and it has been years since that kind of thought process has been around. If anyone has said it, it is rare and an individual’s opinion. Even in the recovery literature it says, “We are NOT doctors”.  

Lynda K. 31 years clean in NA/AA

 

My response

Thanks, Lynda for writing and for the feedback.  I’m glad to hear that it is rare that anyone would say anything about medication.  I know the recovery literature has been more advanced in that thinking but wasn’t sure if old-timer members had moved on.

Thanks for the info.

David

 

Reader #2

As a longtime member of AA, I want to thank you for a wonderful piece on integrating newcomers into the program. We have two kinds of members — those who know they have COD and those who think they are exempt (but are not) — we all have issues, whether we face them or not. Remember our expression, “some are sicker than others”! As a thinking person, I try to maintain the spirit of the Big Book and also debunk some of the nonsense that has grown up in the rooms. AA’s 12th step says “practice these principles in ALL our affairs” — to me, that means accept all comers with love, without discrimination as to what substance they used — or what “problems other than alcohol” they may have.

Phyllis B

 

 

Reader #3

Hi David:

I read with great interest your article on Mainstreaming. I would add to your list that the 3rd Tradition of AA states that the only requirement for membership is a desire to stop drinking. I remind persons of this Tradition when I suggest AA meetings. As a long time member of AA (42 years) I have seen many transitions while still maintaining the “singleness of purpose” that helps us survive and thrive. Just as we AA’s have accepted persons with other addictions, we are beginning to hear more persons share that they have been treated for mental disorders. The important thing to remind persons attending AA is that all are welcome but we focus on our problems with alcohol in an AA meeting. If he or she does not have an alcohol problem, then another meeting is more appropriate. Every meeting is different, but my bias is towards meetings that concentrate on “recovery” – what happened, and what it is like now – with that approach the drug of choice or behavior is not emphasized.

Susan B

 

My comment

Lynda K, Phyllis B and Susan B have between them, many decades of long-term recovery.  I appreciate their perspective on newcomers with COD attending AA/NA.  Just as “every meeting is different” as Susan said, different members may have different perspectives too.

 

Reader #4 below shares his view. I have excerpted and edited his message as English is not his first language, but I wanted to share his gratitude for long-term recovery and his perspective too.

 

 

Reader #4

I would like to share information on choosing 12-Step support group meetings, coming from my 15 1/2 years of experience.  In choosing a 12-Step Anonymous meeting an individual has to be informed of the language of the 12-Step meeting.  What I mean by that is, in certain meetings like AA you have to identify as an alcoholic to speak from the podium and they promote mainly discussing and sharing about alcohol.   If you don’t speak about alcohol, a member will point that out in whatever way fits their personality and it can cause embarrassment to the newcomer.

 

In NA when you speak from the podium or should I say “Share your Experience, Strength and Hope” there is certain language/words that are used and their concept about the disease of addiction is different. They don’t believe “Once an addict always an addict”.  They seem to believe at some time or another you are cured.  Their NA booklet teaches differently from AA concepts of the 12-Step program.  As for speaking from the podium in NA it is not favorable to use the word “sober”.  They use the word “clean”.  You are shot down, yelled at, and not in an appropriate way, embarrassed.   Surely the newcomer will feel “less than” and inadequate, and probably never attend a 12-Step meeting again.

 

I did not read in your information about Cocaine Anonymous (CA).  In their 12-Step meetings they have adopted the 12-Step program outlined in AA.   The meetings are warm and welcoming, and they welcome you to come as you are.  They allow you to share your experience, strength and hope in any way that is comfortable for you.  You do not have to walk on eggshells in Cocaine Anonymous.  “We are here and We are Free” Please visit ca4la.org.  I love Cocaine Anonymous and the 12-Step program outlined in the Big Book of Alcoholics Anonymous.  It got me in contact with a Power that was greater than me, that Power I choose to call God.  I understand this is not a religious program but a spiritual program that saved my life after 29 years of drugging.

 

I am currently attending a local university completing my Masters degree as an Marriage and Family Therapist in October 2016. God is Good! 

DH – “Willing to be of Clean and Sober Service”

 

My comment

Finding the meeting that is right for you takes some experimentation and willingness to try different groups.  So when a person says, “I tried AA or NA and didn’t like it” or “It didn’t work for me”, check out how many meetings and locations they tried. Too often they respond with something like: “I went to a couple of meetings 3 years ago.”

 

 

Reader #5

Dear Dr. Mee Lee,

I read with great interest your article on “mainstreaming” people with co-occurring disorders into AA/NA meetings.  As a recovering 12-step member with a co-occurring mental health issue – and a peer certified recovery coach who works in the addictions field – I can assure your readers that many, many people with substance use disorders also have co-occurring behavioral health disorders.  People with CODs are welcome at any Open 12-step meeting, and at Closed meetings if they believe or know they have a problem with drugs or alcohol.

While several of your diagnosis-specific tips for clients attending their first meeting are on point, your suggestion that someone with Borderline Personality Disorder (BPD) work with 3 sponsors is not something 12-step groups endorse. T he problem with multiple sponsors is that the sponsee can “play” sponsors against one another, much like children play parents against the other – getting a “No” from Mom, and seeking a “Yes” from Dad.  Because of this possibility, 12-Step fellowships suggest working with one sponsor.

Your suggestion to recognize similarities with others rather than differences is one of the most important things a newcomer can do. Addiction is one disease that manifests in a multitude of ways.  Whether an individual abuses alcohol, street drugs, club drugs, marijuana or prescribed medications, he or she can typically identify with the feelings of despair and desperation that brings us to the rooms of AA, NA and other 12-step groups.  This identification allows a newcomer – with or without a COD – to hear the life-saving message of recovery that these support groups offer.

Thank you for your ongoing commitment to the fields of addiction and behavioral health. 

Lisa B

 

My response

Thanks, Lisa, for all that information. Yes, I understand your points about the importance of one sponsor; and I should be careful as that was a bit of tongue in cheek, though a suggestion I had thought of as possibly viable. What should someone with BPD actually do? Would they just end it with the sponsor who might be burning out and start with a new one? Thanks for your advice.

David

TIP 2

Not all mutual help groups are 12-Step.  Consider SMART Recovery and other groups too

Reader #6

I just read your article on mainstreaming people with COD into AA/NA meetings.  I am an ardent supporter of SMART Recovery and urge you to refer to SMART and other alternative support groups such as Women for Sobriety and others.  The 12-Step model while being around for a long time doesn’t work for many people.  All too often the “keep coming back” admonition is counterproductive.  If people know that there are other groups whose approach is self-empowering, the chance of achieving sobriety is increased and your helping to educate the public through your publications will help that.

 

I was introduced to SMART Recovery about 5 1/2 years age when I was a patient in Cincinnati. I attended regularly and after about a year I took the facilitator training course offered by SMART.  I have been facilitating meetings since that time including one, which another facilitator and I started in the local county jail.  In January 2015 I began a term as one of the board of directors for the SMART national organization and am now the interim secretary.

 

I would be happy to do what I can to promote SMART, either by providing further information myself or asking the President Dr. Tom Horvath and or Treasurer and founder Dr. Joe Gerstein to do so.

 

Thank you

Bill Stearns

Reader #7

David, great advice regarding Schizoid/Avoidant personalities.  I have met one or two who do well with online meetings.  I’ve recently begun a SMART recovery meeting at our treatment program. Any thoughts?

 

My response and comment

I think it is great that you are starting a SMART Recovery group; and thanks for mentioning the option of online meetings. We need as many options as possible to give choices to match what works for people.

SKILLS

Two readers shared thoughts and skills coming from their long-term recovery.

 

TIP 1

Consider these tips to pass along to your clients and staff team

 

Reader #8

Greetings, David:

I’m glad you addressed the topic of introducing 12-Step (especially AA and NA) fellowships to clients with co-occurring mental health issues.  I especially appreciated your specific suggestions pertinent to particular diagnoses.

 

Some other thoughts that seem relevant:

1. Look for fellowships in your area that specifically invite individuals with co-occurring disorders such as Dual Recovery Anonymous (draonline.org)

2. Invite local fellowships to offer Hospitals & Institutions panels at your facility. (Meeting people who attend local meetings in this way can make it easier for someone to attend those meetings because they will already find a familiar face.)  Have staff available to debrief clients about how they felt about the panel afterwards.

3. If possible, take clients to some local meetings so they can become familiar with them (but be respectful: sensitive to the size of the meeting so that your clientele does not dominate it, and prepared to address clients’ possible disruptiveness).

4. Encourage clients to go to meetings together so that they can offer each other mutual support and thereby feel more comfortable than showing up in a roomful of strangers.  Having one or more “trudging buddies” helps stabilize and sustain meeting attendance.

5. Demystify some of the 12-Step meeting/fellowship arcana using psychoeducation:

 * How do I introduce myself during a meeting? (To avoid shaming, alert clients to language: people at AA meetings often are touchy about having participants introduce themselves as “addicts” or even “alcoholic/addict”; NA meeting members, likewise, can be feisty about participants who introduce themselves as “alcoholics.”)

 *  Why do people always introduce themselves, every time they speak, by adding “addict” or “alcoholic” to their name?

 *  What if I don’t feel like saying prayers or saying the word God?

 *  Why are most meetings so careful to discourage or curtail “crosstalk” and whyis this important?

 *  What is the role of, and what are appropriate expectations from, a sponsor?

 *  Do I have to say I believe in God to be a part of a 12-Step fellowship? How do Ideal with feeling excluded if I’m a non-believer?

 *  If I am called upon to speak by the person leading a meeting and I do not want to talk, how do I say no?

*  When the (7th tradition) basket is passed for donations, how do I avoid feelingshame if I do not have enough money to contribute?

 

6.  People who work with a substantial number of clients they wish to refer to 12-Step fellowships should themselves gain familiarity by attending an array of meetings and having the best possible working knowledge of the steps.

7.  For clients adamantly resistant to 12-Step fellowships, seek out other community mutual aid groups but investigate the quality of meetings before making a referral. Some of these “secular” support groups are not peer-led and organized by traditions that curb zealotry; some of their self-selected leaders are incompetent or inappropriate.

Michael G

 

My comment

There are a lot of good practical tips for clients and team members in what Michael G listed. Worth passing onto others.

 

 

Reader #9

Dr. Mee-Lee,

Your tips on offering some AA/NA etiquette programming are excellent.  We do a lot of that in our program, and it does help. Thanks.

Offhand, the only additional tips I would offer regarding how to prepare COD clients for AA or NA:

1. I would encourage them to focus on the truly basic reason we go, to “share experience, strength and hope.”  Anything at all that departs from that central focus could be seen as a product of our merely human natures.  We should practice tolerating and forgiving.

This relieves us of the worry brought about by having to memorize a list of responses to various eventualities.  And it’s good practice for a sober life.

2. I encourage my very mentally ill clients to do exactly as you advised – just go. Desensitization can set in, in a positive fashion, as some of the good stuff rubs off.  But, I have had schizophrenic clients’ misguided attempts to work the 4th and 5th steps, build themselves up to such a state of over scrupulous introspection, that they developed unnecessary delusions and hallucinations e.g., visualizing archangels in the sky, brandishing golden tablets and swords and whatnot.  I told one guy to just stop working the steps, just “don’t drink, go to meetings, and fellowship.”

3. All my clients I advise – be yourself.  Just be yourself sober.  Don’t worry.  Be honest, change just enough today to stay sober today, and take it easy.

My client Kevin, IQ 72, said, “I don’t understand the steps.  I don’t know what you are talking about when you talk about the steps.  But I know that when I drink, I get drunk, drive a car, and go to jail.  So I’ll come here instead.”  And all the guys with college degrees shut up and listened to Kevin.

Anyway, thanks, and nice work.

Anonymous Mike W

 

My comment

More good practical tips for clients and team members in what Anonymous Mike W wrote, especially in serving people with severe mental illness.

SOUL

I consider myself a well-traveled, somewhat road-warrior type used to all kinds of travel situations.  But…. earlier this month when I stayed at the Anaheim Marriott Hotel in California, I was blown away by the elevators.  I had never seen anything like it before.

 

How often, in a large high-rise, multi-floor hotel, have you stood at the base of a bank of elevators after pushing the “UP” button, only to see all the elevators ascending to other floors and nothing coming down to pick you up any time soon?  Or there are six choices of elevators, and you wonder which one will reach you first as you track their progress through each floor (of course when you want it in the Lobby level, it is on the 20th floor).  A bell rings signaling an elevator car door has opened.  You look around trying to find which one it is, only to see the doors shut.  You’ve missed that one and now the process starts all over again.

 

This does not happen at the Anaheim Marriott (no royalties were paid for product placement in this SOUL section).  Here’s what intrigued and delighted me:

  • You go to the elevator lobby with six labeled elevator cars (A, B, C, D, E & F) just as in a regular old-fashioned elevator setup.
  • Previously you would press an UP or DOWN button and patiently wait for a door to open.  NOW here’s what you do…. you punch your desired floor number into a keypad (where the old UP and DOWN buttons used to be) e.g., “10”.
  • Immediately in the mini screen of the keypad device a letter (A – F) appears with an arrow pointing you left or right, in the direction of where the elevator doors will open. The notification is instant and the arrival is surprisingly soon after.

If I didn’t explain that very well, through the wonders of the internet, I found this link that explains more (if you are really into this): Thinking outside the elevator box   

Every time I used the elevator that conference week, I remained equally impressed with the efficiency and effectiveness of these new “magic” elevators.  Want the 10th floor? Just punch in “10” and very quickly the elevator was whisking me to the 10th floor.  No floor number buttons to further search and press inside the elevator.  No missed elevator cars because the mini screen told me which of the A – F doors to wait for and where.

 

This may be way too much information about a silly little elevator story.   Perhaps this is something you probably have to touch and experience for yourself to get the full impact.  But for an old road warrior, who thought he had seen just about everything USA hotels had to offer, this was a truly novel experience.

 

Next time you visit a high-rise, big city hotel notice how inefficient the elevator experience is – unless, that is, you are at the Anaheim Marriott Hotel, California or the Sheraton in downtown New Orleans. (Now I’ll hear from scores of readers who’ve seen these elevators for years and I’ll know how naïve I really am.)

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…)

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

Vol. 10, No. 4 July 2012

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

Senior Vice President
of The Change Companies®

(more…)

February 2011 – Tips & Topics – february-2011-tips-topics

TIPS & TOPICS
from David Mee-Lee, M.D.
Volume 8, No. 10
February 2011

In this issue

SAVVY – Nonpharmacological approaches to chronic pain

SKILLS – Evaluating and engaging pain clients

SOUL –Choosing Forgiveness

Until Next Time

Welcome to the February edition of TIPS and TOPICS (TNT).

(more…)

September 2010 – Tips & Topics – september-2010-tips-topics

TIPS and TOPICS from David Mee-Lee, M.D.
Volume 8, No. 5
September 2010

In this issue

-SAVVY: Psychiatric diagnosis gone wild!

-SKILLS: Working with People, not diagnoses

-SOUL: My favorite meals

-STUMP THE SHRINK:
Substance Abuse /Dependence-one size fits all?

-SHARING SOLUTIONS: Readers share their experiences with aging

-Until Next Time

Welcome to the September edition of TIPS and TOPICS.
A number of readers were prompted by the July/August edition to share their experiences with aging parents. Excerpts of their comments and wisdom appear in the occasional section-SHARING SOLUTIONS.

(more…)

March 2006 – Tips & Topics – march-2006

TIPS & TOPICS
March 2006
Vol 3. No.10

– SAVVY
– SKILLS
– SUCCESS STORIES
– STUMP THE SHRINK
– SOUL
– Until Next Time

Welcome to TIPS and TOPICS, especially the many new readers who have joined us recently. This month’s edition follows-up the February edition which focused on paperwork and the search for more meaningful and efficient ways to address the universal paperwork frustrations. The comments, questions, suggestions and success stories generated by last month’s topic prompted me to extend this paperwork focus for the March edition.

(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.

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February 2005 – Tips & Topics – february-2005

TIPS & TOPICS 
Volume 2, No. 10
February 2005

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

Welcome to the February (soon to be March) edition of TIPS and TOPICS. Thanks to all who write with comments and questions. I respond to as many as I can in a timely fashion, but please excuse my tardiness. I do read and appreciate all your messages.

(more…)

April 2006 – Tips & Topics – april-2006

TIPS & TOPICS
Volume 3, No.11
April 2006

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

Thank you for joining me in the April edition of TIPS and TOPICS. I appreciate the positive comments I receive either by e-mail or onsite when I am training. I’m not planning a formal survey, but if you are moved to express appreciation, this helps me to know what works with TIPS & TOPICS. If you write me, just say briefly what works for you, and what you find useful in general about this newsletter.

(more…)

November 2003 – Tips & Topics – november-2003

TIPS and TOPICS
Volume 1, No. 7
November 2003

In this issue
– SAVVY……..
– SKILLS……..
– SOUL………
– STUMP the SHRINK…
– Until next time……

WELCOME!

Welcome to November’s edition of TIPS and TOPICS. Thanks to all of you who take the time to write to tell me how you are appreciating and using the TIPS and TOPICS with your team and agency. I may not have written you back, but I do read all your messages and am very grateful for your comments and questions.

(more…)

May 2004 – Tips & Topics – may-2004

TIPS and TOPICS
Vol 2, No.2
May 2004

In this issue
– SAVVY
– SKILLS
– SOUL
– STUMP THE SHRINK
– Until next time

WELCOME!

Welcome to the May edition of TIPS and TOPICS. Unlike big magazines like TIME where you receive the week’s edition before the date on the cover, this humble effort usually comes late in the month. Finding the “spare time” to get this to you often gets lost in other deadlines. But here it is.

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April 2004 – Tips & Topics – april-2004

TIPS and TOPICS
Vol 2, No.1
April 2004

In this issue
– SAVVY
– SKILLS
– SOUL
– STUMP THE SHRINK
– SUCCESS STORIES
– Until next time

WELCOME!

This April edition of TIPS and TOPICS marks the beginning of the second year of these monthly bits and pieces from me to you. If you have been getting these from the very first edition, I hope they have been useful in your work and life. If you are new to TIPS and TOPICS, welcome to an unscripted array of issues that arise from reflections about my training and consulting practice (often as I sit on airplanes).

(more…)

June/July 2004 – Tips & Topics – junejuly-2004

TIPS and TOPICS
Vol 2, No.3
June-July 2004

In this issue
– SAVVY
– SKILLS
– SOUL
– STUMP THE SHRINK
– Until next time

WELCOME!

Welcome to the June/July edition of TIPS and TOPICS. This monthly publication just suddenly turned into a two-editions-in-the-summer, “monthly” newsletter! You will receive a July/August edition around mid to late August. You can also see this and previous editions on my website.

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April 2009 – Tips & Topics – april-2009

TIPS & TOPICS
Volume 7, No.1
April 2009

In this issue
— SAVVY
— SKILLS
— SOUL
— STUMP THE SHRINK
— SUCCESS STORIES
— SHAMELESS SELLING
— Until Next Time

Time flies when you are having fun. This month’s edition begins year seven of TIPS and TOPICS (TNT). A special welcome to those of you who have been here from the beginning with our first edition in April 2003. If you are a new subscriber, welcome too.

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February 2009 – Tips & Topics – february

TIPS & TOPICS
Volume 6, No.10
February 2009

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

Welcome to all the new readers who joined us this month and to our long-term readers as well. I understand we all receive a lot of information in our inbox each day; I appreciate your taking the time to look this edition over.

(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