January 2012

Vol. 9, No. 10
In This Issue


SAVVY – What do you do when a severely mentally ill person keeps using substances?
SKILLS – Clinical and systems questions, suggestions and solutions
SOUL
Politics of personal destruction
STUMP the SHRINK
Addiction relapse and confidentiality and the courts

 

David Mee-Lee M.D.


SAVVY

For many years, I have been doing case consultations with clinicians and Assertive Community Treatment (ACT) teams who work with severely mentally ill people.

One consultation question continues to come up year after year. The question is this:

What do you do with a client who is ambivalent about, or even outright uninterested in, stopping or cutting back on their alcohol and other drug use?

In addiction treatment, counselors can try Cognitive Behavioral Therapy (CBT), Motivational Interviewing and other methods to try attracting a person into recovery. If these strategies fail to engage the client, it is not unusual for clients to drop out of treatment or even be discharged as “non-compliant”.

For mental health programs and clinicians…. When working with these clients (those with severe mental illness and co-occurring substance use problems) it becomes very difficult to discharge the client- even if they wanted to. The goal of treatment is to attract people into recovery and to make real change, not getting rid of clients when outcomes are poor.

SAVVY this month is not about imparting some nifty tips on this particular topic. There are many clinicians, consumer advocates and peers more expert than me on working with severely mentally ill people. I am opening up this topic to harness that expertise out there. How do we improve clinical and systems approaches to people with co-occurring severe mental and addiction illness?

TIP 1

Consider the clinical and systems dilemmas in working with severely mentally ill people who are not interested in treatment for their substance use problems.

Here is a clinical vignette to set the scene:

 

A client diagnosed with a schizophrenic disorder repeatedly and firmly declines any addiction education or treatment.

  • Diagnostically, the mental health team identifies a clear Substance Use Disorder; the client even acknowledges his alcohol and drug use, but declares no interest in changing his substance use.
  • The mental health team has very little leverage to create incentives for treatment.
  • They have already implemented strict representative payee management of funds by paying for his housing directly with the landlord. They accompany the client food shopping so they can pay the supermarket directly. They give him very little spare cash to discourage using his disability income for drugs or from his being mugged and robbed while intoxicated.
  • Despite such tight care management, the client is able to make enough money (by panhandling and odd jobs in addition to his disability payments) to use those funds to buy and use alcohol and other drugs.
  • The client’s addiction and his mental illness interact creating crises to which the ACT team is compelled to respond. For example—- They transport him to detox if he has run out of money and can’t buy any more drugs for now. They have frequent care management visits to ensure the client is safe and has not overdosed, as has happened several times before. There are other interventions directly related to the client’s refusal to moderate his substance use and get any treatment.

Dilemmas I hear from the clinicians about the clinical and systems implications:

 

1. We want to be responsive to consumers in crisis. But we spend so much time and energy “picking up the pieces” of the clients’ drinking binges and substance-induced psychiatric emergencies, that it seems more like babysitting an out-of- control adolescent.

2. It seems like we waste a lot of treatment and care management resources watching the revolving door of frequent detox admissions and acute psychiatric crises in the emergency room. Clients are not held accountable for their behavior. Then we use expensive treatment and wrap-around resources to deal with the aftermath of their refusal of addiction and/or mental health treatment.

3. I feel like I am “enabling” the client – giving the explicit and implicit message that you can do whatever you want and we will keep “bailing you out”, literally and figuratively. For example, the consumer is evicted from housing because of noisy partying with intoxicated friends, and we scurry around to find a new apartment or hotel room. The client loses his/her disability money due to being robbed while intoxicated, and we make sure the client gets food and shelter.

4. I know about harm reduction, and “Housing First” initiatives which provide housing regardless of a consumer’s commitment to treatment. (See SAVVY, Example D. June 2009 http://www.changecompanies.net/tipsntopics/?p=807)
I see the value of meeting the client where they are and attracting them into recovery. But where do we draw the line? We clinicians feel frustrated and disempowered by what seems to be:
Giving clients the wrong message about personal responsibility and the consequences of a person’s choices.

Inefficient and ineffective use of treatment and care management resources, especially with tight budgets which already means many consumers are unable to access services.
Systems’ mandates that we do ‘whatever it takes’ to keep people in the community, but then staff feel like glorified servants responding to every demand or crisis. Some clients are so used to being transported to appointments, provided food and shelter whenever they have mismanaged their resources, that they have now been trained to say whatever it takes: “I’m in withdrawal and need to go to detox” or “I’m suicidal or hearing voices telling me to kill myself”.

5. I know the importance of establishing a therapeutic alliance and adopting a recovery-oriented, strength-based approach. But how do you attract a person into recovery and help them to see and experience their own strengths and skills, when there is no agreement on a treatment goal of abstinence or cutting back; no agreement on interventions (“I don’t want medication or addiction treatment”) and the working relationship with the client is based on the care manager’s task to fix every housing, transportation or behavioral health crisis?

There you have it!

–> Do you resonate with these dilemmas? Or work with people who do?

–> Do you have solutions you can share?

–> Are there hidden attitudes, biases or values in the way these dilemmas are expressed?

–> Is there a need to change anything we are doing with ACT teams, care management, housing and community reintegration for the severely mentally ill?

SKILLS

As I said, I don’t have all the answers to these clinical and systems dilemmas. But here are some tips to get us started. Actually they are more questions and suggestions than tried and true solutions.

TIP 1

Balance care with confrontation; support with accountability.

 

Mental health systems have a long tradition of caring and supporting people. Some state hospitals still have patients who have lived there for years and even decades. In some private psychiatric hospitals, some treatment models were designed to create the community in the hospital, where patients stayed for months and years.

Addiction treatment has had a long tradition of confrontation and accountability. If a client has alcohol on his breath, he is confronted and may be told to leave. Or if she is late to a group session, the door might be locked. If there is a positive drug screen result for cocaine or opiates, the outcome may be discharge or a legal sanction.

When mental illness and addiction come together, finding the right balance is especially difficult with those with severe mental illness.

How do you find the right balance?

  • The balance between: Empowering consumers to make their own choices, recognizing the strengths and skills they have for recovery and overcoming institutionalization; while at the same time taking care of their housing, transportation, food, income and treatment regardless of what choices they make?
  • The balance between: Having them be accountable for their choices (with the natural and logical consequences of those choices); while at the same time- recognizing their mental and addiction illness may severely compromise their ability to choose effectively?

TIP 2

Assemble all stakeholders to brainstorm about these clinical and systems issues.

 

We need ALL people at the table to find the right balance: consumers and consumer advocates; behavioral health administrators and funders; clinicians, care managers, treatment personnel of all disciplines and credentials; providers of housing, board and care homes, shelters; mental health and drug courts; criminal justice personnel. Even politicians need to be part of the conversation as they frequently have to face the community outcry about mentally ill, intoxicated homeless people roaming the streets.

What could be some innovative clinical and systems solutions which would have the following goals?

Efficient and effective use of treatment and care management resources.

Design and develop a more flexible continuum of treatment and care management services than the current one, which is funded more narrowly with Intensive Case Management (ICM) and ACT teams.

Pilot different clinical approaches to minimize “enabling”. Find approaches successful at holding clients accountable for their outcomes, balanced with their level of severity, recovery potential, skills and strengths.

TIP 3

The Farm – Design a pilot project which promotes recovery, accountability, dignity and success experiences.

 

There are about 15 therapeutic farms in the United States where residents are offered “a tranquil place to learn the value of work and community.” (Behavioral Healthcare, 2009). For a long time I have wondered if a State or County would try a pilot project for the kinds of clients described in SAVVY above. Instead of repeated crises (plus the revolving doors of detox, psychiatric emergency visits, hospitalizations, an array of board and care, hotel rooms, group living and 24 hour supervised living) ……..imagine The Farm!

“The Farm” would model itself on the experience of therapeutic farms having their roots in the 18th century, combined with using strategies and successes of present day therapeutic farms. Naturally much more dialogue is needed to sort out the clinical and financial aspects. The therapeutic farms in the 2009 article are treatment settings that require a daily cost of $150-$250/day. The Farm, as I envision it, would be more a longer-term, supportive, therapeutic community at a lower cost.

Here is the vision:

 

1. Every day, care managers are taking control of repeated failure experiences with clients. Instead… The Farm would provide daily success experiences “enjoying the calming surroundings…..daily interactions with pigs, sheep, horses, cattle, and other animals, as well as work in flower and vegetable gardens.”

2. Every day now, consumers get the message reinforced that they can do whatever they want and the treatment team will pick up the pieces. Instead….The Farm would be “a tranquil place to learn the value of work and community.”

3. Every day, resources are spent, inefficiently and ineffectively, providing acute care detox and psychiatric services. In addition, social services and criminal justice costs are incurred. Instead…..The Farm would provide 24-hour support and services at a fraction of the costs now spent too reactively on acute care, care management, social and criminal justice services.

For clients with severe mental illness refusing to consider cutting back or stopping their substance use, the time would come to stop “enabling”:

“You are either unable or unwilling to function stably in the community. Instead of repeatedly trying to make you function in the community with the ACT team reacting to crises, the plan is to have you live at The Farm. There, you will be supported on a 24-hour basis, because right now we are reacting to your crises rather than being proactive promoting recovery for you. Because The Farm is in the country, you will not be able to come and go, so you might find this more restrictive than you are used to. However we want to give you a chance to be safe, supported and successful.”

 

We can anticipate some clients’ reactions to hearing of this pending change in their living situation. Many clients might object, emphatically stating they don’t want to go to The Farm. They want to roam free, able to do whatever they want, when they want, with whom they want, as they have been doing. Clinicians are frustrated as they have the goal of recovery and sobriety for their clients. Such clients have not agreed on this recovery goal. Now we have a better chance to create agreement on the treatment goal: to avoid going to The Farm. Now we have a chance to focus on improving mental health and substance use functioning.

“I understand why you want to roam free, do what you want to do, when you want and we want that for you too. It’s just that when you keep acting as if you can’t function well yourself in the open community and we have to keep picking up the pieces, that we think about The Farm. Would you like to work on not having to go to The Farm? If so, we can then work on what methods and strategies will improve your functioning in the community so you can stay independent and not need The Farm. However if the outcomes don’t change and we continue to have to “bail you out” as often as we are now, then we have no alternative but to have you be safe at The Farm.”

 

Such a pilot project would achieve the balance of care with confrontation, of support with accountability. This means ALL stakeholders would come to the table to fashion this project. The aim would be: to promote recovery, personal and fiscal responsibility, dignity, success experiences, choice and empowerment.

I believe it is high time to examine the unintended negative consequences of the safety net, ACT and ICM wrap-around services we have created.

References:

 

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

 

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

 

SOUL

Here is one reason I know I will never run for political office…the Politics of Personal Destruction.

You may remember that President Bill Clinton used that phrase in 1998 when under fire for his relationship with Monica Lewinsky. Go back—more than 200 years ago in 1808, Massachusetts Governor Sullivan told Thomas Jefferson that the “principal object” of the Federalists appeared to be “the political, and even the personal destruction of John Quincy Adams.”

I’m no historian, I just Googled it.

I know that when people run for political office, especially Presidential political office, they are not naïve about the Politics of Personal Destruction. Or if they were naïve, they soon wake up. How many times have you seen a candidate say: I am going to take the high road…propose positive solutions not negative attacks against my opponents…uplift and inspire people, not drag opponents through the gutter.

Either…you don’t hear much from them anymore because they drop out of the race, because they have not responded and countered with negative attacks of their own which they know can take them “off message”, Or…. quickly they fight back and start their own negative attacks (or their proxies do). It is just a fact that in politics part of the process of winning the prize requires you to beat the other person down to stand on their shoulders to get to the top.

I have no illusions this will ever change because conventional human nature likes conflict, a good fight, winners and losers, a good debate with clever, cutting sound bites. Imagine if the Super Bowl was played just for the fun of it and no one kept score. There would be no “Super” in the name. Instead of a prime Sunday afternoon time slot, the game would air at 1 AM on your local town cable network- if it aired at all. In political debates, your poll numbers go up if you show you can fight back and defend yourself, and they go down if you are too nice and accepting.

This all seems so opposite to what we value when trying to help people recover and have hope for an empowered life.

We tell clients: Succeed by harnessing what is good and effective in your life, not tearing yourself or others down. Focus on what can be, not on your past failures and shortcomings. Learn from your mistakes, however your mistakes are not the essence of who you are, or how you have to act in the future.

Oh well, I’d much rather live in a democracy than an autocracy or theocracy. So the Politics of Personal Destruction comes with the territory. No political candidate will be beating down my door for consultation on how to run their campaign.

Just so long as the politics of personal destruction doesn’t come anywhere near the business of helping people change and grow.

 

STUMP the SHRINK

 

Question

Dr. Mee-Lee:

“Please direct me toward an answer to this question. I understand the CFR 42 (Federal regulations on confidentiality of alcohol and drug abuse patient records) to say that information about a person’s drug use cannot be used legally, punitively against them. Yet, frequently when we report a relapse to a client’s probation agent, the client is violated or taken back to court. Do we as a treatment program hold any liability for actions taken by corrections or the court after we report chemical use?”

Resa Walker, MS LADC, CCDP-D
Program Director
Neighborhood Counseling Center Dual Disorders Program

My response

Resa:

Thank-you for your question, which is a tricky one. I don’t think you are liable legally if you give a progress report and the court uses it to violate the person, though I understand your dilemma. You would probably be more liable if you refused to give the information of a relapse. The solution, which is worth working on (I have written about this before in Tips and Topics and elsewhere) is to work on your relationship with probation officers and the court to have the court mandate assessment and treatment adherence.

Thus, if someone uses or relapses while in treatment, and the client is willing to change their treatment plan in a positive direction, then you can report that even though the person used, they are still in treatment and complying with the court order. Explain that the person has agreed to change their treatment in a positive direction and therefore should continue treatment rather than interrupt the treatment with re-incarceration or something else that breaks the therapeutic alliance.

If the client is not willing to change their treatment plan in a positive direction, then they are not doing treatment. They can be violated as non-compliant with the court order to do treatment. They are not being sanctioned because of relapsing or using, but because they are not doing treatment.

Thanks,
David

Resa

“Thank-you for the response. It was helpful, but an ongoing dilemma due to our philosophy of harm reduction with the goal of abstinence and recovery.”

SHARING SOLUTIONS

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

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

** An E-Learning Training Module**

ASAM Multidimensional Assessment Course

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

Continuing Ed Credits?

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


** A Participant Interactive Journal**

Understanding the Dimensions of Change

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

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

 

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

 

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

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

Until next time

Thanks for reading. Join us in late February.

David

January 2010

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


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

David Mee-Lee M.D.


(more…)

October/November 2005

Volume 3, No.6
In this issue


SAVVY- SKILLS | SOUL

David Mee-Lee M.D.


 

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

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

 

SAVVY

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

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

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

Tips:

  • Turn frustrations into systems solutions.

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

Everybody has frustrations.

Here is Gerber’s definition of frustration:

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

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

There are 3 types of frustrations:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Systemic Thinking:

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

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

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

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

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

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

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

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

*** Relationship as spiritual practice

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

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

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

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

SKILLS

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

Tips:

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

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

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

Ask these 3 questions of any frustration you might experience.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Specify and quantify further.

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

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

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

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

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

Summary:

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

STEP 3. Seek system solutions

Ask this question.

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

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

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

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

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

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

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

  • Choose to Thrive as a Conscious Choice and Process.

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

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

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

Here is my mission statement and values:

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

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

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

SOUL

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

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

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

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

Happy mowing.

Until Next Time

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

January 2017

Vol. 14, No. 10
In this issue


Enduring principles as healthcare changes
Customer & team values
Marchers’ messages

David Mee-Lee M.D.


(more…)

Vol. 10, No. 12 | March, 2013

In This Issue

SAVVY and SKILLS
Dr. Mee-Lee’s Clichés and what they mean in clinical work and systems change

 

SOUL
First steps – from baby to toddler; and a request reminder for the 10th anniversary edition

 


SAVVY and SKILLS

 

I don’t know about you…. but if you find yourself saving a good article you read, or keeping the notes of a great lecture you heard, it is easy to accumulate boxes and boxes of material over the course of a career.  I wouldn’t classify myself as a hoarder, but you never know when you might want to refer to that article or lecture notes again!Trouble is, you rarely go back through those boxes of pearls of wisdom.  All that valuable material clogs up file cabinets, boxes in the garage or piles on your desk. Or is this just me!?

Anyway, the point is: I am in the process of radical de-cluttering, meaning I am dumping boxes and boxes and boxes- old policy and procedure manuals, yellowed articles pulled from journals and magazines aeons ago, old lecture notes, handouts I knew I would review someday when I had some ‘spare time’….

In the course of that cleansing process trying to achieve good feng shui (look it up on Google), I came across a page of “Dr. Mee-Lee’s Cliches. ” A workshop participant had compiled these as he listened that day thirteen years ago in Phoenix, Arizona. At the end of the day, he handed them to me. I still have his yellow notepad page. I don’t know what the topic was – probably a workshop on the ASAM Patient Placement Criteria, which by the way, we are revising (more on that in another edition of Tips and Topics soon).

So for March, SAVVY and SKILLS is combined.  I am covering some of the phrases on that list compiled by a good listener at my workshop…..or perhaps he was just trying to stay awake by writing stuff down.

TIP 1

Here are some clichés and the meanings and ideas behind them (or at least, my ideas)

Firstly, to say a person is using clichés is not necessarily a complimentary thing to say.

“The term is frequently used in modern culture for an action or idea that is expected or predictable, based on a prior event……A cliché is often a vivid depiction of an abstraction that relies upon analogy or exaggeration for effect, often drawn from everyday experience. Used sparingly, they may succeed, however, the use of a cliché in writing or speech is generally considered a mark of inexperience or a lack of originality.” (Wikipedia).

I don’t see myself as inexperienced or lacking originality. I’ll just ignore that part of the definition of a cliché and focus on the “vivid depiction of an abstraction…drawn from everyday experience.” Here are a few of the clichés that were on the list. I’ll address the meanings and ideas behind the saying as they relate to clinical practice and to systems issues.

1. Turn a blind eye or a deaf ear

Clinical: How often do we see and hear a client saying to us that they are not interested in abstinence, wellness and recovery while we steamroller on with mandates to go to 90 meetings that they don’t like in 90 days? Or comply with medication that gives them more side effects than benefits?

It is as if the focus is on what we think the client should do. It’s like we don’t care what we see in their body language and whether they participate, or not, in treatment. Also it is as though we don’t listen for discord and disagreements they may have with what we are prescribing for them.

Systems: When it comes to systems of care, it sometimes seems they are actually designed to be blind and deaf to the pain of the people we serve.  Do we still provide and fund programs with limited levels of care and inflexible lengths of stay that force us to put people on long waiting lists? Or cause people to call everyday to demonstrate their motivation to access services, even those in severe withdrawal?  Is there no way to see and hear the anguish such waiting lists cause? Can we really not design a better system of care that increases access to care, yet still uses resources efficiently and effectively?

2. Keep their feet to the fire

“Putting someone under pressure. Forcing, or trying to force, someone to do something.”

Clinical: Since all lasting change is self change, forcing change is not likely to last beyond the time you have the “big stick.” But an effective way to reframe this cliché is to hold a person accountable in their mandated treatment experience by focusing on what they really want.

Clinician: “I don’t see, Joe, how you are making a strong case for getting out of 24 hour care when you continue to threaten the staff and get into fights with your roommate. It makes it look like you are too unstable to manage things in the outside community.” This is how to keep clients’ feet to the fire, to stay accountable for their treatment without forcing them to do something.

Systems: The same principle applies if you have staff members more focused on complaining, gossiping, backstabbing or even dragging down morale through negativity and sub-par work. Theoretically you may have the power to write them up and order them to do their work. However if you would rather create a healthy work environment of accountable self-change, there are other ways to keep their feet to the fire.

Do you have a functioning conflict resolution policy, one which empowers people to speak up, advocate for what they believe in, while at the same time requiring respectful communication and resolution? Now there is no tolerance for gossip, negativity or intimidation. It is everyone’s right and obligation to resolve conflicts and keep communication healthy. Do you have effective supervisors who can support supervisees, but also set limits?

3.Keep your eye on the prize

Clinical: Clients and clinicians can easily get distracted into sidetracks that lead nowhere productive. How often do you struggle with clients more focused on telling you how the food or their counselor stinks, how unfair their parents, boss or probation officer are, or how they “don’t even have a problem”? It’s easy for both clients and clinicians to descend into arguments about treatment compliance around medication or rules of the program, and get distracted from “the prize”.

Clinician: “Joe, we can talk all day about how unfair your boss is, or we can put our energy into gathering the data to prove you don’t have an anger or addiction problem. That way we can show her you are a good worker who doesn’t deserve to be fired.”

Systems: Your agency’s mission, I imagine, is to help people achieve their full potential, grow and embrace health and wellness. Yet how focused are you on actually defining and measuring those outcomes for each person? Are you more focused on preserving your particular program model, levels of care, ideology and traditions than on measuring client outcomes to actually demonstrate efficacy and efficiency for the people we serve? Are there struggles between clinical providers and the judge/criminal justice personnel on how to handle positive drug screen results? How can we join together to realize we all want the same outcome: increased health and well-being, decreased crime and recidivism, increased public safety, and safety for children and families?

4.What floats my boat

“An expression which means you can do whatever your preference is.”

Clinical: When working with clients especially severe and chronically mentally ill, it can be challenging to actualize our desire to be strength-based, empowering and recovery-oriented. Our impulse to ‘fix’ what seems so obviously pathological, leads to parent-child type interactions; expert prescriptions on what the client or patient must do; and program and clinician-centered services.

Example: The client who wants people to leave him alone…

Rather than dwelling on his delusions, hallucinations and med. compliance, try conversing and exploring times in his life when he had the freedom and independence to come and go when he wanted, to do whatever he preferred. See if you can reawaken in him what “floats his boat”, turns him onto life. What would inspire him to have hope for joy? Perhaps he wants a job or to return to school for more education. Ask: What worked when you had the job you enjoyed, or attended a school you felt good about?

Systems: It doesn’t matter your role, whether administrator, supervisor or supervisee. Under the cost and time pressures in today’s healthcare system, it is easy to see personal and staff morale plummet. Self-care is not an option. It is an obligation if you are going to be healthily present to serve people – patients and fellow team members. Are you staying in your job out of habit or fear you could fail at something else you might prefer to do? Are you just going through the motions, having lost sight of what attracted you to the job originally? Can those benefits be reawakened? Perhaps the job (or you) has changed so significantly that it no longer matches your needs for fulfillment and meaning?  Self-care may mean re-designing your job or moving on to something that “floats your boat.”

5.A sitting duck

“Something or someone that is easy to attack or criticize.”

Clinical: Have you ever wondered why a client is verbally attacking you for the well-intentioned advice and recommendations you are giving them? As a counselor, isn’t it “my duty” to confront them, point out how their impulse control and anger problems is the cause of their relationship breakdown or legal problems they now face?

Or maybe you don’t wonder why you are a sitting duck. Perhaps you simply tell yourself (and them) that they are “in denial” and need to take suggestions even if they don’t like it. In other words, it is their problem, their resistance, their pathology which explains their anger at you. What’s happening has nothing to do with your approach and interaction with them.

In Motivational Interviewing these “attacks” are evidence of discord (disagreement between two people – you and the client) not resistance (pathology in the client). It is about you and how you engage a person or not, which is as much a part of whether there is discord as it is a problem “in” the client. You’ll be a ‘sitting duck ‘if you always view it as something wrong with the client instead of an interactive process.

Systems: As healthcare reform becomes even more the reality, how you design and deliver services will increasingly be influenced by how you are paid compared to current models. In the current fee-for-service model, you make more money if you provide sick-care rather than health-care. When people are well, don’t need to see you or fill your beds and outpatient slots, you don’t make money. Of course it’s a contradiction: we want people to get well – we don’t purposely try to keep people sick just to fill beds and slots. However, currently, few financial incentives exist to focus more on prevention, or on low-intensity and low-reimbursed outpatient services. The trend to population-based funding and outcomes-driven payment will change that. You and your program will be a sitting duck for loss of business and revenue if you aren’t preparing to move to outcomes-driven services; and ‘health-care’ rather than ‘sick-care.’

–>I hope you discovered some new meaning from old clichés.

SOUL

This month, my granddaughter and only grandchild turned one.  A week later she was taking her first wobbly, yet independent steps.  Soon, no doubt, she’ll be running around.  You would think that with three children of my own, seeing them through all their developmental stages, that this would not be so amazing to witness.  But it is.To see Luna develop from that uncoordinated newborn bundle of love I cuddled just a year ago, to now a walking little person who can wave goodbye, say “ciao,” stand and dance to music with one arm waving high (remember John Travolta, “Saturday Night Fever” style!)- it’s simply amazing.

With the joy of seeing her development, I can’t help but wonder about all the boys and girls her age who don’t have loving supportive parents and grandparents. Who is there for them to hold their hands and comfort them when they cry? Sometimes somebody is there, but sometimes there’s a father or mother passed out in a drug-induced slumber? How can they be emotionally present for this little one, when they are stressed out about how they will get their next meal or are struggling with disabling depression, anxiety or psychosis?

There are an estimated 28 million Americans who are children of alcoholic parents, nearly 11 million under the age of 18. And that is just alcohol-affected children. What about other addictive and mental disorders? Every parent or prospective parent you attract into recovery brings great dividends for the rest of the family.

Have you seen my granddaughter, Luna? (If you want to see more of her dad’s photography, go to http://www.paulodiasphotography.com)

 

P.S. – A request reminder:

Next month is the April Tips and Topics 10th anniversary edition. I’ll publish some of your “appreciation gifts” and celebrate together. So if you are moved to write a brief note of appreciation, or if you remember an edition of a SAVVY, SKILLS, SOUL or STUMP THE SHRINK section that was particularly meaningful or memorable for you, please let me know. Tell me what edition it was in and what was the meaningful part for you.

 

Until next time

Thanks for reading. See you in late April for our 10th anniversary edition.
David

Vol. 11, No. 2

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

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

David Mee-Lee M.D.

SAVVY

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

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

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

TIP 1

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References:

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

SKILLS

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

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

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

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

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

Ways to improve patient safety and care

How The ASAM Criteria helps design/deliver services

 

 Design and deliver chronic disease management of addiction.

Current & Continuing

New & Additional

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

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

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

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

 

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

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

SOUL

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

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

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

Typical Character

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

Speaking

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

Manners

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

Eating

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

Safety

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

Health

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

Traveling

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

Religion

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

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

 

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

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

You can buy in two ways:

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

The special runs through May 31, 2013.

Preorder The ASAM Criteria and get more than the book

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

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

Until next time

Until next time

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

David

Vol. 11, No. 4

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

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

David Mee-Lee M.D.

SAVVY

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

I promised to share readers’ suggestions.

Here are three and some editorial comments:

 

Reader #1
Hi Dr. Mee-Lee:

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

 

Regards,

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

 

–> Comment from David Mee-Lee

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

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

 

Joan Zweben, Ph.D.

Berkeley, CA

 

–> Comment from David Mee-Lee

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

 

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

 

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

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

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

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

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

 

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

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

SKILLS

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

 

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

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

 

 

TIP 1

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Client: Sure, go ahead.

 

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

 

Client: I guess I could do that.

 

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

 

 

And for the depressed client:

 

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

 

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

 

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

 

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

 

Clinician: Have you taken medication before? (Following)

 

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

 

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

 

Client: What do you mean?

 

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

 

Client: I’d rather take medication.

 

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

 

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

 

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

 

 

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

 

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

 

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

SOUL

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

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

 

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

 

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

 

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

 

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

We ask: “Where should we go next?”

Well where would you like to go?”

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

“Well they are both interesting.”

“So what would you recommend?”

“You want me to decide for you?”

 

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

 

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

 

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

Until next time

Thanks for reading. See you in late August.

David

Vol. 11, No. 6

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

David Mee-Lee M.D.

SAVVY & STUMP THE SHRINK

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

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

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

Dear Dr. Mee-Lee:

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

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

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

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

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

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

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

Warmest regards,

Phuong-Anh

Phuong-Anh Urga, Ph.D.

Montreal, Quebec, Canada

My response (supplemented by Tips in SKILLS):

Hello Phuong-Anh:

 

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

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

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

 

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

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

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

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

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

 

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

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

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

SKILLS

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

 

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

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

 

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

 

TIP 1

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

 

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

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

 

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

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

 

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

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

 

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

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

 

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

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

 

TIP 2

Help people “name their emotions to tame their emotions.

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

Here is what the acronym RULER means:

 

Recognize emotions in oneself and others.

Understand where emotions come from and the causes of emotions.

Label emotions and increase your emotional vocabulary.

Express emotions rather than holding them in.

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

 

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

SOUL

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

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

 

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

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

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

 

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

 

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

 

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

 

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

 

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

 

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

SHARING SOLUTIONS

Here is Dr. Phuong-Anh Urga again:

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

 

My response:

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

Until next time

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

David

Vol. 11, No. 7

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

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

David Mee-Lee M.D.

SAVVY

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

 

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

 

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


TIP 1

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

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

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

Common Case Scenario

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

 

 

*Level 1, Outpatient Services

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

 

*Level 3, Residential Services

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

Level 3.1. Clinically Managed Low Intensity Residential

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

 

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

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

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

 

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

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

TIP 2

Broaden your perspectives on addiction treatment

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

Tobacco Use Disorder

Gambling Disorder

 

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

 

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

 

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

 

 

TIP 3

Apply the criteria to special populations

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

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

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

—-clients in criminal justice settings.

 

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

 

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

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

SKILLS

TIP 1

Cultivate interdisciplinary relationships with other health systems

Here are the facts:

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

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

 

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

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


TIP 2

Learn how to manage care yourself

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

 

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

 

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

2. Which ASAM Criteria dimensions do they belong to?

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

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Learning to manage care yourself means:

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

SOUL

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

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

 

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

 

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

 

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

 

Then I think of Malala Yousafzai.

SHARING SOLUTIONS

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

Until next time

See you again in late November.  Thanks for reading.

David

Vol. 11, No. 9

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

David Mee-Lee M.D.

SAVVY

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

 

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

 

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

 

TIP 1

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

 

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

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

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

 

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

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

 

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

 

TIP 2

Review the DSM-5 criteria for Tobacco Use Disorder.

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

 

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

References:

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

 

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

SKILLS

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

 

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

 

TIP 1

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

 

Case 6 (page 391) 

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

 

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

 

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

 

 

TIP 2

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

 

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

 

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

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

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

Reference:

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

SOUL

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

 

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

 

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

 

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

 

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

 

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

 

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

SHARING SOLUTIONS

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

 

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

 

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

 

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

 

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

Until next time

Happy New Year and see you again in late January.

 

David

Vol. 11, No. 11

In This Issue
  • SAVVY : Delaying gratification – innate or environment influences?
  • SKILLS : Check on parental interactions to see what children learn
  • SOUL : Four Mantras to give and get love
  • SHARING SOLUTIONS : All day conference on The ASAM Criteria; “I Don’t Smoke”

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

David Mee-Lee M.D.

SAVVY

One of the wonderful benefits of being a grandfather is the opportunity to reflect on what sort of parent you were when raising your own children.   I have been observing my oldest daughter and her husband as they parent their daughter,Luna.  They share their experiences which dovetail with my observations.

 

When we were busy raising our three children, we were interested in just getting sleep and surviving. There was little time for objective observation, reflection and thoughtful hypotheses on what is happening with your kids and your parenting.   If you’ve never had children, you get to be like an observing grandparent.   Your friends with kids are too busy parenting to stand back and watch.

 

Here are some of my direct observations. Also, our adult children have shared a few oftheir observations, in between their grabbing sleep and some couple time , when little Luna is asleep:

  • Children really watch what you do and say
    – not even 18 months old, Luna would try to fold her arms mimicking what her mother just did.
  • Children tune into and conform to their parents’ expectations about how they should feel and react  
    – Luna was playing with the water fountain at the park. The water spurted out suddenly, startling her. At the same time it was fascinating and exciting. Encouraged to enjoy the new experience, she forced out several giggles that communicated: ‘This is fun, but I’m also a bit frightened and scared.’
  • When parents are clear on their beliefs, values and limits, children respond very quickly to know what is expected and normal. Conversely, if there is a drift away from those practices, children quickly learn to push the limits
    – Luna is not yet 2 years old. Until now she has been used accustomed to asking for water when she is thirsty. As soon as she saw me drinking apple juice instead of water and tried it, she began asking for sweet apple juice instead of water.

TIP 1The ability to delay gratification is influenced as much by the environment as by innate ability.

 

These observations on the power of parental influence are right in line with a fascinating 40-year-old study with very young children; the study tested their ability to delay gratification. A couple of years ago the study was updated – to see what might increase or decrease the ability to delay gratification in these 3 to 5 year olds. It was published in Cognition, an international journal of cognitive science research.

 

1. In the study of 3-to 5-year-olds, researchers randomly assigned 28 children to two groups: reliable (R) and unreliable (UR).

 

Here is how “reliable interactions” and “unreliable interactions” were set up in the experiment: Children were given an arts and crafts project to work on when they arrived.

  • In the “unreliable interaction” group, “the children were provided a cup of dingy, used crayons and told that if they could wait, the researcher (Palmeri) would return shortly with a big set of “better” art supplies for their project. After 2=BD minutes, the researcher returned empty-handed.
  • Next the child was offered a little sticker to decorate their project and was told that if he or she could wait before using it, the researcher would return with a large selection of “better” stickers. After the same wait, the researcher again returned empty-handed.”
  • The children in the “reliable interaction” group got the opposite treatment. “The reliable group experienced the same setup, but the researcher (also Palmeri) always returned with the promised materials – a teeming assortment of new art supplies and a large assortment of fun stickers.”
 
2. Immediately after the reliability/unreliability part of the experiment, “the marshmallow task followed. The researcher explained that the child could have one marshmallow immediately, or wait for the researcher to return with two.

  • Almost on cue, the children in the unreliable group (UR) knew the researcher wouldn’t fulfill her promise and they ate their marshmallow quickly, as opposed to those in the reliable group (R) who knew they would be rewarded as they had been in the past by waiting.”
  • Researchers found that children who experienced “reliable interactions” with a researcher immediately before the marshmallow experiment waited on average four times longer (12 minutes) to eat the marshmallow than children who had an unreliable interaction (3 minutes).
Celeste Kidd, the primary researcher, was inspired by a little girl at a homeless shelter to do this study. If you want to find out how and more about the findings, here’s the link:

 

http://www.usatoday.com/story/news/health/2012/10/16/science-marshmallow-test-delayed-gratification/1636207/

 

Some conclusions about this study

  • The ability to delay gratification is influenced as much by the environment as by innate ability.
  • “I hope people will be more careful to assume that a lack of restraint is a personality defect,” Kidd said. “A lack of impulse control is not necessarily the reason kids make the choices they do.”
  • From the mother of one of the children in the experiment: “I think the reliability played a big part in her waiting as long as she did,” Rose said about her daughter. “She was having fun and knew she was being rewarded by the caregiver. Kids really do watch what adults do more than we think they do.”

 

Reference:

Celeste Kidd, Holly Palmeri, Richard N. Aslin (2013): “Rational snacking: Young children’s decision-making on the marshmallow task is moderated by beliefs about environmental reliability” Cognition 126 (2013) 109-114.

http://www.bcs.rochester.edu/people/aslin/pdfs/Kidd_Palmeri_Aslin_Cog2013.pdf

SKILLS

The next time you are around children and their parents or caretakers, observe their interactions. Notice what the children are watching and experiencing about how the world works.

 

TIP 1

When working with a client, young or old, explore what the “reliable” and “unreliable” interactions were in their life experience. It may say a lot about how they act now and how you should act.

 

The observations of a grandfather and experiments like the marshmallow test remind us of the power of parenting – for good or ill. So many of our clients suffer from impulse control issues, mood regulation difficulties and tremendous longings for nurturance. At the same time they can equally experience fears of not being able to count on anyone being there for them. They feel demoralized and hopeless.

 

When parents and caretakers are themselves depressed, suffering from addiction and/or mental illness, psychotic, preoccupied with chronic pain etc., no wonder we witness the results of “unreliable” nurturing.

 

So what to do:

  • Ask your clients how their parents treated them. What was the quality, consistency and reliability of the parenting they received? See if it helps explain their current signs and symptoms. If so, how?
  • If they have children themselves, explore their parenting perspectives and skills to see if you can help break the cycle of intergenerational “unreliability.”
  • Examine your own interactions with your clients. Can you assist in their having a “corrective emotional experience” in your work with them? Note: this doesn’t mean trying “loving them into health,” flooding them with the nurturance they missed out on. In fact there are dynamics to pay attention to. Read more on this in the October 2009 edition of Tips and Topics
  • Perhaps you have children of your own, nieces or nephews, or friends’ children you know. These are opportunities to raise your own consciousness or that of your friends, relatives and other parents. Consistent parenting is powerful. It creates the conditions for safe, reliable nurturance. Children fortunate enough to be in such environments can manage feelings and function in adaptive and resilient ways.

Like the mother of one of the children in the marshmallow test said: “Kids really do watch what adults do more than we think they do.”

SOUL

For Valentine’s Day this month, my wife, Marcia, gave me a little book: “True Love – A Practice for Awakening the Heart” written by famed Vietnamese Zen Buddhist monk, Thich Nhat Hanh. The inside book cover says the author “shows the way to overcome our recurrent obstacles to love – by learning to be mindful, open, and present with ourselves and others.”

 

It does indeed show some ways to practice ways to love and be loved. What Thich Nhat Hanh offers are four mantras. A mantra is “a magic formula that once it is uttered,can entirely change a situation our mind, our body or a person. But this magic formula must be spoken in a state of concentration…..in which body and mind are absolutely in a state of unity.” Mindfully breathe first: notice your breathing in and breathing out for a few minutes. This prepares you to say the four mantras:

  • Dear one, I am really here for you.” – being there for the ones you love.
  • Dear one, I know that you are there and it makes me very happy.” – recognizing the presence of the person you love.
  • Dear one, I know that you are suffering, that is why I am here for you.” – being there because “when we are suffering, we have a strong need for the presence of the person we love.”
  • Dear one, I am suffering, please help.” – This is used when you are suffering and you think your hurt has been caused by the very one you love. Instead of withdrawing in anger or pain, “you must overcome your pride; you must always go to him or her” and ask for his or her help.

I don’t know about”magic formulas.” Yet these are simple phrases – hard to do, yet when practiced, promote understanding, compassion, happiness, and joy.

 

Many years ago, Marcia introduced me to another important book.  Around another Valentine’s Day edition, I shared some of the main points of that book.  If you want to re-read more about the Love Language of you and your loved ones,read the February 2008 edition of Tips and Topics in the archives.

I think my wife is trying to tell me something with these Valentine’s Day books!

….Oh, and she did give me some chocolates as well. She knows I am a bit of a chocaholic.

References:

1. Thich Nhat Hanh (2011): “True Love – A Practice for Awakening the Heart.” Shambhala, Boston &London.

2. Chapman, Gary (1992): “The Five Love Languages – How to Express Heartfelt Commitment to Your Mate”. Northfield Publishing, Chicago.

 

SHARING SOLUTIONS

There are two resources I want to share:

#1

The American Society of Addiction Medicine (ASAM) has its Annual Medical Scientific meeting in Orlando, Florida in April. There will be a whole day Pre-conference course on “The ASAM Criteria and ASAM Criteria Software: What’s New and How to Use the Criteria – A Live Course” on April 10, 2014, 8:00 am – 5:30 pm. You will hear directly from the authors and workgroup chairpersons on what’s new in The ASAM Criteria:

http://www.asam.org/education/annual-medical-scientific-conference/pre-conference-courses/the-asam-criteria-course

 

Who Should Attend

All levels of those interested in The ASAM Criteria – counselors/clinicians, addiction specialist physicians, drug court professionals, state and county administrators, funders and managed care, national professional organizations.
Course Topics

  • Underlying Principles and Concepts of The ASAM Criteria
  • What is New in The ASAM Criteria
  • Overview of ASAM Criteria Research and The ASAM Criteria SoftwareHow to Organize Assessment Data to Match Level of Care
  • How to Use The ASAM Criteria Software
  • New and Updated Sections
  • How to Apply the ASAM Criteria
  • Interactive Faculty/Audience Discussion

I hope to see you there.

 

 

#2

The second resource to give you focused and specific help with nicotine addiction comes from Joseph Cruse, M.D. who was the founding medical director of the BettyFord Center. A longtime addiction medicine specialist and leader in the field, Joe shares his wisdom in his book “I Don’t Smoke!” – A Guidebook to Break Your Addiction to Nicotine. See more about it at http://www.idontsmoke.net

 

And to help your patients and clients, Dr. Cruse worked with The Change Companies to develop an Interactive Journal by the same name. See more at The Change Companies http://www.changecompanies.net/products/product.php?id=IDS

You can even preview a few pages by clicking on the following link

http://www.changecompanies.net/series.php?id=22 and then on the magnifying glass icon just under the “I Don’t Smoke!” journal

Until next time

Thanks for reading  See you in late March.

 

David

Vol. 11, No. 12

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

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

David Mee-Lee M.D.

SAVVY, SKILLS & STUMP THE SHRINK

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

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

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

My Webinar Point- about “doing time”

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

Question #1:

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

Hi David,

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

Response #1:

Youcan turn “doing time” into active treatment.

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

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

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

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

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

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

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

My Webinar Point – DSM-5 SUD and Homelessness

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

Question #2:

Are the homeless exempt from certain SUD criteria?

 

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

Response #2:

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

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

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

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

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

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

I hope this helps,

David

 
My Webinar Point- about “Graduation”

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

Question #3:

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

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

 

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

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

Response #3:

Focus on functional improvement not program compliance.

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

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

Thanks,

David

Question #4:

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

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

 

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

Response #4:

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

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

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

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

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

November 2007:

January 2004:

December 2006:

Hope this helps.

David

Question #5:

When do you finally discharge a person?

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

 

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

 

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

Response #5:

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

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

Regarding:

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

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

Regarding:

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

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

For example:

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

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

*******

The decision flow makes perfect sense, David.

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

References:

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

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

SOUL

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

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

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

Until next time

See you again in late April.

David

Vol. 12, No. 2

Welcome to the May edition of Tips and Topics. Thanks for joining us this month.

David Mee-Lee M.D.

SAVVY

There is increasing pressure to use Evidence-Based Practices (EBPs) and Evidence-Based Treatments (EBTs) and it makes sense to have the best-proven tools in your clinical toolkit.  However, as William Miller of Motivational Interviewing (and Senior Advisor for The Change Companies) says: “perhaps the proper attitude toward EBTs is one of respect not reverence.” (Miller, Zweben & Johnson, 2005).  There is too much “reverence” for EBP and EBT these days, which squeezes out innovation and encouragement to nurture “promising” practices.  If you want to see more on EBPs, take a look at the August 2007 edition of Tips and Topics.

http://www.tipsntopics.com/2007/08/julyaugust-2007/#more-71

 

The challenge for the field is to find the right balance between EBPs and the therapeutic alliance that:

  • Honors person-centered, shared decision-making
  • Engages people starting where the client is at, not where you want them to be.
  • Facilitates a self-change process which follows the client’s pace of change, not  that of some predetermined manualized treatment protocol

 

I read a January 2014paper by William Miller on “Interactive Journaling as a Clinical Tool” (Miller, 2014).  Bill articulated it well: “interactive journaling (IJ) as a clinical tool combines elements of bibliotherapy (the presentation of therapeutic material) with structured reflective writing.” (Miller, 2014, p. 33).

 

Interactive Journaling brings the balance:

 

The Evidence-Based Practices part

IJ presents treatment-relevant information that incorporates EBPs like MI, cognitive behavioral therapy (CBT), and stages of change work.  This is presented using graphics and text that is colorful and engaging.

 

The Therapeutic Alliance part

Throughout each journal, there are frequent, structured exercises where the client can draw, write and interact with the material to apply it to their life.  This respects their stage and pace of change.

 

 

TIP 1

What is Interactive Journaling (IJ)?

You can see lots moreon what IJ is and how it works, as well as comments from Bill Miller, Stephanie Covington, Claudia Black and others.

https://www.changecompanies.net/ij.php

 

Or take a look at thevideo on “what we do”:

https://www.changecompanies.net/whatwedo.php

 

Here are a few points:

 

1. Interactive Journaling® is a structured and experiential writing process motivating and guiding participants toward positive life change.  Clients receive a lot of information in psychoeducational lectures and material.  How is IJ different? The journals have specifically-designed interactive exercises that emphasize real-life application. These encourage participants to ask, “What does this mean to me?”

 

2.  Interactive Journaling® puts the participant in the driver’s seat to make real and accountable change. But each journal has structure and consistency in the material presented. To enhance the therapeutic alliance, the journals are designed to help individuals achieve their change goals, be easy to follow and to keep participants engaged. This is done through use of color graphics, page design and placement of text that makes the interactive exercises interesting and enjoyable.

 

3. Interactive Journaling® is evidence-based.

 

In the October 2010 edition of Tips and Topics, I referenced Gwendolyn Bounds’ Wall Street Journal article: “How Handwriting Trains the Brain. Forming Letters Is Key to Learning, Memory, Ideas”. The Wall Street Journal. October 5, 2010 Writing by hand is more than just communication. It engages the brain in learning.

 http://www.tipsntopics.com/2010/10/

 

“Spoken language is the primary medium of counseling and psychotherapy. The therapeutic value of written language has also been studied extensively, both to provide self-help information and to elicit personal reflection. Interactive journaling (IJ) is a guided writing process that combines both of these functions…… Experimental and quasi-experimental evaluations support a link between IJ and behavior change.  Research on motivational interviewing offers evidence-basedguidelines for structuring IJ materials to elicit language favoring change, as well as testable hypotheses linking writing processes with outcomes. Implications for counseling practice and research are considered.” (Miller, 2014, Abstract of “Interactive Journaling as a Clinical Tool”)

 

IJ is included in The National Registry of Evidence-based Programs and Practices (NREPP) – a “searchable online database of mental health and substance abuse interventions. All interventions in the registry have met NREPP’s minimum requirements for review and have been independently assessed and rated for Quality of Research and Readiness for Dissemination.” Seemore detail on IJ in NREPP: http://nrepp.samhsa.gov/ViewIntervention.aspx?id=333

 

 

References:

 

Gwendolyn Bounds: “How Handwriting Trains the Brain. Forming Letters Is Key to Learning, Memory, Ideas”. The Wall Street Journal. October 5, 2010

Write to Gwendolyn Bounds at wendy.bounds@wsj.com

 

Miller, W.R., Zweben, J., & Johnson, W.R. (2005): “Evidence-based Treatment: Why, what, where, when, and how?” Journal of Substance Abuse Treatment, 29:267-276.

 

Miller, W.R (2014): “Interactive Journaling as a Clinical Tool” Journal of Mental Health Counseling, Volume 36, Number 1

Available from MetaPress and Amazon (at half the price)

SKILLS

If you look at the hundreds of journals on a wide variety of topics available atwww.changecompanies.net, it would be easy to be overwhelmed. But how can you know where to start? I turnedto a couple of experts at The Change Companies to help with this.TIP 1What are the most popular Journals that providers and agencies buy and find most helpful for their clients?

 

Impaired Driving classes

–> Responsible Decisions  – Our national “off the shelf” program; it meets all 50 states’ criteria for DUI Education; is an American Society of Addiction Medicine (ASAM) Criteria Level of Care 0.5, Early Intervention.There is a video designed to go along with Responsible Decisions as a motivation/engagement resource.
–>  There are custom curricula for Driving Under the Influence (DUI).
There are 18 states with custom curricula. For example, the state of Colorado also requires Level 2 offenders (multiple offender, high blood alcohol concentration (BAC, etc.) to attend a minimum of 42 hours of therapy. In addition to Responsible Decisions, they also use The Change Companies’Motivational-Educational-Experiential (MEE) series Journals.

 

Addiction Treatment Settings

–> MEE (Motivational-Educational-Experiential) series– for adults
–> KIDS Journal System (Keep It Direct & Simple) – for adolescents
 
Both have cognitive behavioral and 12-Step topics. They integrate the Transtheoretical Model of Behavior Change’s 10 Processes of Change through structured writing and Motivational Interviewing(MI).

–> Self-management: A Guide to Your Feelings, Motivations and Positive Mental Health: Addiction Treatment Edition. (Miller, Mee-Lee, 2010).

 

Mental Health Treatment Settings

Here are some of the journals:
–> Life Skill Series, Self-management: A Guide to Your Feelings, Motivations and Positive: Mental Health Edition (Miller, Mee-Lee, 2012)
–> Living As If  
–> Trauma In Life (Women’s) 
–> Traumatic Stress and Resilience (Men’s)  
–>  Successful Living with a Co-occurring Disorder (part of the MEE series).

 

Criminal Justice Settings
For Probation Officers

–> TheCourage to Change (adult)   

–> Forward Thinking (youth)
These journals match up with the most frequently occurring risk areas (Domains) associated with legal recidivism.

For In-prison treatment programs

–> RDAP (Residential Drug Abuse Program)

–> Freedom from Drugs (education)
–> Challenge (step-down)
–> Co-Occurring series 
–> Changing Offender Behavior (core-cognitive program)  
–> Getting It Right (reentry to the community)  
–> SAFE (domestic violence)
–> Turning Point (sex offender pre-treatment)
–> Changing Course (jails self-directed)

For Drug Courts

–> Drug Court Journal

 

For Probation and Parole

–> Breaking the Cycle (non-residential program)    

-> The Courage to Change (adult)

–> Forward Thinking (youth).

 

For Adolescents

–> KIDS Journal System (Keep It Direct & Simple) – for treatment settings    
–> Alternatives – for education and diversion settings 
–> Helping Children Thrive – for teens infoster care 
–> Voices – for adolescent females (Stephanie Covington)

 

Special Topic: Gambling

–> Safe Bet – for problem gambling prevention and education designed for individuals at risk for problem gambling behaviors   
–> 12-Step Guide for Compulsive Gamblers – introduces the 12 Steps of Gamblers Anonymous; helps participants work through each step and develop a plan for positive change.

 

Special Topic: Veterans

–> Coming Home – a two-part Interactive Journal series designed toprovide veterans with skills for their transition to a full, meaningful civilian life.

 

  • A picture is worth a thousand words….so if it is easier for you to visualize these journals take a look at https://www.changecompanies.net/products/.
  • You can click on a journal and then the magnifying glass to see a few pages electronically. Happy hunting!

 

 

TIP 2

Why can’t programs and clinicians just photocopy some of the exercises and hand these out in group?

 

Besides the fact thatthe journals are copyrighted, there are some good reasons not to photocopy pages and hand flimsy black and white pages to clients:

  • The importance of color – Color increases comprehension and retention over 70%.
  • Heavy weight paper – The thickness of the paper promotes permanency. Individuals keep their journals. Many treasure them and refer back to them in continuing care.
  • Ownership in participants’recovery – Participants are engaged more accountably when given a quality full color Journal they interact with in an experiential way. Many take pride in their own journal ratherthan loose pages of exercises.
  • Journals are priced to be affordable – Bythe time you photocopied in full color on heavy weight paper, the cost would be the same, if not more, when you take into account, paper, ink and staff time.
  • Walking the Talk – If you are photocopying copyrighted materials, what message are you sending to your clients? “Do as I say: takeresponsibility to follow the law and society’s expectations of you at home, school and work. But don’t do as I dobecause I’m an exception to the rule and I don’t need to obey the law.” Sounds like some criminogenicthinking and poor role-modeling doesn’t it?

 

 

TIP 3

Is Interactive Journaling difficult to teach to prepare facilitators to use IJ with their clients?

 

Very easy to teach. Facilitator Guides provide insight into the key concept on each page of the Journal with facilitation strategies for 1 to 1 individual work and in group work. Additional activities are presented for homework or application of skills between sessions.

 

–> There are “Training for Trainers” sessions on Interactive Journaling so agencies and programs don’t eat up all of their resources sending staff off each time for training on the Journals.

 

–> All IJ Facilitators don’t need to be licensed clinicians or counselors. Probation and correctional personnel, teachers and educators, Federal Bureau of Prisons mentors (lay people), ministers can be trained to facilitate IJ. Even fellow criminal justice inmates have been trained as facilitators.

 

–> IJ can be used/facilitated in a range of settings with a variety of provider skill sets. IJ Facilitators can be lay individuals doing mentoring or coaching; probation officers and paraprofessionals; or licensed clinicians and physicians.

 

–> There are a variety of methods to receive training: eTraining modules, coaching from The Change Companies, or telephone trainings. 90-minute sessions via the internetare becoming more popular.

 

–> The most effective trainings are still multi-day live trainings with practicums with feedback. Over the years it has been very consistent on how many individuals say they are seasoned facilitators highly proficient in stages of change work, MI and CBT. However they often cannot demonstrate the skills when asked. Journals provide a standardized delivery system of narrative writing, stages of change, motivational enhancement and cognitive-behavioral skill buildingthat can enhance the abilities of all change agents.

SUCCESS STORY

In the October 2012 edition, I asked Ashleigh Simon, Clinical Director, The Bridge, Inc. to share how she and her team were making the shift to more individualized services, away from fixed program-driven care.

http://www.tipsntopics.com/2012/10/

 

Since I knew they have been using Interactive Journaling, I wondered how this was working for them in their ongoing shift to person-centered care.  Here’s how Ashleigh responded:

 

Over the past several years at The Bridge Addiction Treatment Centers, we’ve transformed ourservices from program-driven to client-centered, outcome-informed treatment. We’ve converted forms, altered service levels and changed our way of thinking to ensure the client is a partner in the treatment process. Throughout this change process, the one constant has been The Change Companies Interactive Journaling series. The journals serve as a tether that keeps us grounded in a structure that enables our therapists to deliver individualized treatment.

 

The Change Companies journals empower our therapists who engage the client in treatment through developmentally-appropriate core concepts such as peer pressure, self-image and family systems. Grounded in principles of Motivational Interviewing, Transtheoretical Model of Change and The ASAM Criteria, these journals address patterns of behavior in our clients while utilizing an evaluative process of coping strategies for high-risk situations.

 

By encouraging clients to choose the journal that corresponds with their treatment plan goals, treatment becomes individualized, thereby shifting our focus from fixed lengths of stay and programmatic services to achieving outcomes based on each individual’s process of recovery. Regardless of the constant changes withevidence-based practices and evolving business systems tied to the PatientProtection and Affordable Care Act (PPACA), The Change Companies journals remain the common core for our clinicians.”

Ashleigh Simon, MS, CAADP, LPC, NCC, ACS

Clinical Director, The Bridge, Inc., Gulf Coast Campus

Mobile, Alabama

E-mail: a_simon@bridgeinc.org

 

(Founded in 1974, The Bridge provides substance abuse treatment and behavioral rehabilitation programs for adolescents (ages 12-18). We provide servicesin residential, intensive outpatient, drug court and community-based programs. Our programs are staffed with caring and qualified professionals usingproven, evidence-based practices. Our commitment to quality and excellenceis evident throughout the organization as we continue to seek ways to enhance and broaden our services.)

SOUL

This is not a new observation.  I know others have highlighted this before. But when you watch with a grandfatherly eye, your 2 years, 2 month old granddaughter, the insight gets vivid again.

What I’m talking about is how kids:

  •      Live and play in the moment
  •      Play without worrying what work they should be doing instead
  •      Are totally tuned into what they feel, want, like, don’t like
  •      Have no trouble asking (demanding) for what they want
  •      Express emotions easily and unambivalently
  •      Give and get love affectionately and flowingly

 

And the list could go on.

 

The thing is, though, that a lot of adults pay large sums of money and spend countless hours in individual or group therapy, workshops, retreats, self/mutual help meetings, and numerous self-help, self-improvement books, CDs and DVDs…….all so they can get back to being like a kid again.

 

I’m not saying thatis bad.  I’m as much a result of whatever it is we do “growing up” that seems to squeeze out the essence of the joy of living that children do naturally.

 

So it was interesting as I we were recently organizing old photos and scrapbooks, to come across several of my childhood essays that were published in the Sunday newspaper, children’s section. I had won a prize every year from age 11 to 16.  I even won a wristwatch for best essay one year and received my prize on the local TV station.

 

The newspaper published my little essays with riveting “headlines”: “City Boy Who Worked Sheep“, “From Atoms to Oxygen“, “Finish was best part of cross-country race” and “Whirlwind in School Grounds“.

 

It is fun to look back and recognize the childhood roots of Tips and Topics and all those papers, articles and book chapters listed in my Curriculum Vitae. Actually SOULis the adult version of those childhood essays in the newspaper.

 

So maybe there are still remnants of my childhood joy seeping through……..while I keep working on getting back to playing without worrying what work I shouldbe doing instead!

SHARING SOLUTIONS

You would think I would know all the resources we have at The Change Companies to help you use The ASAM Criteria and the two ASAM co-branded journals onUnderstanding the Dimensions of Change and Moving Forward.  But I actually just discovered The ASAM Resource User Guide.       Not only does it helpyou use the journals to implement The ASAM Criteria in your clinical work,but it has two informative charts.

 

See page 8 for adults; and page 9 for adolescent treatment, which shows the journals that key tospecific ASAM Criteria assessment dimensions.

 

Here’s how to get it:

Go to http://www.asamcriteria.org

Click on Resources & Training.

On the right hand side, notice: “Download the ASAM Resource User Guide”

Until next time

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

Vol.12 , No. 4

Welcome to the July edition of Tips and Topics. If you are in the northern hemisphere, I hope your summer is fun. If not, stay warm!

David Mee-Lee M.D.

SAVVY

This month, there was a vigorous discussion amongst some members of a relatively new and small group of Addiction Medicine Physicians called “Like Minded Docs”.

 

“We Like Minded Docs are a group of compassionate physicians who support efforts to improve the quality of care for persons with addiction. We seek to put more “heart and soul” back into all aspects of the practice of addiction medicine. As we strive to achieve that shared goal, we will continue to work with the American Society of Addiction Medicine (ASAM) and other organizations toward a comprehensive, integrative approach to addiction treatment.”

www.likemindeddocs.com 

 

We Like Minded Docs don’t actually walk lock step on a variety of issues in addiction treatment, as I discovered full well this month. A discussion began about people who use alcohol or other drugs while in residential or inpatient treatment, and what to do about that. It was fascinating to see how this group of committed physicians, all of whom firmly believe addiction is a disease needing chronic disease management, varied in their views on what to do when a patient has a flare-up of addiction and uses substances while in treatment.

 

In the 1980s, I established and directed an inpatient addiction treatment unit. There we had a zero tolerance policy and discharged patients who used while in treatment. I have long argued, since then, about a zero tolerance policy. It is not consistent with viewing addiction as a chronic disease characterized by loss of control of use, and prone to relapse or acute exacerbation of addiction illness.

I have written on this several times before. You can read more in the October 2012 and November 2012 editions of Tips and Topics.

http://www.tipsntopics.com/2012/10/

http://www.tipsntopics.com/2012/11/

 

TIP 1

Consider these steps when a person uses substances while in treatment.

 

1. View such a flare-up as a poor outcome, which needs assessment and a change in the treatment plan.

2. Collaborate with the patient to discover: What went wrong? What is s/he willing to do differently in their treatment plan that is in a positive direction?

3. Call a crisis patient community meeting.   Highlight the dangers of use in the treatment community and address any triggering or even actual use by others.

4. Work with any patients affected by their fellow patient’s flare-up. Help them learn from this and change their treatment plan accordingly.

5. Discharge the person who used only if s/he is not interested in treatment and just wants to “do time” in a treatment program and continue using trying not to get caught.

 

Now not all my Like Minded Docs agree with these steps. It was interesting to note different approaches by some addiction medicine specialists. Here are some excerpts and my commentary on their approaches:

 

Comment #1

I had a patient once who took meds brought in by another, and I did not ‘kick out’ the one who used in treatment who had been given the drugs by the ‘smuggler’. She was forever grateful that we let her stay and process her use. But the person who brings drugs in and violates the safety of the milieu, is a ‘vector of disease’ and this person must be removed, for his/her own good, and to protect the integrity of the environment….

 

If someone brings drugs into a residential environment, for WHATEVER reason, is that ‘enough’ of a ‘violation’ that even if it is ‘predictable addiction behavior’ we need to transfer them to another location? I argue that it is……and this isn’t ‘punitive’ to the person, but it’s necessary for the care of the OTHERS in treatment…bringing drugs into a residential setting is assaultive to the community….it’s one of the expellable offenses that makes the treatment environment unsafe and “untherapeutic.”

 

My Commentary #1

The patient you did not “kick out” is an example of good therapeutic action and results: retaining in treatment the patient who used and this becoming a learning experience for which she was eternally grateful.

 

The patient who was the “smuggler” should have been discharged if he did so because he was willfully not interested in treatment. If he figured he would just hang out in a program because he was mandated, continue to party, use substances and pull others down with him, then discharge fits the assessment of his not being”in treatment”. It is assaultive to the community and expellable if the person has no interest in looking at or working on his addictive behavior.

 

However- if your “smuggler” was a patient in crisis, whose addiction was acutely flaring up with use, then that patient is in need of the same assessment and process to change the treatment plan as the patient who was not “kicked out”.  I would argue that the treatment environment is strengthened and made more therapeutic by embracing the crisis of this patient’s acute exacerbation of addiction, which is not willful misconduct. The community is strengthened by helping this patient who (there but for the grace of God) could be any one of the other patients. Furthermore it addresses the needs of anyone else who also used with him or her.

 

And why are we even using terminology like “kicked out” and “smuggler” anyway when we are talking about a chronic disease?

 

 

Comment # 2

“Patients come into treatment in a residential setting and are extremely vulnerable whether they are in detox, just finishing, or after detox. They come into residential treatment with the hope and expectation that the environment is safe and drug-free. I cannot allow someone to bring drugs into the community and not do anything. If their using jeopardizes the community, then they need to be removed from that community by going to a different level of care within the current system or transfer to another system. We move them to an increased structure.”

My Commentary # 2

A zero tolerance policy prioritizes keeping the treatment community safe.Equally important is the patient in crisis AND keeping the treatment community safe. “Doing something” is equated with discharging or transferring the patient. However it IS”doing something” to take the following actions:

  • Call an emergency community meeting with all patients. Have the patient explain what happened in their flare-up and substance use.
  • Mobilize the community to take care of anyone who is triggered, not least of which the person who just had an acute exacerbation of addiction.
  • Assess what went wrong to get a poor outcome of substance use. Change the treatment plans of all affected by the crisis. Change level of care only if the new treatment plan cannot be delivered and provided in the current level of care.

 

When there is an acute exacerbation of addiction illness, it is not therapeutic action to discharge or transfer someone out of the milieu. Psychiatric patients also enter an inpatient unit very vulnerable. If we discharged every patient who cuts themselves, attempted suicide, became psychotic, angry, loud and violent in order to keep the inpatient community safe, we’d have no patients.

 

When someone physically attacks other patients, commits sexual predatory behavior, then that is behavior which “jeopardizes the community”. If the program is unable to help the patient contain those behaviors, a safer place may be needed. All addiction patients must learn how to deal with triggering situations. Addiction flare-ups create triggering situations. Treatment must address both the patient in crisis AND others in the therapeutic milieu. Good therapeutic results can occur for the patient in crisis in their hour of need; and the others affected by his addiction flare-up.

 

 

Comment # 3

“The bringing in of drugs should be assessed and if there is no “correctable cause” found then the risk of it happening again is too great to continue in the current level of care. If the cause is found but the patient won’t engage to correct it and decrease risk, same thing, transfer or discharge is needed.

 

However, like any other symptom of the illness, if a correctable cause is found and corrected so that one can say that risk of recurrence is no greater than someone else bringing in a drug, then there should be no contraindication to the patient staying.”

 

My Commentary # 3

This physician’s approach parallels what is done with other signs, symptoms and flare-ups of any illness or disease. Bringing in or using substances is a sign and symptom of a flare-up of addiction illness for which a correctable cause is assessed and treated.

For example: Did the person get into an argument with his partner, which triggered drug use? Were cravings to use overwhelming so all he could think of was to buy and use drugs? Did he attempt to self-medicate anxiety or depression by using? Is the patient still hanging out with using friends?

 

Once a correctable cause is discovered with the patient, treatment continues if the change in the treatment plan addresses the problem:

e.g., “OK I won’t hang out with those friends anymore. Help me know how to say “no” to them.”
Or “when I get upset, depressed or anxious, I’m now ready to practice reaching out to someone for support and practicing my progressive relaxation exercises.”
When/if the patient is not interested in addressing the correctable cause of their substance use, they have a right to choose no further treatment and leave.

 

 

Comment # 4

“In our setting we identify relapse as a symptom of addiction, and if the patient self- reports we would dissect his relapse as a community process, and so far we have not seen relapse occur as an epidemic….our patients will soon enough be in a real world setting where relapse is the experience of many peers, especially in opioid recovery. Helping patients, and the patient who relapsed, have a process for understanding the chronicity of addiction and how to return to recovery following relapse can save them from saying “F- -k it, I relapsed, I failed – I’ll just stay high” and then fatally overdosing.”

 

My Commentary # 4

This resonates with the physician in Comment #3.
When a person uses substances while in treatment, it is a reminder to everyone that addiction is a chronic illness that can easily flare up.  Our job is to assess and help them get back on track, rather than do anything that makes them feel defeated and give up.
I wonder how many of those patients I discharged for using (back in the day) felt like a failure, perhaps resumed active addiction and maybe even overdosed.

The unintended negative effects of a zero tolerance policy include:

  • The effect on the rest of the patients: “I better keep this to myself if I see someone else BUDDING (Building up to a drink or a drug) or actually using, if I don’t want to be the rat who turns my fellow patient in.”
  • This sets up an environment where substance use in treatment goes underground. People can’t openly confront and deal with any triggering that may be happening to them by someone else’s BUDDING.
  • The message to patients is: Substance use by an addicted person is willful misconduct for which you will be sanctioned, removed, discharged or transferred away from your treatment environment.
  • This makes it very hard for patients to be honest about any use, especially if they want to “complete” the program to keep their job, gets their kids back or get off probation.

SKILLS

One of the Addiction Medicine physicians shared a case. It provided a great illustration on what taking action and doing something means…..other than the often-usual transfer or discharge of  the person who used substances while in treatment. For confidentiality reasons, I have altered the case. As well, I have excerpted clinical case material and interspersed my comments and suggestions on how to take therapeutic action.

 

TIP 1

What does taking action look like when a person uses while in treatment?

 

This week one of the patients admitted to the staff and other clients that he got some vodka at an Alcoholics Anonymous (AA) meeting and drank it.”

  • The fact that the patient let staff and other clients know that his disease had flared-up is huge, especially if you hope to have an honest program. First this must be acknowledged as it’s so hard to admit powerlessness over this disease.
  • The fact he drank is not a good outcome. However he got honest, and this is something to be positively reinforced, not suffer a transfer away from continuing care in the program.
  • Poor outcomes in treatment leads next to an assessment of what went wrong; then a collaboration on how he will change his treatment plan. Stu Gitlow, M.D., President of ASAM uses the metaphor of being in a locked room desperate to escape: “Addicts feel like they’ve been in the locked room for too long and that they must do something. It’s not a choice once they reach that point. What is a choice is whether they use other methods to escape the room prior to reaching that point. ”
  • Once addiction flares up and a person uses, Like Minded Docs seem to be in disagreement. Is this willful misconduct or out-of-control disease? I agree with Stu that “it is not a choice once they reach that point.”
  • Also I agree with: “What is a choice is whether they use other methods to escape the room prior to reaching that point. ” If patients knew how to do that perfectly, they wouldn’t need treatment and wouldn’t be severe enough to need a residential treatment level of care.

 

Andrea Barthwell, M.D., Founder, Two Dreams Outer Banks and Director, Encounter Medical Group approach referenced William E. McAuliffe in a National Institute on Drug Abuse (NIDA Research Monograph 72, 1986) about recovery training. According to Andrea, McAuliffe described treatment as complete when:

(a) the patient acknowledges addiction,
(b) commits to recovery, and
(c) reduces or eliminates inducements to use.

 

“When I apply that to where a patient is” Andrea said, “substance use is not “relapse” unless those three simple criteria have been met:
(a) acknowledge – knows the disease and understands he has it;
(b) commit- heartfelt acknowledgement and willingness to follow lead of peers and professionals without resistance;
(c) reduce/eliminate- follows assessment of untreated issues and takes care of them (risky peer group, drug dealing boyfriend, untreated bipolar disorder, etc.).”

 

Dr. Barthwell continues: “So, I look to keep building on the gains made in treatment until these three criteria are met and thus look at substance use as really just “continued” use and not ‘relapse’.”

  • So now that this patient has told staff and clients about his continued drinking this is a crisis for both him and the treatment community.
  • For him,it is critical to build on his honesty that he drank vodka. We must now assess and make changes around how he failed to “use other methods to escape the room prior to reaching that point.” Or, as Andrea says: “assessment of untreated issues and takes care of them (risky peer group, untreated bipolar disorder, etc.).”
  • Here are questions to explore with the patient: “What happened when you were at the AA meeting and got vodka? What could you have done before you even looked at the vodka? Before you drank it? Or even before that, what could have done for your BUDDING signs (Building Up to a Drink or Drug)? Do you even know what your BUDDING signs are? Are you in a risky peer group? Do you still stay in touch with drinking friends? Is there an untreated co-occurring mental disorder? What stopped you from reaching out BEFORE you even looked for alcohol?”
  • A good assessment will help this patient in his acute exacerbation of his disease and will help all the other clients, some of whom might even have drunk with him. That must be opened up before the community becomes toxic.

The case continues:

I wanted him out and transferred to a higher level of care, being a traditional inpatient program. He clearly needs a more structured program.”

  • Why do we want to transfer patients out when they get honest about an acute flare-up of addiction, and are clearly in a state of crisis? They need help, now, with staff and clients who already know them and can immediately build on whatever treatment has already started.
  • Good things have apparently already happened in treatment so far – the patient was honest and shared about his alcohol use. That action is to be positively reinforced, not punished, especially if we believe addiction is an illness where it is common for people to lose control.
  • In any poor outcome of any illness, the next step is to assess what is the problem(s). What services are needed? The intensity of services needed determines the level of care – not automatically “up” the intensity ladder.
  • The patient may not need a more structured program- if he now sees that he needs more names and numbers, OR a sponsor, OR to call people before he picks up a drug, OR to have a psychiatric evaluation, OR to stay away from certain friends OR to be on an anti-addiction medication….or whatever the problem and treatment needs are.
  • In no other disorder do we automatically think a person needs a more intensive level of care when there is a poor outcome or deterioration in progress. Why do we treat addiction differently from other chronic diseases?

The problemis it was Friday at 5 pm before the weekend. We were not able to make it happen until Monday. If we streeted him he probably would immediately relapse and of course risk continued heavy drinking. If we kept him we worried about what the other clients would think: “I guess it is okay to drink and use in rehab and nothing happens“.

  • Yes, if this patient was “streeted” for having an acute exacerbation of his disease, that would increase his chance of further deterioration and risk of further heavy drinking and even death.
  • The next step: Call an emergency community meeting with the patients, staff and program community. Explainwhat needs to be done to re-assess this patient and anyone else who got triggered. Then continue treatment if the patient (and anyone else affected) is willing to change their treatment plan in a positive direction.
  • The patients will learn that it is not OK to use; that this is a crisisand an acute exacerbation of their addiction; and that honesty is the bestpolicy to face their mistakes and learn from them.
  • They would learnthat a flare-up of addiction and drug use is like a flare-up of mental illness- feeling suicidal or psychotic.  In the physical arena it is likesomeone who has another asthma attack. The flare-up must be shared immediately with staff and patients so they can get quickly back on track.
  • They will learn the program is here for their support so long as they are making commitment to progress in their recovery; and that they don’t have to be perfect.
  • The patients will learn they need to be vigilant for themselves and for their fellow patient who just used, to help each other get backon track ASAP. It is a crisis.

 

The compromise we made was he can’t stay in our program but we will keep him until Monday. This was discussed with all the clients at a community meeting so theyknew we were taking action. Had he given or offered alcohol to any other client I probably would not have let him stay in the program until Monday.”

  • If the patient indeed wants treatment (but is not perfect) then the best placefor him is to continue treatment with the staff with whom he has formed a therapeutic alliance.
  • In outcomes literature, the therapeutic allianceaccounts for a greater impact on the outcome than even the evidence-based practices used.

 

The Bottom Line

Even among Addiction Medicine physicians there are mixed feelings about:

 

1. Whether alcoholand other drug use in people with addiction is willful misconduct and a choice, which requires expulsion for being assaultive to the treatment community; or whether it is out-of-control addiction where “choice” is no more relevant than “choosing” a heart attack.

 

2. Whether the highest responsibility of providers in inpatient and residential settings is to the other patients to keep the community drug-free and therefore transferor discharge the person who used substances; or whether the milieu can be kept therapeutic by actually dealing openly with the patient whose addiction flared up and with those affected by the patient in crisis.

 

3. Whether zero tolerance policies are effective in keeping an environment safe and therapeutic; or whether the unintended negative effects are for substance use to go underground, encouraging dishonesty and non-confrontation of BUDDING and actual use.

 

Even criminal justice is coming around to the futility of just removing drug users from the community to keep the community safe from drugs.

SOUL

July is Germany’s month…..if you were into the World Cup for soccer or “football” (depending what country you are in.) Germany won it all.

 

For me personally though, July was also my Germany month. “Das ist sehr gut” = that is very good. Not because I spent so much time traveling the country, but because I do love foreign travel. I had the opportunity to conduct a training in Mainz, not far from Frankfurt. No – I didn’t have to do the training in German,”Ich spricht nicht Deutsch” = I don’t speak German… or is it “Ich nicht spricht Deutsch”? It was for adolescent addiction counselors throughout the USA military bases and schools in Japan, Korea, Europe and Hawaii.

 

What was fun was simply noticing the differences in how other countries approach a variety of everyday things:

  • I confess I like driving fast on the highway, however I had to close my eyes several times while my taxi driver sped along the German autobahn that has no Federally mandated speed limit.
  • Hisspeedometer only went up to 180 km/hour on the display and we were hitting160 km/hour or more at times…..over 100 miles/hour.
  • Another taxi driver reported he had tested out his car when he first bought it. He pushed it to 230 km/hour…about 143 miles/hour. My daring 80 mph is chicken feed compared to that!

Then there was getting into and out of the country. No forms to fill out arriving or leaving. Nocustoms declaration of goods brought in or taken out. No inspection of bags. Passport control was over in about 30 seconds with a simple stamp in my passport.

 

The security checkpoint for boarding the plane in Frankfurt was very civilized. In the USA, you often have to search for the cart of plastic trays into which to place yourliquids, gels and toothpaste. (The Transportation Security Administration (TSA) personnel have not yet moved the empty trays stack back up to where the passengers are lining up.)

 

In Frankfurt, the trays arrive on a smooth-flowing conveyor belt exactly where you need them.  It slots the next empty tray into place as soon as you remove one to use.  If you happen to need two trays, you simply reach down and retrieve the next one. No frantic pushing and shoving to grab the last tray on anempty cart, or calling out to a TSA person to bring more trays.

 

One more thing: the stores were closed on Sunday to allow for a more relaxed weekend for people and their families. Not good for an American tourist who wanted to shop, but a reminder that consuming and shopping should take second place to life-work balance.

 

Now for August and mytrip to Australia. That is the opposite extreme and I don’t just mean driving on the left hand side of the road. There, you had better stick strictly to the speed limit or risk a camera-tracked speeding ticket of hundreds of dollars. No 5 to 10 miles/hour grace margin.

 

But at least the US dollar gets me a healthy Aussie dollar exchange rate compared with the dollar-busting exchange rate for the European Euro.

 

Happy travels!

Until next time

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

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.

Vol.12, No. 9

Welcome to the September edition of Tips and Topics (TNT). I’m glad that we have many new subscribers to join our longtime TNT community.

David Mee-Lee M.D.

SAVVY

It is difficult to work in the mental health and addiction treatment field without interfacing with clients involved in the criminal justice system. Some addiction treatment programs receive 90% or more of their clients from the criminal justice system.

 

“In a 2006 Special Report, the Bureau of Justice Statistics (BJS) estimated that 705,600 mentally ill adults were incarcerated in State prisons, 78,800 in Federal prisons and 479,900 in local jails. In addition, research suggests that “people with mental illnesses are overrepresented in probation and parole populations at estimated rates ranging from two to four time the general population” (Prins and Draper, 2009). Growing numbers of mentally ill offenders have strained correctional systems.”

http://nicic.gov/mentalillness

 

Here’s another headline from the Bureau of Justice:

 

STUDY FINDS MORE THAN HALF OF ALL PRISON AND JAIL INMATES HAVE MENTAL HEALTH PROBLEMS

“More than half of all prison and jail inmates, including 56 percent of state prisoners, 45 percent of federal prisoners and 64 percent of local jail inmates, were found to have a mental health problem”. This was according to the 2006 study published by the Justice Department’s Bureau of Justice Statistics (BJS).

http://www.bjs.gov/content/pub/press/mhppjipr.cfm

 

And now, note this headline on addiction and criminal justice:

 

NEW CASA REPORT FINDS: 65% OF ALL U.S. INMATES MEET MEDICAL CRITERIA FOR SUBSTANCE ABUSE ADDICTION, ONLY 11% RECEIVE ANY TREATMENT

NEW YORK, N.Y., FEBRUARY 26, 2010

 

The National Center on Addiction and Substance Abuse at Columbia University, a

drug policy organization, found that “of the 2.3 million inmates crowding our nation’s prisons and jails, 1.5 million meet the DSM-IV medical criteria for substance abuse or addiction, and another 458,000, while not meeting the strict DSM-IV criteria, had histories of substance abuse; were under the influence of alcohol or other drugs at the time of their crime; committed their offense to get money to buy drugs; were incarcerated for an alcohol or drug law violation;or shared some combination of these characteristics, according to Behind Bars II: Substance Abuse and America’s Prison Population. Combined, these two groups constitute 85% of the U.S. prison population.”

http://www.casacolumbia.org/newsroom/press-releases/2010-behind-bars-II

 

Any way you cut it, in clinical work it is increasingly important to understand Drug Courts, Mental Health/Behavioral Health Courts, other Problem-Solving Courts, and how to interface with Probation and Parole officers, Judges and their court teams.

 

TIP 1

What Are Problem-Solving Courts?

 

Here’s how the Center for Program Evaluation and Performance Measurement explains these courts:

 

“Problem-solving courts began in the 1990s to accommodate offenders with specific needs and problems that were not, or could not be adequately addressed in traditional courts. Problem-solving courts seek to promote outcomes that will benefit not only the offender, but the victim and society as well. Thus problem-solving courts were developed as an innovative response to deal with offenders’ problems, including drug abuse, mental illness, and domestic violence. Although most problem-solving court models are relatively new, early results from studies show that these types of courts are having a positive impact on the lives of offenders and victims and, in some instances, are saving jail and prison costs.

 

In general, problem-solving courts share some common elements:

  • Focus on Outcomes Problem-solving courts are designed to provide positive case outcomes for victims, society and the offender (e.g., reducing recidivism or creating safer communities).
  • System Change Problem-solving courts promote reform in how the government responds to problems such as drug addiction and mental illness.
  • Judicial Involvement Judges take a more hands-on approach to addressing problems and changing behaviors of defendants.
  • Collaboration Problem-solving courts work with external parties to achieve certain goals (e.g., developing partnerships with mental health providers).
  • Non-traditional Roles.These courts and their personnel take on roles or processes not common in traditional courts. For example, some problem-solving courts are less adversarial than traditional criminal justice processing.
  • Screening and Assessment Use of screening and assessment tools to identify appropriate individuals for the court is common.
  • Early identification of potential candidates Use of screening and assessment tools to determine a defendant’s eligibility for the problem-solving court usually occurs early in a defendant’s involvement with criminal justice processing.”

https://www.bja.gov/evaluation/program-adjudication/problem-solving-courts.htm

 

 

TIP 2

Access “A Technical Assistance Guide For Drug Court Judges on Drug Court Treatment Services

 

The Justice Programs Office, School of Public Affairs at American University, Washington D.C. http://www.american.edu/justice has published a very useful guide that helps judges understand what is addiction treatment. It helps treatment providers understand Drug Courts. You can Google the guide (paste in “A Technical Assistance Guide For Drug Court Judges on Drug Court Treatment Services“)and it should come right up.

 

There is even a small section on The ASAM Criteria (2013) which I was privileged to contribute.

SKILLS

In May this year, I gave a presentation on The ASAM Criteria at the National Association of DrugCourt Professionals in Anaheim, California. It was such a learning experience for me to be around so many judges, attorneys, court team professionals and treatment providers. In a session I attended on Judicial Leadership principles, I was struck by something one of the judge panelists said when speaking of client outcomes (sorry, I didn’t note which judge it was):

 

“People don’t failDrug Court, Drug Court fails them by not meeting their needs.”

 

Problem-Solving courts are focused on outcomes. But knowing how easy it is to blame the offender and participant in Drug and other Problem-Solving Courts for any poor outcome, that statement really got my attention………and got me thinking:

  • How should Drug Court, the judge, court team and treatment provider work together to meet the needs of participants?
  • How do we collaborate to get the outcomes of increased public and community safety and decreased legal recidivism and crime that we all want?
  • When client outcomes are not going well, what is the balance between client accountability and the treatment provider’s responsibility to improve assessment and treatment planning?
  • What is the role of court sanctions and incentives in holding offenders accountable for treatment adherence?
  • What is the role of treatment providers to keep the court informed about the participant’s threat to public safety?

Some judges are rightly concerned that treatment providers are not watching public safety closely enough.  Not sure that they trust treatment providers’ reports, judges sometimes take treatment into their own hands. This can result in judges working outside their scope of practice and issuing sanctions or mandates that are not clinically assessment based.  Here are some examples:

  • Mandating 90 days of residential level of care
  • 90 Alcoholics Anonymous meetings in 90 days
  • Ordering sanctions that may be ineffective in producing improved treatment engagement and real client functional change.

 

TIP 1

Consider these thoughts on how to deal with sanctions and incentives in Drug Court (and other Problem Saving Courts)

 

Drug court participants are varied and can present with addiction, mental health and physical health complexity. These diverse clinical presentations highlight the need for individualized approaches to sanctions that are:

 

1. Based on assessment of each client’s multidimensional needs as per The ASAM Criteria six dimensions (I’m biased of course, and there are other assessment tools and parameters that address high risk and high need).  So assessing if a person is developmentally disabled and suffers from an intellectual developmental disorder (previously called Mental Retardation) is important compared with a person who has antisocial personality disorder or lifestyle and is very institutionalized and used to incarceration. The intellectually developmental disordered person has deficits in reasoning, problem solving, abstract thinking, judgment, learning from instruction and experience etc.  The institutionalized antisocial person experiences sanctions like water on a duck’s back.

 

2. Based on treatment engagement and good faith effort of the client in treatment. Participants with co-occurring mental and addiction issues will have more difficulty with engagement and have needs that require awareness of their multiple vulnerabilities. Treatment plans need to be assessment-based and person-centered not program and compliance based. Because of different client learning styles and their array of needs, any manualized and evidence-based curriculum may require adaptation to fit each client’s problems and progress/outcomes.

 

This calls for a level of clinical sophistication to use Evidence-Based Practices (EBPs) in a person-centered and outcomes driven manner rather than a compliance and one-size-fits-all manner.  Interactive Journaling is an evidence-based method to facilitate self-change using Motivational Interviewing, stages of change work and CBT.  The Change Companies has a Drug Court journal that can be used along with other journals designed for criminal justice populations used by Federal Bureau of Prisons and many others.

 

3. Based on outcomes in treatment.  Is the client making progress in real accountable change? Are they demonstrating improved functioning that will increase public safety, decrease legal recidivism and crime and increase safety for children and families?  Active credible treatment is not just about compliance with attendance and negative drug screens.  Is the client invested in a change process at a pace that fits their assessed abilities and vulnerabilities? Or is the client merely passively complying, which does not translate into lasting change and increased safety?  How do we impact the revolving door of repeated episodes of treatment and incarceration, which wastes resources and does not produce the outcomes we all want?

 

TIP 2

What is the “bottom line” on how to move from punishment to accountability for lasting change – implications for sanctions and incentives?

 

A. Sanction for lack of good faith effort andadherence in treatment based on the clinical assessment of the person’s needs, strengths, skills and resources.  Don’t sanction for signs and symptoms of their addiction and/or mental illness in a formulaic manner that is one-size-fits-all.

 

B. The treatment provider is responsible for careful assessment and person-centered services and to keep the court apprised of any risk to public safety. The court should be informed about the client’s level of good faith effort in treatment; and whether the client is improving in function at a pace consistent with their assessed needs, strengths, skills and resources. The provider should not just report on passive compliance with attendance and production of positive or negative drug screens….passive compliance is not functional change.

 

C. If the client is not changing their treatment plan in a positive direction when outcomes are poor e.g., positive drug screens, attendance problems, passive participation, no change in peer group activities and support groups like AA etc., then the client is “doing time” not “doing treatment and change.” Providers need to then inform the judge that the client is out of compliance with the court order todo treatment.  The client consented to do treatment not just do time and should be held accountable for their individualized treatment plan. If the client is substantively modifying their treatment plan in a positive direction in response to poor outcomes; and adhering to the new direction in the treatment plan, then the client should continue in treatment and not be sanctioned for signs and symptoms of their illness(es).

 

D. Incentives for clients can be explored and matched to what is most meaningful to them.  For example, incentives that allow a client to choose a gift certificate or coupon for a restaurant may be meaningful for some clients.  But others may find assistance in seeing their children; or receiving help with housing; or advocacy to change group attendance times to fit better their work schedule to be more meaningful incentives to be used.  This requires an individualized approach recommended to the court by providers who should know their client’s needs, skills, strengths and resources.  It is too much to expect the judge can work all this out in a busy schedule of court appearances.

 

E. A close working relationship between the client, judge, court team and treatment providers is needed to actualize this approach.

 

These ideas come from my clinical bias and experience, but they are offered with awareness:

  • That we need more discussion to make this work in the world of courts and criminal justice.
  • That to achieve the public safety outcomes we all want, we have to move treatment from a passive compliance and a ‘jumping through the hoops’ mentality that allows many clients to “do time” in treatment instead of “doing treatment and change”.
  • That treatment providers will need to rise to the occasion and improve assessment and person-centered treatment planning that values outcomes-driven services.
  • That judges and court personnel can expect treatment providers to design and deliver individualized care; and to keep them well-informed on any threats to public safety. Reports need to be on functional improvement not just compliance with attendance and drug screens.

SOUL

Recently a colleague was to meet up for dinner but had to cancel because he strained his back and was in a lot of pain. I know what that is like. Over 20 years ago, I reached up to place my roll aboard suitcase in the overhead bin on the plane only to be shocked by a sharp back pain that left me walking like a 120 year old.

 

Hopping out of a car is a quick turn to the side, swinging your legs to the outside and rising out of the car seat….right? Not when you have back pain. Even in slow motion, each of those maneuvers can be excruciating. If you think back pain is mind over matter, let me know after you get your first attack.

 

On the other hand, it is true that people can milk back pain for all kinds of advantages: “I’d help you move those tissue boxes, but I have a bad back.” “Sorry I can’t come to the volunteer community park cleanup, I have a bad back (and by the way, the game is on TV).” I’d help with the dishes, but you know my back is bad today.”

 

Twenty years ago, I had almost crippling back pain in Greece on vacation, in Australia on vacation and when I moved to California. But I haven’t had an acute episode in nearly 18 years!

 

Lucky streak of good health? I don’t think so. On that bad back attack in Australia, I saw a musculo-skeletal physician who was quick to prescribe not narcotic analgesics,but rather muscle strengthening exercises. They take less than five minutes a day and I swear by this preventive remedy.

 

Here’s the three sets of exercises the Aussie doctor taught me:

1. Modified windshield wipers – I lie on my back with knees bent and feet flat on the floor. Arms are by my side and I sway my legs back and forth like windshield wipers. This seems to loosen up the back and spinal muscles.

 

If you want to do the real thing, you can check out:

How to do Windshield Wipers

http://www.health.com/health/video/0,,20732158,00.html

http://workouttrends.com/how-to-do-windshield-wipers

 

2. Next, do Pelvic tilt exercises. Same position on my back, feet flat on the floor, arms by my side. Then I tilt my pelvis up and down repetitively.

 

If you want to see a professional teach this, go to:

How to Do Pelvic TiltExercises -YouTube

https://www.youtube.com/watch?v=lTX15Qk1xTM

 

3. The third exerciseinvolves abdominal crunches. Same position on my back, but this time, I raise my legs and rest my feet on a stool or chair. Keeping the neck in line with your spine, not bent forward with chin touching your chest, do some crunches to strengthen abdominal muscles. I cross my arms across my chest butyou can check out a couple of ways here:

How to Do Crunches

https://www.youtube.com/watch?v=Xyd_fa5zoEU

http://www.wikihow.com/Do-Crunches

 

How many repetitions of these are necessary? I don’t know what works for you, but at first, if the back pain is still acute, just do a few to get the idea…maybe five each. But I have worked up to do 3 sets of 20 windshield wipers and pelvic tilts and 2 sets of 20 crunches in sequence: wipers, tilts, crunches to tilts,wipers and crunches and ending with tilts and wipers.

 

I talked to another colleague today. He is going for an MRI in preparation for back surgery, hopefully to fix his chronic back pain.

 

I feel bad for him and I know I don’t want to get anywhere near that. I better do my wipers, tilts and crunches.

Until next time

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

David

Vol.12 , No. 7

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

David Mee-Lee M.D.

SAVVY

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

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

 

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

 

TIP 1

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

 

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

 

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

 

1. Acute intoxication and/or withdrawal potential

2. Biomedical conditions and complications

3. Emotional/behavioral/cognitive conditions and complications

4. Readiness to Change

5. Relapse/Continued Use/Continued Problem potential

6. Recovery environment

(The ASAM Criteria 2013, pp 43-53)

 

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

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

 

Dimension 1: Acute intoxication and/or withdrawal potential

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

 

Dimension 2: Biomedical conditions and complications

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

 

Dimension 3: Emotional/behavioral/cognitive conditions and complications

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

 

Dimension 4: Readiness to Change

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

 

Dimension 5: Relapse/Continued Use/Continued Problem potential

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

 

Dimension 6: Recovery Environment

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

 

TIP 2

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

 

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

 

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

 

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

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

 

Reference:

Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013).

The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies.

SKILLS

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

 

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

 

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

 

TIP 1

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

 

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

 

The software offers:

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

 

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

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

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

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

SOUL

 

70

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

 

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

 

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

 

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

 

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

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

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

 

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

Until next time

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

David

Vol.12, No. 8

Welcome to the November edition of Tips and Topics (TNT). For all in the USA, a Happy Thanksgiving!

David Mee-Lee M.D.

SAVVY

Whenever I raise a sometimes controversial issue in Tips and Topics (TNT), I am never quite certain how it comes across. Fortunately I see many of you at workshops and conferences. I appreciate it when readers tell me they always seem to get something useful out of each issue. (Of course the readers who don’t get much out of TNT never come and let me know how disappointed they are. After all, TNT is free!)

The emails and verbal appreciations are gratifying.  This month however, one reader, Izaak Williams, went much further than simply read and digest a previous edition.In the March 2011 edition, I wrote in SKILLS about the sometimes negative, unintended consequences of “graduation” ceremonies in residential treatment.

http://www.tipsntopics.com/2011/03/march-2011-tips-topics/#more-1625

 

Izaak researched the topic and wrote his version in a peer reviewed paper entitled “Drug Treatment Graduation Ceremonies: It’s Time to Put This Long-Cherished Tradition to Rest” He even received permission to allow you free access to the whole paper at this link:

http://www.tandfonline.com/doi/full/10.1080/07347324.2014.952995

 

So I asked Izaak Williams to summarize his paper for the November edition. Here is how he did that (with some minor edits from me.)

 

TIP 1

Are Graduation Ceremonies a Therapeutic Celebration or Hollowed Concept? You Be the Judge

 

1. Where did substance use treatment graduation ceremonies originate?

The history of this tradition finds its roots in “early 19th century treatment institutions. It was the practice in the Keeley Leagues (KL) – (for example, the patient-led recovery mutual aid fellowship within the Keeley Institutes) for the person leaving treatment to recount their experience, receive the best wishes and guidance of other KL patients before KL members walked the departing patient to the train station in Dwight, Illinois. The function of this ritual was to reaffirm commitment to sobriety, cement the bonds of fellowship, and form a bridge between the institutional group and the Keeley League meetings in one’s own home” (Personal Correspondence, W. White, November 6, 2014).

 

2. What’s wrong with using the term graduation or commencement?

Just about any dictionary definition of “graduation” or “commencement” spells out the notion of “wholeness” that refers to completion of everything needed or required. When we talk about graduation in the education system the discussion shifts to prerequisites and credits towards a degree program—requirements that are clearly articulated.

 

For example, asking a high school or college student if he or she will graduate would invite the student to talk about how many credits they’ve completed or what classes they plan to take in the near future in order to graduate or commence. Moreover, while the meaning of commencement in the dictionary may refer to “a beginning”, this very same definition is often qualified with cross-reference to graduation. In other words, to start anew or “begin” one must first completely finish (high school or college degree program).

With this in mind, how does one commence or graduate from a substance use disorder?

Why might it not be such a Good Idea to Graduate Treatment Participants?

 

Here are Izaak’s thoughts on how graduations appear to affect participants:

  • There can be an overblown sense of confidence about their prospects of not returning to use. This reinforces a willpower stance toward addiction. It seems to foster a particular relationship with their drug of necessity which directly contributes to continued drug use or relapse.
  • For some clients who tend to reward or celebrate with drug use, a festive celebration with entertainment value may trigger a drug craving in order to enhance the fun.
  • It may foster the false belief that “cure” has occurred and that treatment support or ongoing mutual aid is no longer needed or will ever be required.
  • Treatment participants may be working on repairs or making amends while relationally cutoff from loved ones. If loved ones are not invited or refuse to participate in graduation, this can provoke client distress, anxiety, and other not-so-good feelings and negative emotions.
  • Returning to treatment after graduating would seem to provoke a sense of stigma in light of embarrassment and disappointment of having to face treatment staff and possibly other peer clients who celebrated with them.

3. What is the future for graduation ceremonies?

There are many ongoing changes in drug treatment industry standards in light of the Affordable Care Act (ACA) and Mental Health Parity and Addictions Equity Act (MHPAEA)(2008).  In the future, the existence of graduation ceremonies will hinge on the availability of empirical evidence to support it as a therapeutic practice.  This is because traditional stand-alone addiction treatment programs which perpetuate this tradition mostly aim at targeting drug use on the basis of stabilization. This is an acute care model; it’s not sophisticated enough to be effective for chronic disease management.  One emerging model of care is the patient-centered “medical home” or “Patient-Centered Primary Care Home Program” (PCPCHP) (see: http://www.oregon.gov/oha/pcpch/Pages/index.aspx for patient-centered primary care programs). In short order, here are but a few of the key standout words characterizing this model: comprehensive, integrated, coordinated, continuous, patient and family centered, collaboration.

 

As treatment industry standards encourage collaborative plans of intervention that are holistic and promote wellness, the future of both acute care model and graduation ceremony is bleak. This is because both appear antithetical to the new standards of care conforming to the medical model of drug addiction promoted by ACA and MHPAEA.

 

4. Is there another way of thinking about Graduation Ceremonies?

  • One suggestion is that the word “graduation” and its substitute or euphemism-“commencement”— be avoided in program speak. This would then permit the notion of continuum of care transition to creep into thought rather than “end of treatment”, “completion”, or “graduation.”
  • Perhaps the proverbial graduation ceremony performed in a grand ballroom could be scaled down to a more individualized patient-centered setting-an intimate meeting-  between the treatment team, client, family members, sponsor, and friends willing to offer ongoing support.  This forum would provide a structured opportunity to talk safely and formulate support roles.  Add to this: the possibility of clarifying misconceptions about addiction dynamics and facilitating ongoing treatment recovery processes.
  • As David Mee-Lee suggests, this could be called the Reflection, Celebration, and Anticipation (RCA) (seehttp://www.tipsntopics.com/2011/03/march-2011-tips-topics) stage.  At its very essence, what this entails is establishing a road map to help patients and his/her support system see where they are now and where they are headed in treatment recovery.  This might be called a ”life in recovery transition day” centered on the sharing of a solid, longitudinal, community-based Continuing Care Recovery Plan (CCRP) in supporting further stages of recovery.

 

In closing, Izaak indicated that Thomas McGovern, editor of the Journal of Alcoholism Treatment Quarterly invites comments in response to the article entitled “DrugTreatment Graduation Ceremonies: It’s Time to Put This Long-Cherished Tradition to Rest” (Vol. 32 issue 4). “We welcome critique and criticism to stimulate further dialogue, compel critical thinking, and encourage empirical scrutiny of substance use disorder treatment graduation ceremonies.”

 

Izaak L. Williams, Hawaii State Certified Substance Abuse Counselor (CSAC), was selected in the 2014 cohort of emerging leaders by the Center for Substance Abuse Treatment’s(CSAT’s) Behavioral Health Leadership Development Program. He can be reached at: izaakw@hawaii.edu

 

Reference:

Williams, Isaak L (2014): “Drug Treatment Graduation Ceremonies: It’s Time to Put This Long-Cherished Tradition to Rest” Alcoholism Treatment Quarterly Volume 32, Issue 4, pages 445-457

Published online: 06 Oct 2014http://www.tandfonline.com/doi/full/10.1080/07347324.2014.952995

SKILLS

In April of 2011, theBoard of the American Society of Addiction Medicine unanimously adopted a new definition of addiction. There is a “short version” (shown below), as well as a “long version” definition (available at http://www.asam.org/for-the-public/definition-of-addiction), which serves as more of a description of the condition.

Short version: “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.”

 

Izaak provided what he called “Stimulus” questions for you to think about. Reflect on these to see how you view graduation ceremonies in the context of your definition of addiction. I responded with a few thoughts his questions stimulated for me.

 

TIP 1

Consider the following “Stimulus Questions” about Graduation Ceremonies

 

Question:

How do graduation ceremonies provide mutual support and aid drug addiction treatment and recovery for participants?

My thoughts:

It is always a joy to see people change (if they have) in attitude, thinking and behavior from the beginning of an episode of care to their transfer or discharge. Celebrating these changes creates a sense of accomplishment that too many clients and patients have rarely experienced in their lives. However, on the path of life-long recovery, their episode of care is just one step; it is a beginning not an ending. For many clients, families and mandating agencies “graduation” sounds like cure, as if a broken leg is now fully healed and ready for weight-bearing. It may seem that the term “commencement” might be a better word, to signify a beginning process, except in people’s minds this word is still associated with graduation ceremonies.

Question:

What do such ceremonies provide to family members when their loved one is reintegrating into the community out of treatment?

My thoughts:

Many families have suffered for years from the effects of addiction in their lives and their loved one. Finally, after treatment, the family finds it wonderful to have their son, daughter, father, mother or partner back. They get back the loved one they haven’t experienced for years, due to the ravages of addiction. But I have seen so many families disappointed and hurt by expectations of “treatment completion and graduation.” They thought this would finally be the miracle.

When families think of addiction treatment as finding the best program (like researching a world expert surgeon, cancer center, miracle medication or procedure) “graduation” offers false hope. They need to understand addiction requires continuing recovery and care. Flare-ups and acute exacerbations of this ongoing disease are common, just like asthma, diabetes, hypertension, bipolar disorder or panic disorder. Families are in need of recovery help as much as their loved one. “Graduation” sends the wrong message.

 Question:

What values and perceptions about the nature of addiction are you expressing when you have graduation ceremonies?

My thoughts:
You can tell what I think. In providing your services, what do your practices, policies and procedures with clients and families communicate to them about the nature of addiction? What messages do clients and families receive, explicitly and implicitly, in how you describe your program or service? How do you speak about length of stay and program rules? How do you treat the end of a treatment episode, discharge planning, family work and graduation ceremonies?

Question:

Are such values and messages consistent with what the research says about addiction?

My thoughts:

Obviously I view addiction and treatment as an ongoing process of recovery; it needs to be viewed as chronic disease management in a flexible continuum of care. The ASAM Criteria has set out the criteria for how to do chronic disease management since 1991. Ponder your definition of addiction. How consistently do you walk the talk about addiction – its nature and its treatment.

Question:

Does participation in graduation lead to better recovery outcome?
Do “graduates” find it easier to maintain their therapeutic gains?

My thoughts:

Whether you are for or against “graduation”, we are most often speaking from tradition, personal life and work experience, and clinical opinion. The research evidence is slim to nothing. This would be a worthy research focus for an up and coming scientist in the field.

Question:

How does graduation ease the transition from treatment to longitudinal recovery care management in the community?

My thoughts:

Unfortunately, I believe the unintended negative consequences outweigh the understandable advantages of joyful celebration. I wonder, as Izaak Williams’ paper suggests, whether “It’s Time to Put This Long-Cherished Tradition to Rest”.

SOUL

I am pretty good at saving money. My father was frugal and I have been socialized to be the bread-winner and provide the best I can for my family. But when it comes to saving time, it’s a different matter. Somehow, I just never seem to have enough time.

 

Now before I go on further, let me acknowledge that this SOUL was inspired by reading Scott Provence’s “Time Robbers” in his weekly stories about superheroes and behavior change. Scott is Vice President of Product Development at The Change Companies and in his blog, Superhero is learning about the science of self-help. You’ll be entertained and educated by the antics Superhero gets up to. You can see the November 3, 2014 story I’m referring to at the website Scott calls “I’ll Save You (and other lies)”. Check out the Archives and subscribe there too if you want.

http://www.illsaveyouandotherlies.com/blog/2014/10/28/the-hero-of-time-and-money

“Time Robbers” started me thinking about parallels between money and time, and the language we use:

  • We save money to spend later. We save time by taking a shortcut on a road trip.
  • We spend a lot of money on what is important to us. We spend a lot of time on what is important to us.
  • We can waste money on ill-founded schemes or trivial pursuits. We can waste time on ill-founded schemes or trivial pursuits.
  • If you don’t watch out to keep your money safe, it can get stolen. If you don’t watch out for how life flies by, you may find on your deathbed that time can also be stolen.
  • We can be generous or stingy with our money. We can be generous or stingy with our time.
  • If you manage your budget well, you can have extra money. If you manage your schedule well, you can have extra time on your hands when you arrive early for an appointment.
  • You can worry about how much money you have and stress yourself out. You can worry about how much time you have left in life and stress yourself out.
  • Some people just never seem to enough money. Some people (looking in the mirror) just never seem to have enough time!

Well this could go on endlessly. What I realized is that I need to look at what works so well for me in having enough money, then apply the same skills to having enough time.

 

Here’s what I came up with for starters:

With money:

1. I set my priorities between retirement savings, living expenses, charity, travel and vacation.

2. I watch what I spend for quality and value.

3. I check my bank account and credit card accounts frequently to make sure expenditures and savings are in balance.

 

I do all that well.

 

Now for time, it is the same three principles:

1. What are my priorities between work, love and play?

2. How can I be more conscious about spending quality time with people, places and things of value?

3. How can I regularly check that all is in balance?

 

I’m sure my wife willbe happy to keep my feet to the fire on how I spend my time. I can see NewYear’s Resolutions gradually taking shape.

Until next time

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

David

SAVVY & STUMP THE SHRINK

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

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

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

 

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

 

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

 

TIP 1

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

 

Case #1

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

 

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

 

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

 

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

 

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

 

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

 

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

 

 

TIP 2

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

Diagnostic Criteria Sets 

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

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

References:

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

 

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

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

SKILLS

Case #2

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

 

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

 

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

 

Here is the documentation on Dimension 4 assessment:

Dimension 4: Readiness to Change:

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

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

 

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

 

TIP 1

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

 

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

 

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

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

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

 

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

SOUL

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

 

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

 

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

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

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

 

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

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

 

This is where Feng shui “eyes” come in.

 

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

 

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

Belated Happy Chinese New Year!

SHARING SOLUTIONS & STORIES

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

 

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

 

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

Until next time

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

David

Vol.12, No.12

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

David Mee-Lee M.D.

SAVVY

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

 

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

 

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

 

TIP 1

Distinguish between gender dysphoria and gender identity issues

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

 

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

 

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

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

 

TIP 2

Become familiar with current Transgender Terminology

 

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

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

 

Here are a few highlights to note:

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

References:

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

 

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

 

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

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

 

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

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

SKILLS

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

 

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

 

TIP 1

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

 

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

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

 

Here are some of the points his article raises:

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

 

TIP 2

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

 

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

 

Dimension 1: Acute intoxication and/or withdrawal potential    

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

Dimension 2: Biomedical conditions and complications

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

Dimension 3: Emotional/behavioral/cognitive conditions and complications

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

Dimension 4: Readiness to Change

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

Dimension 5: Relapse/Continued Use/Continued Problem potential

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

Dimension 6: Recovery Environment

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

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

 

References:

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

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

 

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

SOUL

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Enjoy.

Until next time

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

David

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. 5

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

David Mee-Lee M.D.

SAVVY

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

 

The New York Times

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

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

TIME (8/12/15) reported:

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

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

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

Addiction Treatment

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

 

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

 

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

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

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

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

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

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

 

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

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

 

Strong Network Development Plan”

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

 

Care Coordination Design

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

 

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

 

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

 

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

 

The California Initiative

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

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

 

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

 

TIP 1

If your state is considering enhancing care for individuals with SUD, take a look at what California is just now embarking on in their system of care redesign.

 

Here is the introduction to California’s system re-design states:

 

“The Drug Medi-Cal Organized Delivery System (DMC-ODS) provides a continuum of care modeled after the American Society of Addiction Medicine Criteria for substance use disorder treatment services, enables more local control and accountability, provides greater administrative oversight, creates utilization controls to improve care and efficient use of resources, implements evidenced based practices in substance abuse treatment, and coordinates with other systems of care.

This approach provides the beneficiary with access to the care and system interaction needed in order to achieve sustainable recovery. The DMC-ODS will demonstrate how organized substance use disorder care increases the success of DMC beneficiaries while decreasing other system health care costs.”

 

The State Implementation Plan and Standard Terms and Conditions for the DMC-ODS are located at http://www.dhcs.ca.gov/provgovpart/Pages/Drug-Medi-Cal-Organized-Delivery-System.aspx

 

Reference:

Mann, Cindy and Osius, Elizabeth (2015): “Medicaid’s New Role in the Health Care System” Journal of the American Medical Association (JAMA), Volume 314, No. 4 pp. 343-344.

SKILLS & SHARING SOLUTIONS

If your agency, county or state is preparing to implement The ASAM Criteria, here are some tips to get you started.

 

TIP 1

Involve all systems and stakeholders in the implementation process from Day 1.

 

Whenever I am asked to train or consult for a “kick-off” for implementing The ASAM Criteria, one of the first strong recommendations I offer is to make sure ALL stakeholders affected by The ASAM Criteria are in the room from the beginning.

 

Why is this? Because implementing the true spirit and content of the Criteria affects everything:

* How you engage and attract people into recovery;    

* How you conduct screening and assessments;

* How you collaborate with clients, patients, families and referral sources on individualized treatment;

* How you design, deliver and pay for a continuum of addiction services; and

* How you move people through a disease management continuum of care.

* Not least of all, how you select and train staff on all these processes.

 

Implications for stakeholders

  • Counselors and clinical staff will need to move away from program-driven services to individualized, person-centered, outcomes-driven treatment.
  • Administrators and supervisors must figure out how to use economies of scale to provide a broad continuum of care, to stretch resources to achieve good outcomes.
  • Payers and managed care companies will have to ‘speak’ the common language of The ASAM Criteria – to collaborate with treatment providers on care and utilization management decisions.
  • Quality improvement and auditors must understand the correct application of The ASAM Criteria and what it really means for documentation, treatment plans and continuing care decisions.
  • Referral sources, especially mandated treatment settings like Drug Court and other criminal justice personnel, Child Protective Services, employers and schools, will have to understand that mandating assessment and treatment adherence is the correct stance – rather than mandating a particular level of care and length of stay.

TIP 2

Broaden understanding of the clinical application of The ASAM Criteria beyond intake, admission and level of care placement.

 

Some counselors and clinicians think The ASAM Criteria is a checklist of levels of care to justify admission to the program. Then they think they are done- to pursue treatment as usual. Nothing could be further from the truth, which is why we removed the wording “patient placement” from the 460-page 3rd edition (2013) book.

 

It is much more than initial placement criteria. That’s why there are multiple chapters on application of the criteria to special populations. There are chapters on working effectively with managed care, tobacco use disorder and gambling disorder. Appendices on withdrawal management instruments were added to address Dimension 5, Relapse, Continued Use or Continued Problem Potential.

 

Take a look at www.ASAMCriteria.org and “How to Really Use the New Edition of The ASAM Criteria: What to Do and What Not to Do” Counselor Magazine Nov-Dec., 2013

See more: http://www.counselormagazine.com/2013/Nov-Dec/ASAM_Criteria/#sthash.wOk2zq6r.dpuf

 

There are some proprietary instruments to help you. The Change Companies® is the sole distributor for Evince Clinical Assessments, the field’s most complete system of clinically-driven assessment, diagnostic and patient placement and planning tools compatible with the DSM-5 and The ASAM Criteria – Third Edition.

 

Included in this comprehensive system is the DAPPER (Dimensional Assessment for Patient Placement Engagement and Recovery), the assessment tool most closely aligned with the new ASAM Criteria. To view a description and sample pages click https://www.changecompanies.net/products/?id=DA-T

 

TIP 3

Consider Interactive Journaling to help you use Evidence-Based Practices.

 

Many states now require counselors and programs to use Evidenced-Based Practices. In this new initiative California requires at least two of the following evidenced-based treatment practices (EBPs):

1. Motivational Interviewing

2. Cognitive-Behavioral Therapy

3. Relapse Prevention

4. Trauma-Informed Treatment

5. Psycho-Education

 

What too few realize is that there is actually one evidence-based practice that incorporates most of these EBPs above in one method. Interactive Journaling (IJ) is an EBP on the Substance Abuse and Mental Health Services (SAMHSA) National Registry of Evidence-based Programs and Practices (NREPP)

 

If you missed it, you can read all about IJ in the May 2014 edition of Tips and Topics:

https://www.changecompanies.net/blogs/tipsntopics/2014/05/

 

TIP 4

For a Standardized Assessment learn more about The ASAM Criteria Software.

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

 

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

 

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

 

Reference:

Miller, W. R. (2014). Interactive Journaling® as a Clinical Tool. Journal of Mental Health Counseling, 36(1), 31-42.

SOUL

Have you ever been stuck in gridlock on the highway with no clue why you are now in a parking lot!? You see some drivers pulling out to the shoulder, trying to catch a glimpse of what’s up ahead: “Is it a bad car accident? Or roadwork? A collapsed bridge? Is it 4 lanes narrowing down to 2? Maybe it’s just thousands of people interested in going to the same place as me?”

 

When you hear sirens and ambulances, you guess there is indeed an accident. Then you settle back for the long wait while cars crawl by rubbernecking at human tragedy. What’s frustrating is when you have no idea why you are speeding along at 3 miles per hour.

 

Switch scenes now. You’re sitting on a plane which was late taking off and now late arriving. This is threatening the very close connection to your next plane that you can’t wait to board. You want to get home after a long week “on the road”. Yes, that’s me.

 

Here’s my beef with airplane pilots. They can see perfectly well why the plane is 50 feet from the jet bridge and why we aren’t docking to let connecting passengers race to their next gate. Haven’t they ever been in a gridlocked parking lot on the highway? Don’t they know what it feels like to be stuck- with no idea why we aren’t moving?

 

Yes, they do usually give some brief explanation but:

  • Sometimes it is so general, it doesn’t help: “Folks, we aren’t at the gate yet, so please stay seated with your seat-belts fastened and your luggage stowed.”
  • Then a long silence with no explanation on why we are not at the gate yet. Is it because the gate is occupied by another plane that is nowhere near ready to push back? If so I almost certainly will miss my connection. Or is there a new trainee struggling to operate the jet bridge joystick and wobbling all over the airport, missing alignment with the plane door? Could we be waiting for a tow vehicle to hook up the plane to pull us into the gate? Pilot…..please tell us what is going on!
  • Even when they do tell us something more specific like: “There isn’t a gate agent yet to maneuver the jet bridge” or “There is a plane occupying our gate” or “We’re waiting for a tow vehicle,” they never keep you informed. They are up front looking through the windshield. We passengers have blank walls and no-smoking signs to look at. A few play-by-play updates would be nice: “Looks like the gate agents are busy, still no-one showing up. I’ve called them again.” Or “The plane does look like it is starting to push back, shouldn’t be long now.” Or “I can see the tow operator headed our way.”
  • Worst of all, is when they say: “It’s just going to be a few minutes and we’ll be at the gate” and then you get radio silence with no explanation and no updates AND it certainly is NOT a few minutes.

Maybe I’ve had too many frustrating plane trips lately, but next time I sit next to a pilot traveling to their next assignment, I’m going to bare my SOUL.

Until next time

Thanks for reading this month. See you in late September.                                

David

Vol. 13, No. 8

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

 

David Mee-Lee M.D.

SAVVY

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

 

TIP 1

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

 

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

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

 

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

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

 

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

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

 

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

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

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

 

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

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

 

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

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

 

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

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

 

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

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

 

TIP 2

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

 

1. “Heavy drinker”

  • Someone who weighs 250 lbs. and drinks.

 

2. “Problem drinkers”

  • People who spill more than they swallow.

 

3. “alcohol abuse”

  • Pouring water into good Scotch.

 

4. “Data is not the plural of anecdotes”

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

 

Norman Hoffmann, Ph.D.

President, Evince Clinical Assessments

E-mail: evinceassessment@aol.com

www.evinceassessment.com

 

Bio:

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

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

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

SKILLS & STUMP THE SHRINK

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

 

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

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

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

Thanks,

Ian Evans MFTI #78016

Clinician I, Adult Forensic Care Team

Yolo County Department of Health Services, California

Work Cell: (530) 681-8165

Voicemail: (530) 666-8099 ext 1803

E-mail: Ian.Evans@yolocounty.org

 

TIP 1

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

 

Hi Ian:

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

 

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

 

A. Tips and Topics, July 2014:

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

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

B. Tips and Topics, October 2012:

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

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

 

 

C. Tips and Topics, November 2012:

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

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

 

 

D. Tips and Topics, June 2009:

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

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

 

 

E. Tips and Topics, October 2004:

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

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

 

 

F. Tips and Topics, September 2006 SKILLS section:

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

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

 

Hope this helps, but let me know if not.

David

 

TIP 2

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

 

BARCLAYS OFFICIAL CALIFORNIA CODE OF REGULATIONS

Health-Related Services.

Title 9 Section 10572 (e) that states:

 

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

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

 

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

 

Ian’s message:

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

 

Thanks for your time,

Ian Evans

 

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

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

Let’s start the conversation.

SOUL

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

 

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

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

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

 

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

 

Go Pats!

Until next time

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

                              

David

Vol. 13, No. 8

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

 

David Mee-Lee M.D.

SAVVY

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

 

TIP 1

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

 

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

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

 

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

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

 

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

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

 

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

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

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

 

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

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

 

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

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

 

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

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

 

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

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

 

TIP 2

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

 

1. “Heavy drinker”

  • Someone who weighs 250 lbs. and drinks.

 

2. “Problem drinkers”

  • People who spill more than they swallow.

 

3. “alcohol abuse”

  • Pouring water into good Scotch.

 

4. “Data is not the plural of anecdotes”

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

 

Norman Hoffmann, Ph.D.

President, Evince Clinical Assessments

E-mail: evinceassessment@aol.com

www.evinceassessment.com

 

Bio:

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

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

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

SKILLS & STUMP THE SHRINK

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

 

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

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

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

Thanks,

Ian Evans MFTI #78016

Clinician I, Adult Forensic Care Team

Yolo County Department of Health Services, California

Work Cell: (530) 681-8165

Voicemail: (530) 666-8099 ext 1803

E-mail: Ian.Evans@yolocounty.org

 

TIP 1

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

 

Hi Ian:

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

 

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

 

A. Tips and Topics, July 2014:

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

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

B. Tips and Topics, October 2012:

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

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

 

 

C. Tips and Topics, November 2012:

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

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

 

 

D. Tips and Topics, June 2009:

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

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

 

 

E. Tips and Topics, October 2004:

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

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

 

 

F. Tips and Topics, September 2006 SKILLS section:

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

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

 

Hope this helps, but let me know if not.

David

 

TIP 2

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

 

BARCLAYS OFFICIAL CALIFORNIA CODE OF REGULATIONS

Health-Related Services.

Title 9 Section 10572 (e) that states:

 

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

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

 

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

 

Ian’s message:

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

 

Thanks for your time,

Ian Evans

 

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

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

Let’s start the conversation.

SOUL

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

 

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

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

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

 

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

 

Go Pats!

Until next time

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

                              

David

March 2016

Vol. #13, No. 12


In this issue

Criminal justice reform; treatment and functional change; sanctions and incentives

David Mee-Lee M.D.


(more…)

Getting Real about Gambling Disorder and Speeding again

Vol. 14, No. 1

Welcome to the beginning of our 14th year of Tips and Topics. It is hard to believe thirteen years ago I published our first Tips and Topics.  Thanks for starting a new year with us.

David Mee-Lee M.D.

SAVVY

I recently received this message from a long-time Tips and Topics reader:

 

“Hi Dr. Mee-Lee:

 

I’ve enjoyed Tips and Topics for a number of years and sometimes use excerpts from it as teaching and supervision tools for our students. I was also present for your keynote address to the National Conference on Problem Gambling (NCPG) last year and appreciated your thoughts about removing Substance Use Disorders and Gambling Disorder from their separate silos to help addictions clinicians and programs develop stronger competencies in both areas.

 

I do have a suggestion for Tips and Topics. Most of the insights in your newsletter relate well to the challenges counselors face working with problem gamblers and their family members, yet almost invariably when Tips and Topics refers to addictions, only Substance Use Disorders (SUDs) are mentioned. I’m wondering if, in the spirit of your keynote address to the NCPG conference, Gambling Disorder can be included, where appropriate. It could help raise the consciousness about this among your readers.

 

Thanks for taking the time to read and consider this.

 

Rick Berman LPC, CADCIII, CGACII

Director, Problem Gambling Services

Lewis & Clark Graduate School of Education and Counseling

4445 SW Barbur Blvd. Suite 205

Portland, Oregon 97239

E-mail: eberman@lclark.edu

 

I can’t always respond to all suggestions readers make, but in this one, Rick has a point. I’ve talked before about addiction being more than just substance-related. Moreover, in The ASAM Criteria (2013) on pages 357-366 we even have a whole chapter on Gambling Disorder. Yet I have written or spoken of gambling hardly at all in Tips and Topics.

 

So this month’s edition fixes that problem a bit. I will share excerpts of my presentation on July 10, 2015 at the 29th National Conference on Problem Gambling in Baltimore, Maryland: “Getting Real about Gambling Disorder: How The ASAM Criteria Can Help“.

 

TIP 1

Why Consider Gambling Disorder?

 

American Society of Addiction Medicine (ASAM) Definition of Addiction

 

* The Definition of Addiction adopted by the ASAM Board of Directors in April 2011 states that persons with addiction can be seen as “pathologically pursuing reward and/or relief by substance use and other behaviors.” One of those “behaviors” is gambling.

* This definition does not state that Alcohol Addiction, Opioid Addiction, Nicotine Addiction and Gambling Addiction are separate conditions. It states that addiction can be involved with various substances and behaviors. (Nicotine addiction is the other neglected addiction).

* People with addiction manifest a pathological pursuit of reward or relief, and have a “disease of brain reward, motivation, memory and related circuitry” which is “characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response.”  

 

Statistics on Gambling Disorder

 

* Gambling Disorder is widespread and often co-exists with substance-related disorders as well as other mental disorders. Various estimates indicate that 1-2% of U.S. adults and 2-4% of U.S. adolescents are diagnosable with Gambling Disorder. (The ASAM Criteria, 2013)

* Lifetime prevalence is about 0.4%-1% – females about 0.2%; males about 0.6%; African Americans about 0.9%; whites about 0.4%; Hispanics about 0.3% (DSM-5, page 587, 2013)

* “Up to half of individuals in treatment for gambling disorder have suicidal ideation, and about 17% have attempted suicide.” (DSM-5, page 587, 2013)

* For 6-9 million Americans, gambling is a damaging behavior that can harm relationships, family life, and careers. (SAMHSA – http://blog.samhsa.gov/?s=Gambling+Disorder#.VYXAHGCnRfQ)

 

TIP 2

Getting Real about Health Coverage for Gambling Disorder

 

(The ASAM Criteria 2013, page 358)

* In contrast with substance use disorders, it is currently uncommon for commercial or governmental health plans to offer payment for treatment in residential or inpatient levels of care unless there are co-occurring medical or psychiatric problems, which would, in and of themselves, justify reimbursement for such placements.

* Most insurance companies that do not categorically exclude coverage for the treatment of gambling disorder have had benefits for the treatment of gambling disorders. But those benefits do not include payment for residential or inpatient treatment unless there is another, primary diagnosis such as major depressive disorder. It is the major depressive disorder which generates the reimbursement, not the gambling disorder. A state or local drug and alcohol authority could elect (and some do) to pay for the treatment of gambling disorder, regardless of level of care.

* Even partial hospitalization or intensive outpatient treatment programs for gambling disorder have historically been considered a “non-covered benefit”; patients needed to meet criteria for a substance use disorder or a separate mental disorder in order for payment to be authorized when the treatment focus would otherwise be the person’s pathological gambling.  

* “Across all states, there was a lack of uniformity regarding what types of problem gambling services were funded. Some states funded a comprehensive array of services ranging from prevention through multiple levels of treatment, while other states provided only one service (e.g., a problem gambling helpline or a prevention program).”

* “Among state agencies this variability in services provided was often rooted in the legislation that originally established the problem gambling program. Some states had legislation that restricted the use of funding to specific service areas. Another driving factor for which services were funded was linked to budget pragmatics, such as having insufficient funds to expand the range of services offered.” (2013 NATIONAL SURVEY OF PROBLEM GAMBLING SERVICES, March 2014)

 

TIP 3

Getting Real about Staff Credentials and Competence for Gambling Disorder

 

(The ASAM Criteria 2013, page 358)

* Staff providing treatment to patients with gambling disorder should have a state-sponsored or -approved Gambling Counselor Certification.

* Not all states have such credentialing – some states accept a national credential such as the National Certified Gambling Counselor (NCGC), provided by the National Council on Problem Gambling.

* State certification or licensure as an Alcohol and Drug, Chemical Dependency, or Substance Abuse Counselor should not be considered a substitute for or equivalent to a Gambling Counselor Certification.

* In the future, the evolution of professional training and professional certification, possibly being influenced by the 2011 ASAM Definition of Addiction, may mean that all addiction counselors will receive sufficient training in addiction associated with gambling, and thus separate certification will not be necessary. But at this time, there are relatively few well-trained and certified Gambling Treatment counselors.

 

TIP 4

Getting Real about Filling Gaps for Gambling Disorder

 

2013 NATIONAL SURVEY OF PROBLEM GAMBLING SERVICES: 

Survey participants were asked to identify one item as their state’s “greatest obstacle in meeting service needs to address problem gambling.”

 

* “Inadequate funding” was most frequently identified as the largest gap.

* The second most commonly endorsed service gap was a lack of public awareness about problem gambling.

* Problem gambling treatment availability.

* Need to increase the number of treatment providers.

* Improve research.

* Increase the number of prevention providers.

* Improve information management services.

* Increase the size of administrative staff.

 

References

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

 

2013 NATIONAL SURVEY OF PROBLEM GAMBLING SERVICES

Prepared by Problem Gambling Solutions, Inc. for Association of Problem Gambling Service Administrators (APGSA) and the National Council on Problem Gambling (NCPG). March 2014

 

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

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

 

“The Definition of Addiction” Adopted April 12, 2011.

http://www.asam.org/quality-practice/definition-of-addiction

SKILLS

Note the following about gambling:

  • Gambling problems are assessed under ASAM Dimension 3, Emotional, Behavioral or Cognitive Conditions and Complications.
  • Gambling commonly co-occurs with substance use disorders (SUD).
  • Either gambling or substance use may act as a trigger for relapse to the other disorder.
  • Screening for gambling problems should be a routine part of SUD assessment.

 

TIP 1

Getting Real about Screening and Assessment for Gambling Disorder

(The ASAM Criteria 2013, page 361)

 

The purpose of screening is to conduct a preliminary inquiry to rule an individual “in” or “out.” If “ruled in,” the next step is to perform a comprehensive diagnostic assessment using the DSM-5 criteria for Gambling Disorder.

 

Once a Gambling Disorder diagnosis is established, the next question – answerable by use of The ASAM Criteria – is: What is the severity of the disorder? Severity of illness guides the clinician to an intensity of service recommendation for the patient.

  • There are over 27 instruments for identifying disordered gambling, though there is debate about them and what they measure.
  • An appropriate instrument should be able to screen for gambling disorders in both the general population and a population of persons who have a substance use disorder.

Two screening tools are recommended.

 

A. The first is the two-item “Lie/Bet Screen.”

* Advantage is that it is only two questions, and is more likely to be used in community and clinical settings where clinicians feel overwhelmed with current assessment responsibilities and other paperwork.

 

The “Lie/Bet” two item questionnaire are:

1) Have you ever had to lie to people important to you about how much you gambled?

 

2) Have you ever felt the need to bet more and more money?

 

B. The second and better-known and researched screening instrument is the South Oaks Gambling Screen (SOGS), a 16-item scorable questionnaire, which is in the public domain and can be found on the Internet.

 

 

TIP 2

Compare and Contrast ASAM Multidimensional Assessment for Substance Use Disorders versus Gambling Disorder. 

ASAM Multidimensional Assessment (The ASAM Criteria 2013, page 362-363)        

Here are examples of questions that would be asked in a multidimensional assessment of individuals with substance use disorders; and questions as they would apply to individuals with gambling disorders. The italics identify the differences.  There are such common characteristics between assessment of both disorders, with the least overlap being in Dimension 1: Acute Intoxication and/or Withdrawal Potential. The assessment questions of the other dimensions are generally a very close match.

 

ASAM Criteria Dimension 1:  Acute Intoxication and/or Withdrawal Potential

Sample Questions:

1. Substance Use Disorder:

  • Are there current signs of withdrawal?

1. Gambling Disorder:

  • Are there current signs of withdrawal (restlessness or irritability when attempting to cut down or stop gambling)?

 

2. Substance Use Disorder:

  • Does the patient have supports to assist in ambulatory withdrawal management if medically safe?

2. GamblingDisorder:

  • Does the patient have supports in the community to enable him/her to safely tolerate the restlessness or irritability when attempting to cut down or stop gambling?

3. Substance Use Disorder:

  • Has the patient been using multiple substances in the same drug class?

3. Gambling Disorder:

  • What forms of gambling has the individual engaged in?  Has the patient also been using psychoactive substances to the point where alcohol or other drug withdrawal management is necessary?

 

ASAM Criteria Dimension 2: Biomedical Conditions and Complications

Sample Questions:

1. Substance Use Disorder:

  • Are there current physical illnesses, other than withdrawal, that need to be addressed or which complicate treatment?

1. Gambling Disorder:

  • Are there current physical illnesses, other than withdrawal, that need to be addressed or which complicate treatment? Does the individual manifest any acute conditions associated with prolonged periods of gambling (e.g., urinary tract infection)?

2. Substance Use Disorder:

  • Are there chronic illnesses, which might be exacerbated by withdrawal (e.g., diabetes, hypertension)?

2. Gambling Disorder:

  • Are there chronic medical conditions such as hypertension, peptic ulcer disease, or migraines that might be exacerbated by either cessation or continuation of the gambling behavior?

 

ASAM Criteria Dimension 3: Emotional, Behavioral or Cognitive Conditions and Complications

Sample Questions:

1. Substance Use Disorder:

  • Do any emotional/behavioral problems appear to be an expected part of addiction illness, or do they appear to be separate?

1. Gambling Disorder:

  • Do any emotional/behavioral problems appear to be an expected part of the gambling disorder, or do they appear to be separate?

ASAM Criteria Dimension 4:  Readiness To Change

Sample Questions:

1. Substance Use Disorder:

  • If willing to accept treatment, how strongly does the patient disagree with others’ perception that s/he has an addiction problem?

1. Gambling Disorder:

  • If willing to accept treatment, how strongly does the patient disagree with others’ perception that s/he has a gambling problem?

 

ASAM Criteria Dimension 5:  Relapse, Continued Use or Continued Problem Potential

Sample Questions:

1. Substance Use Disorder:

  • How aware is the patient of relapse triggers, ways to cope with cravings, and skills to control impulses to use? 

1. Gambling Disorder:

  • How aware is the patient of relapse triggers, ways to cope with cravings, and skills to control impulses to gamble?o accept treatment, how strongly does the patient disagree with others’ perception that s/he has a gambling problem?

  

ASAM Criteria Dimension 6:  Recovery Environment

Sample Questions:

1. Substance Use Disorder:

  • All Recovery Environment questions similar between SUD and gambling disorder. An additional question listed for Gambling Disorder

1. Gambling Disorder:

  • Are the patient’s financial circumstances due to the gambling or associated legal problems an obstacle to receiving or distraction from treatment, or a threat to personal safety (e.g., loan sharks)?

SOUL

What do January 2006, May 2010, October 2011 and April 2016 all have in common? Before you feel bad these might be some historical events you should know about, let me hasten to say that these dates only matter to ME.

 

You might be thinking: So why are you talking to me about dates that only matter to you? Because, there but for the grace of God go you. Actually, as I think about it, it has nothing to do with the “grace of God”. It has all to do with inattention, lack of commitment and risky behavior.

 

I did it AGAIN! I landed a speeding ticket this week, driving in Maine after a full day of training in Portland, Maine. If you’ve been a Tips and Topics reader for some years, you may remember the speeding topic has come up before in SOUL. Here are the links if you want to feel superior to me:

January, 2006 https://www.changecompanies.net/blogs/tipsntopics/2006/01/

May, 2010 https://www.changecompanies.net/blogs/tipsntopics/2010/05/

October 2011 https://www.changecompanies.net/blogs/tipsntopics/2011/10/

 

I don’t have a speeding addiction. That’s not “denial”; it is just a fact that by comparing my speeding with the “Lie/Bet” two item questionnaire for gambling disorder, I am zero-zero. I understand that’s a screening tool for gambling addiction not speeding, but it is comparable, trust me. I compared my speeding with the diagnostic criteria for gambling disorder and I didn’t come close to the required threshold for addiction. As well, I don’t want to trivialize the devastating disease and real tragedy of substance-related and gambling addiction by throwing around the word “addiction” and my speeding.

 

This is not to say, however, that I can sound like a person not yet in recovery from addiction. Here are reasons I am not addicted to speeding:

  1. Three of the four times I received a speeding ticket, I was driving a rental car. In my familiar car at home, I can feel when I’m speeding. (Oh, so they don’t have speedometers in rental cars that you can look at and monitor your speed?!)
  2. In the 2010 incident I was driving a brand new Prius, not yet used to the feel of speeding like in my old familiar car. (Oh, so again, the Prius didn’t have a speedometer to look at and monitor your speed?!)
  3. I thought I was following the flow of the traffic, so I bet I wasn’t the only one speeding. Why didn’t they catch them? It was probably racial or professional profiling, picking on Australian-born Chinese psychiatrists. (Yeah, right.)
  4. This latest speeding ticket was only for 79 mph in a 70 mph zone. Well actually the police officer took pity on me. Since it was decades since I have had a violation in Maine, he reduced my “speed” from the 83 mph to 79 (and saved me some dollars.) (79 mph and certainly 83 mph are both breaking the law and are both speeding – 70 mph is 70 mph, not 79 mph or 83.)
  5. The police are just trying to raise revenue by ticketing good citizens like me. They should be out there stopping real criminals like burglars and murderers. (So your illegal behavior is not as bad as those crimes, so you should get a break?!)

I surrender. My inattention, lack of commitment to not speeding, and risky behavior got me the ticket. I’m telling you now in hopes that my fine, my bank account and my public confession will change my speeding ways.

Interactive Journaling:

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This 32-page Interactive Journal is designed for individuals at risk for problem gambling behaviors. Safe Bet challenges individuals’ common conceptions about gambling, helps individuals recognize their motivations for their gambling and offers tips and strategies to replace or diminish harmful gambling behavior. The Journal motivates individuals to take on the responsibility of making healthy gambling choices in the future.”Safe Bet” – Problem Gambling Prevention and Education

Minimum purchase of 25

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This 48-page facilitator guide provides quick and easy to use reference for facilitation; offers core activities and alternative strategies; highlights key journaling activities with mini-pages.”Safe Bet Facilitator Guide”

Here it is: https://www.changecompanies.net/products/?id=SBF

 

To order: The Change Companies at 888-889-8866; www.changecompanies.net

Until next time

Thank you for joining us this month. See you in late May.

Sincerely,

David

Lifestyle, Sick-care; MI training; Acceptance

Vol. #14, No.5

Welcome to the August edition of Tips and Topics. This edition is coming quite a bit earlier than usual as I have some exciting news on Motivational Interviewing training to share with you.

David Mee-Lee M.D.

SAVVY

It’s nearly 40 years since I graduated from my psychiatry specialty training in Boston and then entered private practice. Hard to believe. I am a physician, psychiatrist and addiction treatment specialist. Over the years, I have been focused on illness, disease, pathology and sick-care. There is still much to do to improve health care for all. However over the past few years, I have added a focus to my attention: the need to move from a sick-care and health-care system to one of health, wellness and well-being.

 

That’s why a few years ago, I became a co-founder of the Institute for Wellness Education (IWE) whose mission is “to help drive cultural transformation so that health and wellness become the norm for individuals, communities, and the nation.”

https://www.instituteforwellness.com

 

TIP 1

People’s difficulty changing lifestyle and behavior increases costs and fuels a sick-care system.

  • Chronic disease treatment accounts for over 75% of national healthcare expenditures.
  • Half of adults do not receive recommended preventive care and screening tests (guidelines for age and sex).
  • On average, 50% of people with chronic diseases do not comply with their treatment plan.
  • Productivity losses (personal & family health problems) cost U.S. employers, on average, $225.8 billion/year.
  • Individual lifestyle determines 50% of health status and 60-75% of health costs.

Living a life of health and wellness doesn’t just feel good; it does good for everyone associated with you at home, work and play. We all know the old saying of “an ounce of prevention is worth a pound of cure.” As much as we know this, millions still struggle to change habits and embrace lifestyle change. It is going to take a cultural transformation, not just a few new nutritional, exercise and stop-smoking programs.

 

TIP 2

Change is hard as evidenced by these estimated statistics.

  • 33% of patients don’t fill prescriptions given to them by their doctors

(Tamblyn R, Eguale T, Huang A, Winslade N, Doran P. The Incidence and Determinants of Primary Nonadherence With Prescribed Medication in Primary Care: A Cohort Study. Ann Intern Med. 2014;160:441-450. doi:10.7326/M13-1705.)

  • 50% of people drop out of therapy after the initial session

(Premature discontinuation in adult psychotherapy: A meta-analysis. Swift, Joshua K.; Greenberg, Roger P. Journal of Consulting and Clinical Psychology, Vol 80(4), Aug 2012, 547-559.)

  • 92% of people set New Year’s resolutions and don’t keep them

(University of Scranton. Journal of Clinical Psychology, December 27, 2015.)

  • 50% of dieters lose weight only to gain back what they’ve lost, plus more

(Wing RR, Phelan S. Long-term weight loss maintenance. Am J Clin Nutr. 2005 Jul;82(1 Suppl):222S-225S.)

  • 50-75% of people with diabetes don’t adhere to their prescribed regimen of care

(García-Pérez L-E, Álvarez M, Dilla T, Gil-Guillén V, Orozco-Beltrán D. Adherence to Therapies in Patients with Type 2 Diabetes. Diabetes Therapy. 2013;4(2):175-194.

Peyrot M, Barnett AH, Meneghini LF, Schumm-Draeger PM. Insulin adherence behaviours and barriers in the multinational Global Attitudes of Patients and Physicians in Insulin Therapy study. Diabet Med. 2012 May;29(5):682-9.)

  • 50-90% of people relapse after a period of recovery following treatment for a substance use disorder

(Moos RH, Moos BS. Rates and predictors of relapse after natural and treated remission from alcohol use disorders. Addiction (Abingdon, England). 2006;101(2):212-222.)

 

Change doesn’t have to be out of reach for anyone. Where’s the problem? It is that most people who want to change don’t know how. Or, initially they aren’t even considering making changes, but may be forced into it by external factors.

 

One of the most common barriers to change is ambivalence. It’s “yes, but” thinking:

  • “I’d like to get exercise, but I get home from work late and then have to take care of my kids.”
  • “I’d like to cut back on my drinking, but it’s what I do when I hang out with my friends.”
  • “My doctor told me I have to lose weight, but they don’t understand that everyone in my family is big-boned.”

Motivational Interviewing is an evidence-based approach helping people get beyond “yes, but.” It helps people change behavior…for good…on their own terms and in their own way, the only way change will really “fit” and “stick.”

SKILLS & SHARING SOLUTIONS

In my 14 years of writing Tips and Topics, I have often shared solutions to improve knowledge (SAVVY) and SKILLS. This month I am excited about new learning opportunities, which will improve your knowledge and skills in Motivational Interviewing (MI). I know many of you have had trainings on MI and you may think you have it down.

 

Too often it all makes sense in the workshop, but…… translating that workshop knowledge into real practice change in your counseling or therapy sessions can be a whole new ballgame.

 

TIP 1

Take a look at a brand new learning opportunity on Motivational Interviewing from IWE.

 

At IWE, we’re putting convenient, evidence-based online training into the hands of people across the nation. Our courses give people (whether professionals in healthcare or other industries, or everyday people trying to do better at home, work, or in the community) the science-based tools to make change happen that fits each individual and change that sticks.

 

Here’s my invitation: Consider boosting your staff’s skills and effectiveness by enrolling them in a new motivational interviewing course the IWE team and I have created. Perhaps you know someone interested in helping people change?   

  • At home as a parent or family member
  • At school as a teacher, guidance counselor or principal
  • In the community as a concerned citizen or wellness coach
  • At work as a human resource person, team leader or co-worker

This MI course was designed to make sense to ALL, not simply healthcare professionals.

 

It offers the critical elements that make training in MI a success:

1. Convenient scheduling:

The online course can be accessed 24/7 from any computer, laptop, table, or phone; and students have up to 12 months to finish the course.

 

2. Effective learning format:

The course features a rich variety of learning activities: interactive practice, video demonstrations, concise and practical explanations, illustrations, and live teleconferences for skill building.

 

3. Rigorous training:

The course is designed to promote extensive deliberate practice because it’s the kind of practice that leads to real mastery.

 

4. Affordable:

Students get the benefit of a rigorous, interactive course with live feedback…. without having to take time off from work or travel for a workshop “blitz” often leaving students with lots of great ideas but not enough practice.

 

Surf the website link to learn more about the course. Be sure to scroll to the end of the web page to see some attractive special discount, sign-up deadlines you won’t want to miss. 

Click here for IWE’s MI Modules and Time-Sensitive info

 

 

TIP 2

Take a look at Train for Change, Inc.’s approach to skill retention and organizational change.

 

Train for Change (T4C), Inc., is a sister company of The Change Companies. T4C offers training solutions, which build on and go beyond skills training for individuals to promote real changes in organizations and leaders. More on this approach here: T4C’s Comprehensive Approach

 

At T4C, there are:

  • Onsite training and e-Learning modules.
  • Strategies that promote systems change – like Change Agent and Supervisor Training.
  • An array of training and implementation strategies for ASAM Criteria and Motivational Interviewing.

You can see more detail at:  T4C’s Array of Training Opportunities

  

Both T4C and IWE use knowledge from adult learning principles; organizational development; and systems and culture change to create effective and efficient learning opportunities.

SOUL

Recently, I was delivering a Motivational Interviewing (MI) training. I was discussing people ambivalent about stopping smoking. Here’s what I said: I would always first recommend someone stop smoking. However, if in our continued conversation, it became clear the individual was ambivalent about ceasing, I’d say they should continue to smoke if they want.

 

A workshop participant challenged me with this question: “Isn’t that just being manipulative and using reverse psychology?” I acknowledged it can sound that way, however intent is everything. My approach with a client is from a place of acceptance of their autonomy to make decisions about his/her own life and health. And anyway, I am truly powerless over making him/her change.

 

“Acceptance” is such an easy word to throw around. In the current edition of Motivational Interviewing (pages 16- 19, 2013) however, Miller and Rollnick break “acceptance” down into four parts – easy to list, but not so easy to actually live/practice in our work with people:    

  • Absolute Worth – full respect for whom the person is as a unique individual.
  • Accurate Empathy – “ability to understand another’s frame of reference…and that it is worthwhile to do so.”
  • Autonomy Support – “honoring and respecting each person’s…right and capacity for self-direction.”
  • Affirmation – “to seek and acknowledge the person’s strengths and efforts.”

Acceptance is part of the true spirit of MI. There is a new e-Learning module from Train for Change out to guide you in understanding all about the Spirit of MI.  Here’s the link: The Spirit of MI training  It’s the middle course in the top row of learning opportunities.

 

A few years ago at a workshop, another participant shared phrasing his supervisor had taught him, and which I said I would “steal” and teach myself:

“How is what I am doing with this client at this time, helping them to help themselves?”

In other words: our work with people is not about our brilliant insights and confrontations of clients’ knowledge deficits and thinking errors. It is not about teaching them what is wrong with them; and then having them do what we think they should do and be.

 

What is it about? It’s about partnering with them in a self-change process within an atmosphere of acceptance, compassion and discovery. That takes a lot of SOUL.

 

Reference:

Miller, William R; Rollnick, Stephen (2013): “Motivational Interviewing – Helping People Change” Third Edition, New York, NY. Guilford Press.

Upcoming conference; 14 minutes at Longwood University; Stump the Shrink

Vol. #14, No. 7

David Mee-Lee M.D.

SAVVY AND CONFERENCE ANNOUNCEMENT

Upcoming Conference:

If you’d like to come to sunny California soon for the 7th Western US Journal Training Conference October 24-26 2016, in Newport Beach, CA, The Change Companies is featuring a “Justice Services Track” for all those who work directly within the Justice System. I will be speaking and attending. And there is much more – take a look at

http://www.usjt.com/Conferences/2016/7th-Annual-Western-Conference-on-Behavioral-Health-and-Addictive-Disorders/ 

Hope to see you there.

David

Earlier this month, I got an email from Kevin Doyle, Ed.D., LPC, LSATP., who is a “longtime counselor in substance use disorder treatment, now Assistant Professor in Counselor Education at Longwood University in Farmville, Virginia. If “Longwood University” sounds familiar, but you aren’t quite sure why you remember the name, it is because it was the site of the October 4 Vice-Presidential Debate.

Kevin was asked to give one of about 10 faculty talks that afternoon as part of Longwood University’s debate-related activities. He talked about “Addiction and Public Policy” and covered many topics that I have written and spoken about before – only he covered them not in a day’s workshop, but in 14 minutes. You can see his presentation at: https://youtu.be/5UP5njyders

Since the Presidential election is heating up to a fever pitch, I thought a summary of Kevin’s points would keep us in the election mood, since he was up close and personal to at least the VP candidates. And by the way, Kevin is an “avid reader of Tips and Topics, which I enjoy very much.”

TIP 1

Review how attitudes and terminology about addiction, perpetuates stigma

Kevin reviewed many points about stigma and the way the public, payers and providers view addiction treatment. Here is his list with some comments I added:

1. How we perpetuate stigma – we talk of “addict” and “alcoholic” instead of saying “a person with addiction or a substance use disorder” – Use person-first language

The most recent Tips and Topics on this is September 2015:

https://www.changecompanies.net/blogs/tipsntopics/2015/09/

2. When a person goes for help for treatment, we say they were “sent to rehab” instead of “they are seeking help for a condition or a particular problem.”

The public, payers and policy makers and even treatment providers think addiction treatment is doing a set length of stay in “rehab” – a residential program from which the person will graduate and complete. Some insurance benefit plans then limit the number of “rehab” admissions to two, 30-day episodes a year, instead of understanding an addiction treatment continuum of care.

3. Families and clients sometimes say “We tried treatment and it didn’t work”. But if a cancer patient tried chemotherapy and the cancer recurred, most would try it again or certainly not give up on treatment and dismiss it.

With addiction, families and even physicians feel that if treatment hasn’t cured the person, then treatment doesn’t work and it’s no use going back to treatment.

4. “Treatment is a waste of time unless the person really wants it” – few people wake up and spontaneously say this is the day for recovery. Most people getting into addiction treatment have some external pressure or loss that prompts them to seek treatment and may even say “I don’t need this. I’m no worse than anyone else. I can stop any time I want.”

Expecting people to show up fully ready for recovery from day one before treatment is available, is a good way to decrease case loads and not help people. Treatment’s job is to attract people into a change process and recovery by using motivational enhancement methods.

5. “We need to lock those people up and they can learn their lesson that way” – Society responds to addiction with a criminal justice, punishment perspective.

Happily there is a bipartisan recognition and effort to see addiction treatment as a cost-effective way to increase public safety and decrease legal recidivism and crime rather than to just incarcerate those with addiction.

 6. When a person gets a urine drug screen result that is positive for a substance(s), we say they have “dirty urine” – We would never say a patient had “dirty cholesterol” and scold or sanction them for their laboratory result.

If a person’s urine is “dirty”, what does that imply? They are “dirty” too and we perpetuate stigma and discrimination.

 

TIP 2

Note how payers perpetuate stigma by policies that don’t see addiction as a disease

Payers’ policies often don’t treat addiction as a chronic disease process needing treatment.

1. “We can’t pay for residential treatment until there has been an outpatient treatment failure.” Instead of allowing a person to go immediately into a level of care that is needed, such a “fail first” policy expects a clinically inappropriate level of care to be used first.

We would never expect a person with diabetic coma to try outpatient diabetic dietary changes before admitting them for a diabetic crisis. We would never expect a patient with a heart attack to try weight loss, exercise and stopping smoking before admission to the cardiac care unit. It is true that if a person is safe to do treatment in an outpatient setting, that level of care should be tried first rather than residential care. But if they need residential treatment from day 1, then they should not need a “treatment failure” in outpatient first.

2. “Sometimes people are penalized for doing well”.  If a client is progressing well, payers expect the person to be transferred to a less intensive level of care and limit further reimbursement for care. Providers feel it is then necessary to play games by reporting their client is not doing well in order to assure ongoing payment for treatment. 

The solution is to explain honestly, the progress a person is making. But then the provider has to convey what clinical severity still exists that needs services that can only safely be delivered by more time in the current level of care before transferring them.

3. “Burdensome processes for accessing benefits that lead to longer waiting times and put barriers in place to get someone into treatment.” When someone is ready to access treatment, waiting lists and appointments several days and even weeks away work against treating addiction as the disease it is.

 

TIP 3

Now note how providers perpetuate stigma by policies that don’t treat addiction as a disease

1. “Length of stay is not individualized according to the needs of the client.” – 28 day programs based on insurance coverage, not based on severity of illness and progress in treatment. Adolescent treatment program design has added 2 weeks for a 42 day program because adolescents can be difficult to treat; and cookie cutter programing expects all clients to need and do the same interventions e.g., everyone has to go to Alcoholics Anonymous. For some it might not be the best fit for a mutual help group as powerful and effective as it is for others. 

2. “Kick people out for violating the rules and boundaries of the program.” For example discharging people for using substances on a pass when addiction is characterized by loss of control of use – that is what addiction is that needs more treatment, not discharge. 

3. “Inappropriate contact between clients can get clients thrown out because of a moralistic sense instead of this being a disease process” e.g., clients found holding hands – “Should we discharge them?” Kevin’s staff once asked. 

4. “Treatment programs may be only open from 9 -5 in OP; or only open Monday-Friday.” This doesn’t fit the needs of people with addiction who are using at all hours of the day and week. This is another example of how providers do not adhere to a therapeutically-based approach.

5. “Even people in recovery can perpetuate stigma by using terms like “sober”, “clean” or “straight.” These are “good and bad” and “positive and negative” stigmatizing moralistic terms rather than empowering terms like “I am a person in long-term recovery” (“Anonymous People” film). Such terms work against a public health and treatment approach to addiction.

 

TIP 4

Consider these Addiction and Public Policy Issues

Public policy implications:

1. Be aware of these stigmatizing terms and avoid using them.

2. Treat addiction like the chronic disease that it is and compare with what we do for other chronic diseases like diabetes, asthma, heart disease and hypertension. Some say “but addiction is different because there is choice involved in using substances.” But with other chronic diseases people make diet and lifestyle choices all the time that affect the progression of their disease and their recovery. For example, 70% of cardiovascular disease can be prevented or delayed with dietary choices and lifestyle modifications (Forman D, Bulwer BE, Curr Treat Options Cardiovasc Med. 2006;8:47-57) 

For more facts and figures on lifestyle change, see the October 2015 edition of Tips and Topics:

https://www.changecompanies.net/blogs/tipsntopics/2015/10/

3. Individualize treatment for the variety of needs that people present with.

4. Eliminate waiting lists.

5. Respond to relapse from a treatment perspective not punitively. 

6. Negative consequences can motivate change e.g., an encounter with the legal system can motivate a person to seek help, so there is no need to pamper people or not hold them accountable for their behavior. But treatment is the response for someone who has addiction that results in illegal or bad behavior, not punishment.

“From uncomfortability comes change” said one of Kevin’s mentors. 

SKILLS AND STUMP THE SHRINK

More and more states are looking to The ASAM Criteria to help reorganize their addiction treatment system. I wrote about these changing forces in the August 2015 edition of Tips and Topics

https://www.changecompanies.net/blogs/tipsntopics/2015/08/

TIP 1

Understand ASAM Criteria Level 3.1 and 3.5 and Moving from Program-Driven Services

Here are some excerpts from questions about New Hampshire’s residential levels of care and my response about the true content and spirit of The ASAM Criteria levels of care.

Dr. Mee-Lee,

Hello, my name is Paul Kiernan. I am the clinical services specialist at the Division of Behavioral Health for the State of New Hampshire. You and I had exchange emails some time ago regarding helping us better define the clinical requirements for level 3.1, Clinically Managed Low Intensity Residential, a level of care provided by several agencies that are contracted with us. We are having a bit of difficulty that I was hoping you could shed some light on.

The contracted agencies we work with are required to provide services consistent with ASAM Levels of Care. The problem we are encountering is determining what services fall under the scope of the level of care (these issues are being encountered in levels 3.1 and 3.5 primarily) and what services are above and beyond this and therefore can be billed as separate services. Many of the agencies are providing Recovery Support Services with groups such as Smoking Cessation, Managing Anxiety, Importance of Self-Care, Money Management, jewelry Making, Designing a resume and Self-Empowerment to name a few. Recovery support services are listed under both levels of care but frequency is not defined.   The contracts state that the contractor will provide services in accordance with ASAM Criteria, which leaves us with a bit of ambiguity. Any support or direction you could offer would be greatly appreciated.

Paul Kiernan, LADC Clinical Services Specialist

Division for Behavioral Health

Bureau of Drug and Alcohol Services

Clinical Services Unit

Concord, NH

Email address: paul.kiernan@dhhs.nh.gov

 

My response:

In Level 3.1, the person is getting at least 5 hours of clinical services per week. Since 3.1 is more of a 24 hour living support level, I can see that any formal individual or group clinical services could be charged separately because a person could be living in 3.1 but getting services in an outpatient (OP) agency separate from the 3.1 site.

The kind of 24 hour counseling support that is part of 3.1 would be provided under the 3.1 daily fee, because there should be trained staff there on a 24 hour basis, who can handle informal counseling support to someone who is having, for example, cravings to use at 11 PM or 2 AM and needs someone to talk to. But if there are formal clinical services like a group or individual session in 3.1, then that can be provided onsite or in collaboration with another OP service agency.

Recovery support services are not referring to Jewelry making. Helping with money management, resumes and vocational counseling if needed by the client on their treatment plan could qualify as a clinical service for Dimension 6, Recovery Environment, needs and be counted in the five hours or more of clinical services.

The daily fee for Level 3.1 would be lower than 3.5, Clinically Managed High Intensity Residential, which is for people who need 24-hour services because of imminent danger and instability. Sessions like Money Management, Jewelry making, Designing a Resume would not be in a Level 3.5 treatment plan that should be focused more on stabilization of imminent danger and preparation for continued care in less intensive levels of care. Because 3.5 is 24 hour care, the daily fee should be higher and include any formal individual and/or groups clinical sessions in the daily fee and not unbundled as in Level 3.1.

So the frequency of clinical services is not defined in the ASAM Criteria book for either level 3.1 or 3.5 as in 3.1, it depends on the severity and function of the person and the needs in their individualized plan. In 3.1 it has to be at least 5 hours/week to distinguish 3.1 from a general recovery home, halfway house or Oxford House. 3.1 clients are more severe needing the availability of 24 hour living and counseling support plus at least five hours of formal clinical services.

In 3.5, clients need 24-hour care and therefore formal and informal counseling sessions and supports all included in the daily fee. Again, frequency of sessions in 3.5 depends on the level of instability of the client and what they need to be stabilized sufficiently to continue care in a less intensive level.

Paul’s Reaction to my Response

You helped clarify a misconception I had about the 3.1 level of care and also got me thinking about what patients are appropriate for what residential levels of care and what interventions are appropriate for those patients.

We have really been trying to move to a more patient-driven system of care and have specific language in the contracts stating that patient stays are treatment plan/patient driven. Treatment plans have to be personalized and the levels of care must follow ASAM guidelines. The reality is that these are, and continue to be, program-driven with arbitrary assignments and Evidence-Based Practices (EBPs) implemented with no real evidence that they are clinically appropriate for the particular client.  

In the past year I have really immersed myself in understanding ASAM clinically but also in philosophy. One of the things that I will be working on is development and implementation of a comprehensive plan to help our contracted agencies become patient-driven. Any support along the way we be greatly appreciated. I find it very difficult to articulate how grateful I am for your input.

Thank you

TIP 2

ASAM Criteria Level 3.3 and Dealing with Behavior Problems

Another question from Paul

On another note I would like to pick your brain on Level 3.3, Population Specific High Intensity Residential Level of Care. We have none in our great State of New Hampshire and this seems to be a level of care a lot of folks who “fall through the crack” may benefit from. Patients who are not meeting criteria for psychiatric admission, but cannot function in a typical patient milieu. Patients who have behavioral problems who end up getting discharged for rule infractions (throwing things at staff, cursing at staff, stealing from other patients, stealing medication and hiding it in there room etc). For now, we have been trying to get folks set up with Co-Occurring enhanced 2.1, Intensive Outpatient or 2.5, Partial Hospitalization where there are less restrictions and it is easier for them behaviorally. Obviously problems arise when dangerousness and lethality are high. Wondering if you have any suggestions of other states that are doing this well or what a good 3.3 would look like? Also if the interim solution I mentioned is a good idea for now.

My response:

I know 3.3 is tricky and I don’t have a mecca state for you to go to. But I would make the distinction that 3.3 is for people with cognitive difficulties and Traumatic Brain Injury (TBI) that makes it hard for them to be in a typical milieu. In contrast, patients who have behavioral problems may or may not be having those because of cognitive issues like TBI. Rule infractions can be caused by multiple reasons including, but not limited to:

1. Programs that are more focused on phases in a program-driven system where patients advance by being compliant with rules. “Breaking rules” is seen a behavioral problem requiring behavioral contracts, rather than assessing why the person “broke the rule” and making this part of an individualized treatment plan.   It may help to look at Tips and Topics, Volume 10, No. 11 February 2013

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

2. A patient may be mandated to a program and is not really doing treatment and just “doing time”. If the program is not skilled in Motivational Interviewing and stages of change work, they are going to be more focused on rule breaking and compliance instead of engaging the person in a “discovery” plan rather than a “recovery” plan for which the patient may not be ready. Such a person would be better treated in OP levels unless in imminent danger and then in 3.5 only for the time they are unsafe and unstable. Working with a person who is more interested in getting off probation than in getting into recovery and using residential levels for that work is a setup for rule breaking and the revolving door of discharging people for bad behavior.

3. If there are issues in Dimension 3, Emotional, Behavioral or Cognitive Conditions or Complications, that are causing a person to “break rules”, then the focus should be on assessing what the Dimension 3 problem is and what to do about it, not discharge. If it is an issue in Dimension 5, Relapse, Continued Use or Continued Problem Potential, and the person is willing to change their treatment plan in a positive direction, treatment continues as stealing medication and trying to get and use drugs is normal for people with addiction.

This behavior is not about rule breaking, but about the cravings of addiction. If the person is not interested in treatment, and just thinks they can have fun while “doing time” then discharge or court sanctions are appropriate, not for having used, but because they are not interested in treatment, as evidenced by not participating in a reassessment of what went wrong and changing their plan in a positive direction to get a better outcome next time they get a craving to use. In other words “rule breaking” should be assessed as a bad outcome needing a new treatment plan.

(See Appendix B on Dimension 5 in The ASAM Criteria (2013).

4. It may be that a program has too many rules trying to control behavior rather than assess six dimensional needs and do individualized treatment. Residential levels should focus on preparation of people for OP services not seen as a place for a total life makeover in residential.

Yes, there should be more OP levels that can take people with co-occurring mental disorders and addiction (COD) and for those in early stages of change who need motivational services. We should use residential only for people who need 24-hour services to be imminently safe. So developing levels 1, Outpatient, 2.1 and 2.5 that can be more enhanced and complexity capable is not an interim solution, it is an important solution in an array of approaches.

Paul’s Reaction to my Response

Dr. Mee-Lee,

You helped clarify some misconceptions I had about the 3.3 level of care. During the Quality Assurance (QA) of the treatment plans, these are exactly the types of things I am encountering. On one treatment plan the goal was actually “the client will reduce feelings of shame and improve self-esteem”. I don’t think that goal is Specific, Measurable, Achievable, Realistic, or Time-Limited (SMART)

One of the many obstacles we deal with is clinicians’ knee jerk reaction to treat cases as imminent danger. So many people are dying that folks ignore or misinterpret imminent danger criteria C (“the likelihood that such adverse events will occur in the very near future, within hours and days, not weeks or months.” – The ASAM Criteria 2013, pp 65-68; 420) and are treating their own anxiety. As a result, patients end up in what appears to be an inappropriate level of care. So we have been engaging our providers in a community of practice to help them sharpen their ASAM skills and in a lot of cases teach them a basic understanding.

I have to be honest, prior to the newest edition I was one of those who just did the 1 page checklist! We have done 2 webinars consisting of an overview of the 6 ASAM Criteria dimensions, severity rating, withdrawal management, levels of care, treatment planning and a special Paul Kiernan soap box lecture on what really constitutes imminent danger. 

A point I stressed during these is that just because two patients have a high severity rating in dimension 5 for example, does not mean that they are going to have the same treatment plan. One patient may be using because they do not like dealing with negative emotions and another patient may just really like getting high. Another patient may have absolutely no internal dialogue prior to using (perhaps a red flag to revisit dimension 4, Readiness to Change) where the other person has a real internal struggle. 

These are some of the things that we are working on in hopes of moving providers to a patient-driven model.

Again I am so grateful for your correspondence.

Cheers,

Paul

Reference:

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

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

SOUL

Warning: The following is an unpaid, unsolicited, political opinion. If you are definitely voting for Donald Trump as President of the United States of America, please stop reading. I do not want to argue with or alienate you. I value you as a Tips and Topics reader and more. 

But if you are undecided, you may be interested in my thoughts and concerns. These are not academic political science observations, but just my opinions that you could rightly take with a grain of salt:

1. President of the United States and leader of the free world requires intelligence, integrity, political experience and knowledge of how political systems work. While it is understandable to think career politicians are the problem, I have always favored change from within, rather than blowing things up and radical change from without. It is easy to see solutions when on the campaign trail, but much harder when faced with the real negotiations and issues when in actual office e.g., Barack Obama declared he would close down Guantanamo Bay and meant it. But easier said than done.

2. For any job, especially a highly complex position that requires interfacing with many systems, countries and personalities, I would only consider candidates who have some demonstrated experience in the duties, dilemmas, challenges and complexities of the position. Hilary Clinton apparently delivered on a consensus, collaborative and across-the-aisle style when she was a Senator; and slogan or not, I favor “Stronger Together” than “Build a Wall” type politics.

3. How a candidate has defined their life’s mission and occupied their actual work energies, tells me whether there is a consistency in what they stand for and believe in. Have they demonstrated a commitment to public service or to causes that are consistent with public service? Has their work and systems experience encompassed the kinds of challenges they will face as President? Do the values of their life’s work speak to compassion, integrity, honesty, and fair play; or to materialism, adversarial power plays, bullying and self-centeredness? Is there a value of “it takes a village” or “I alone, can make things great again”?

4. Finally, you have almost certainly heard about the infamous audio and video of Donald Trump bragging about kissing and groping women because as a star, you can do whatever you want. If you don’t know what I’m talking about, see the link:

http://talkingpointsmemo.com/livewire/trump-lewd-comments-women-2005-hot-mic

I give many workshops and keynotes and have often been the featured speaker at a conference. What would you think of my integrity and values; my leadership and presentation content if I were to say that because I’m the keynote speaker I could kiss or grab any woman I wanted at the conference; and then say that if I didn’t do that, it was the woman’s fault that she wasn’t attractive? I am no star and I am not running for President. But I am mystified that millions are not fazed by Donald Trump’s demonstration of distorted values, lack of respect, abuse of power and failure of integrity.

I rarely speak my mind about politics, but in this case, I felt compelled to speak up. I hope you will vote – for whomever your conscience says has the skill; compassion and integrity; and knowledge, character and values to be President of the United States.

Until next time

Thanks for joining us this month . See you in late November with President Clinton or President Trump.                                                                                                                                               

David

The ACE Study; the 3 E’s, 3R’s plus 4th R; 5 components; Attraction, not promotion.

Vol. 14, No. 8

Welcome to the November edition of Tips and Topics. Thanks for joining us this month. 

David Mee-Lee M.D.

SAVVY

In August this year, I presented at the Detroit Wayne Mental Health Authority’s 2nd Annual lnterdisciplinary Conference, “Raising the Bar”. One of the side benefits of my work is to be able to listen to other conference speakers for free! It is always satisfying to hear a topic from the “horse’s mouth.”  This is what happened when I heard Robert Anda, M.D. present on the Adverse Childhood Experiences (ACE) Study.

Dr. Anda played the “principal role in the design of the ACE Study, served as its Co-Principal Investigator, and authored or co-authored more than 70 publications from the Study.” (https://robertandamd.com).  It was a treat to hear it from the person there from the start and who made it all happen. (When I train on The ASAM Criteria, I let people know that on that topic, I have been there from the start too.  As Chief Editor that work was commenced in the 1980’s.  When people hear an ASAM Criteria presentation from me, they too are hearing it from the “horse’s mouth”, preferably that part of the anatomy, not another part!) 

Dr. Anda shared a fascinating anecdote about how the term “Adverse Childhood Experiences” got its name.  He was with a colleague at McDonald’s (he must eat at the same gourmet restaurants as I do.) They were discussing what to call this study on trauma. “Trauma” seemed too easily confused with physical accidents because this study was all about emotional trauma and its profound impacts on development and health.

“Childhood” as part of the terminology was easy, he said.  This was all about what happened in one’s childhood.  “Adverse” was also fairly easy too, as traumatic experiences certainly caused many negative effects.  The “Experiences” part took a bit of brainstorming – “environments” popped up in their conversation back and forth. However, they thought, that term could be confusing, since it focuses attention on where a person lives. Was it about the family or significant others in the environment? or the cultural environment? or poverty? or inner city or suburban?  or what environment?

Then they happened on “Experiences” and liked it. Why?  This term focused the attention back on the person affected and not the external “environments”.  This allowed them to study and quantify on the ACE score how many childhood experiences the person had had, without having to make the person delve into the emotion and details and pain of the actual trauma.

So there it is: That’s how it became to be known as the Adverse Childhood Experiences (ACE) Study. 

Here are some interesting and meaningful nuggets I was furiously scribbling down listening to Dr. Anda speak.  They are in no particular order of importance.  

TIP 1

Ponder how important hope is in health and well-being

Dr. Anda opened his presentation referencing a 1993 paper he had written on “Depressed affect, hopelessness, and the risk of ischemic heart disease (IHD) in a cohort of U.S. adults.” He found that hopelessness significantly predicted who would die from a heart attack and even predicted the increased risk of nonfatal IHD. This was in a group of more than 2,800 initially healthy men and women from the National Health Examination Follow-Up Survey (NHEFS).

  • This study indicates that depressed affect and hopelessness may play a causal role in the occurrence of both fatal and nonfatal IHD.

As we counsel with clients who have had ACEs, Dr. Anda stressed that being trauma-informed in our work is to create a different path of hope, meaning and purpose for the people we serve. The message to clients, he said, should encompass:

  • It is not what is WRONG with you.
  • It is what HAPPENED to you.
  • Create a different story of your life by getting an accurate accounting of adverse childhood experiences through your ACE score.
  • You can shift from shame, confusion and hopelessness to hope, meaning and purpose.

TIP 2

What is an ACE Score?

“Dr. Anda created The ACE Score Calculator, allowing individuals to calculate their own ACE Scores, based on the original scoring criteria of the ACE Study.

To use this survey, add up all of the YES responses. The sum is the ACE Score. The ACE Score can range from “0”, meaning no exposure to the ten categories of child abuse and trauma investigated by the Study, to “10”, meaning exposure to all ten categories. The Study found the higher the ACE Score, the greater the risk of experiencing poor physical and mental health, and negative social consequences later in life.”

Finding Your ACE Score

While you were growing up, during your first 18 years of life:

1. Did a parent or other adult in the household often or very often…Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?

If yes enter 1 ________

2. Did a parent or other adult in the household often or very often…Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?

If yes enter 1 ________

3. Did an adult person at least 5 years older than you ever…Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?

If yes enter 1 ________

4. Did you often or very often feel that …No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?

If yes enter 1 ________

5. Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

If yes enter 1 ________

6. Were your parents ever separated or divorced?

If yes enter 1 ________

7. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit at least a few minutes or threatened with a gun or knife?

If yes enter 1 ________

8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?

If yes enter 1 ________

9. Was a household member depressed or mentally ill, or did a household member attempt suicide?

If yes enter 1 ________

10. Did a household member go to prison?

If yes enter 1 _______

Now add up your “Yes” answers: _______ This is your ACE Score.

http://www.acestudy.org/the-ace-score.html

TIP 3

Review how persistent stress changes brain architecture

Dr. Anda referenced the Harvard University Center on the Developing Child.

“Extensive research on the biology of stress now shows that healthy development can be derailed by excessive or prolonged activation of stress response systems in the body and brain.  Such toxic stress can have damaging effects on learning, behavior, and health across the lifespan……When we are threatened, our bodies prepare us to respond by increasing our heart rate, blood pressure, and stress hormones, such as cortisol. “

http://developingchild.harvard.edu/science/key-concepts/toxic-stress/

  • Stress of severe and chronic childhood trauma releases hormones (adrenaline and cortisol) that physically damage the developing brain.
  • These flight, fight or fright (freeze) hormones in the Limbic system work well if there is a vicious dog chasing you (flight); or if cornered, to help you fight; or stop breathing and freeze in fright if a predator is nearby and you are trying not to be detected.
  • The adrenaline and cortisol shuts off the thinking prefrontal cortex of the brain to focus on the immediate need to run, fight or freeze.
  • But if the stress is now a daily event (witnessing or experiencing violence, belittling or verbal abuse, sexual and boundary issues etc.) not a one-time, unusual event like facing a bear or vicious dog, then the emergency response system activates over and over again every day.
  • The stress hormones, when turned on for too long day after day become toxic. When a child is always ready to fight or flee the prefrontal cortex that is needed to form a sentence or do a math problem becomes stunted. Emergencies take precedence over doing math or writing an essay.
  • With this overstimulation of the limbic system, the brain begins to dissociate and disengage in the state of hyperarousal survival mode. This affects learning and adaptive coping functions.

TIP 4

Take a look at “Resilience- The Biology of Stress & The Science of Hope”

This film was an official selection of the Sundance Film Festival. “Resilience chronicles the promising beginnings of a national movement to prevent childhood trauma, treat toxic stress, and greatly improve the health of future generations.”

https://acestoohigh.com/2015/12/08/resilience-an-official-selection-of-sundance-film-festival/

See the trailer for the film: http://kpjrfilms.co/resilience/ 

Dr. Anda highlighted the importance of building resilience and hope in schools, prisons and the creation of self-healing communities.  He referenced work that is being done in Washington state.

http://www.rwjf.org/en/library/research/2016/06/self-healing-communities.html

References:

1. Anda R, Williamson D, Jones D, Macera C, Eaker E, Glassman A, Marks J. (1993): “Depressed affect, hopelessness, and the risk of ischemic heart disease in a cohort of U.S. adults.” Epidemiology Jul;4(4):285-94. 

2. Center for Disease Control and Prevention. (2010): “Adverse Childhood Experiences Reported by Adults – Five States, 2009,” Morbidity and Mortality Weekly Report 2010 No. 59, pp 1609-1613.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5949a1.htm

3. Felitti & Anda (2010): “The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders, and sexual behavior: Implications for healthcare,” in R. Lanius and E. Vermetten, Eds., The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease. Cambridge University Press, 2010.

4. Porter L, Martin K, and Anda R (2016): “Self-Healing Communities- A Transformational Process Model for Improving Intergenerational Health” June 2016 Publisher: The Robert Wood Johnson Foundation.

SKILLS

In September, I presented at the Mental Health Recovery Summit 2016 Moses H. Cone Memorial Hospital, in Greensboro, North Carolina. Kelly Graves, Ph.D., Associate Professor, North Carolina A&T State University also presented on trauma and shared some succinct definitions and guidelines.

TIP 1

Understand the 3 E’s of trauma

Event – There is an Event or series of Events that trigger the emergency response system of the individual.

Experienced – Those Events or series of Events are Experienced by the person as harmful and threatening.

Effects – The Effects on the person are adverse on the individual’s functioning physically, emotionally, mentally, socially and spiritually. 

TIP 2

Facilitate Trauma-informed care and trauma-specific services – The 3 R’s + 4th R of trauma-informed cultures

Trauma-informed: “A trauma-informed approach to the delivery of behavioral health services includes an understanding of trauma and an awareness of the impact it can have across settings, services, and populations. It involves viewing trauma through an ecological and cultural lens and recognizing that context plays a significant role in how individuals perceive and process traumatic events, whether acute or chronic.

In May 2012, the Substance Abuse and Mental Health Services Administration (SAMHSA) convened a group of national experts who identified three key elements of a trauma-informed approach:

(1) Realize the prevalence of trauma and its widespread impact.

(2) Recognize the signs and symptoms of trauma and how trauma affects all individuals involved with the program, organization, or system, including its own workforce.

(3) Respond by putting this knowledge into practice and update policies, procedures, and practices in all settings. (SAMHSA, 2012, p 4).

(“Trauma-Informed Care in Behavioral Health Services” Treatment Improvement Protocol (TIP) Series 57. Page xix, 2014).

4th R: Resist Retraumatization e.g., heavy confrontation in a Therapeutic Community; male nurse coming into a female client’s room at night for routine bed checks triggers the trauma-affected client – inform clients with trauma histories about routine procedures; ensure female staff enters the room.

TIP 3

Promote 5 core components for healing in all services

Dr. Graves identified a common core of conditions across different lists of services that promote healing. She summarized this common core into five components:

1. Safety – the client must have a sense of safety in any counseling relationship. This can be a challenge for people who have been exposed to daily adverse experiences and are living in a state of hyperarousal.

2. Trust – when parents, relatives or other neighborhood acquaintances have repeatedly abused the client and violated boundaries, trust does not come easily.

3. Collaboration – creating hope and healing communities requires collaboration across systems and disciplines, but most importantly collaboration between the client and clinician.

4. Choice – clients should have real choice in the pacing and planning of treatment; and even in more mundane things like the date and time for the next appointment.

5. Empowerment – for too long, clients with significant ACEs have had to endure the memories, pain and limitations of past trauma by themselves. Empowerment upholds hope and healing. 

References:

1. Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women” Treatment Improvement Protocol (TIP) Series 51. DHHS Publication No. (SMA) 09-4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.

2. Center for Substance Abuse Treatment. “Trauma-Informed Care in Behavioral Health Services” Treatment Improvement Protocol (TIP) Series 57. DHHS Publication No. (SMA) 14-4816. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

SOUL

Although I am not a member of any 12 Step program, there is much wisdom in so many of the sayings and slogans. One in particular that is so meaningful in general as well as in the work of  motivational enhancement and stages of change is: “Attraction, not Promotion.”  

You cannot push, pressure, persuade, prescribe and pester someone into real and lasting change. Only as you inspire and attract people to think and act differently will you initiate a process of change.

I broke my long held rule and belief in “attraction, not promotion” in last month’s pre-election SOUL section. I spoke out about my political views on the election in hopes of persuading undecided voters and readers of Tips and Topics.  In my defense, I did warn readers that if they had already decided to vote for President-elect Trump, they should stop reading as I didn’t want to argue or alienate them. (But of course saying that is like telling a child not to shake or touch the Christmas presents under the tree until Christmas Day.) 

*  One reader wrote me: “I think you should not have voiced your political opinion here, in your monthly newsletter“and in retrospect I think I agree. It distracted from my mission and purpose of Tips and Topics.

*  Another reader said: “I have been a faithful reader of your tips and topics. I don’t appreciate your views on politics and now It makes me question your abilities.

That got my attention. Were my views on politics actually a reflection on my abilities as a trainer/consultant?  It made me think about the role and responsibilities in leadership and public discourse.

I responded to those who wrote to me, however I won’t share my responses as I deleted the emails! (That’s a joke – OK enough of election rhetoric).

Here is something I did say in my response and say again now:

The bottom line for me as regards writing this in Tips and Topics is that I am sure everyone who bothers to read Tips and Topics are all people of good will who want the best for the people we serve in our work; and the best for our country.  While we may differ on a number of things, there is much more that binds us together in the values and vision we have for America. I am sad that this election seems only to have drawn us further apart both within the Republican party and across parties.  I hope that once the election is over that everyone will rally to bring us together for the greater good of the country.” 

Incidentally, the “faithful reader of Tips and Topics” who questioned my abilities ended her response to my message to her with: “So I thank you for allowing me to share my thoughts and have a good discussion.  I look forward to your tips and topics in the future.”

I may have done too much political “promotion” for the preferences of some readers, but I’m glad we can move on together.

Happy Thanksgiving everyone!

Year 15 of Tips & Topics; Spirituality & ASAM Criteria; Heart, patience and empathy

Vol. #15, No. 1

Welcome to start of our 15th year of publishing Tips and Topics. It is hard to believe there are now 14 years of back issues in the Archives at Tips & Topics.

David Mee-Lee M.D.

SAVVY

Several months ago, I started a conversation with Rev. Jack Abel, M.Div., MBA, Senior Director of Spiritual Care at Caron Treatment Centers. Caron, a leading not-for-profit addiction treatment center, is headquartered in Wernersville, Pennsylvania, and is not a religious organization. Jack leads a team of spiritual counselors, and adapts the historic model for Clinical Pastoral Education (CPE) common in hospitals and end-of-life care. He and his team are intentional about work in the practice gap of spirituality. They have refined a formal model of spiritual assessment and care as an integrated discipline of addiction treatment.
The ASAM Criteria editors have always believed in the importance of spirituality in addiction treatment. However we have not articulated well in The ASAM Criteria how to integrate spirituality into multidimensional assessment and treatment. On page 54 of The ASAM Criteria (2013) there is a section on spirituality: “By assessing if and when spirituality has been meaningful for the individual in any or all of the assessment dimensions, strengths, skills, and resources can be identified to be incorporated into the service plan.”
Jack Abel agreed to lay out for Tips & Topics how he and his team at Caron Treatment Centers uses the structure of The ASAM Criteria assessment dimensions to integrate spirituality into the care at Caron. Spirituality is like comedian Rodney Dangerfield’s joke that he gets “no respect”. So here’s what Jack wrote. I reconfigured his content to fit with the style of Tips & Topics, but it is Jack’s work:

 

“The Chaplain Gets No Respect”:
Caron Treatment Centers uniquely integrates professional spiritual care
This month we take a close look at how one treatment provider is moving into this area in a way that draws heavily upon the ASAM Criteria.

 

TIP 1
Spirituality may or may not play a role in how we think about placement and ongoing care – but it can and should!
 
Many behavioral health facilities offer some access to persons who are trained in pastoral care, spirituality, or chaplaincy services. The provider may be a pastor, priest, rabbi, or shaman that comes in from the surrounding community. It might be someone on staff who brings mindfulness, grief counseling, visitation, or a “chapel” component to our care. There’s no uniform standard, and few formal models for how spiritual care is delivered, but it’s also something we see experimentation with, and a good bit of talk about.
Spirituality in Six Dimensions
The 2013 Third Edition of The ASAM Criteria notes, “many have asked why there is not a Dimension 7 on spirituality.” The paragraphs on page 54 go on to suggest a few examples of how spirituality can be integrated across the six dimensions. At the same time, “specific criteria have not been written incorporating the role of spirituality in placement or treatment decisions explicitly.”
The current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) also offers:
  • A new “Cultural Formulation Interview” (CFI) among several proposals for further research.
  • It is one of several assessment and monitoring tools “for which we determined that the scientific evidence is not yet available to support widespread clinical use” (p. 23f).
  • The introduction to the CFI chapter explains, “Culture includes language, religion and spirituality, family structures, life-cycle stages, ceremonial rituals, and customs, as well as moral and legal systems” (p. 749).
So, spirituality, faith, religion, and culture: these are on the “radar” for ASAM and DSM-5, but also lacking clarity in terms of specific models and methods. Hence the title of our tip, “the Chaplain gets no respect.”

 

TIP 2
How a spiritual care provider interfaces with the rest of the treatment team
  
A Respectable Chaplain’s Work Day
In some settings, the role of the chaplain may be quite ancillary or quite integrated. A small hospital without a formal program may allow clergy from outside to visit, with little or no documentation. On the other hand, a hospice program may include chaplains in treatment planning with patient and family involved.
What makes sense for addiction care at various levels?
Caron’s approach to the integration of spiritual care is on the more formalized end of this continuum.
  • Patients are assigned a spiritual counselor who is a member of their treatment team, and automatically scheduled for a formal spiritual interview, which typically occurs between the 3rd and 7th day of treatment (depending on availability and readiness, given the complexities of addiction withdrawal).
  • The assessment interview is captured in an extended narrative that becomes a part of the patient’s medical record, and is frequently referred to by other members of the treatment team.
  • Any action steps or interventions devised in the assessment are incorporated in relevant goal areas in their written treatment plan. Thus, the team and patient are engaged collaboratively in spiritual work as an integrated part of treatment goals.
The spiritual counselor then remains an engaged member of the patient’s treatment experience.
  • He or she provides lectures, small groups, specialty groups (e.g. grief and loss)
  • May collaborate in these components with other disciplines.
  • Patients with significant areas to explore that were identified in the initial assessment may benefit from an individual follow-up consultation if time and resources allow.
  • The spiritual counselor is a partner in the dialogue as the team provides ongoing treatment plan updates and works to author a plan for next level of care.

 

TIP 3
The Importance of Story
  
For each assessment, a variety of tools are woven into a foundational portrait of the recovery process as narrative and journey.
  • How can the individual and family move toward greater connectedness?
  • What are the barriers that impede this movement?

Story or “narrative” plays an important role in theology, philosophy, and social psychology. One of the central resources in Caron’s spiritual care training program focuses on the work of Arthur Frank, and his text, “The Wounded Storyteller”. It may not be obvious to persons who are unfamiliar with this material, but Frank looks masterfully at the types of stories people use to navigate through illness, and emphasizes the role of an “epic” story style in circumstances of serious illness and personal or family crisis.

 

As the continuum of care unfolds from initial inquiry through residential treatment to aftercare, a patient and their family members may tell the story of their journey in different ways.
  • It is not uncommon for people to adopt a “restorative” narrative, one that sees the treatment episode as brief and compartmentalized, a kind of ‘penalty box’ experience after which the ‘player’ returns to the ‘game’ of life.
  • At other points, the sense of having a coherent narrative may fall away, leaving a person in a “chaos” or un-utterable phase – a time when no story seems to make sense.
It is not surprising that 12-step recovery communities are largely story-based.
  • Ultimately, successful recovery is generally accompanied with a different kind of story, a story that often has classic features of epic narratives or “heroic” journey.
  • The traveler embarks upon a quest, entering the ‘sick world’ where a combination of helps and challenges shape movement towards a new, hoped-for outcome.
  • Connectedness, a fundamental aspect of spirituality, is central to every phase of the quest journey.
Saying yes, making alliances, facing trials, learning lessons: these are ways in which the spiritual counselor helps the patient and family tell the story of their experience, hopes, and challenges.

SKILLS

TIP 1
The Nuts and Bolts of Spiritual Assessment
 
One of Caron’s innovations involves elucidating spiritual needs in parallel with the ASAM Criteria dimensional framework. This enhances collaboration with interdisciplinary partners in the treatment process, and supports the involvement of patients and families in understanding this model of the recovery journey. This SKILLS segment explores in some detail:
  • What spiritual assessment and interventions may consist of
  • Some of the models most useful for designing them
  • How differing personal and cultural backgrounds are taken into account.
Spiritual Assessments
1. In general, the spiritual counselor’s assessment presents findings about the patient’s suffering and its impact on their connection to self, others, the natural world, and to universality, faith, or transcendence as they may conceive it. Pastoral, theological, and clinical frameworks can, and should, be referenced to provide context and support for the assessment.
2. These frameworks are a foundation of clinical chaplain training. Different spiritual care clinicians will bring different preferences and experience. Typical models through which a patient is viewed include stage-based models of human development, grief and loss, or trauma.
3. Another aspect of assessment is the patient’s cultural or personal history – how does their tradition or exposure to none or many influence their negotiation of the recovery journey? Twelve-step recovery concepts and models are often in view as well, for example addressing self-reliance through sponsorship and “higher power” relationships, addressing resentments with an inventory and reconciliation process, or coping with distress through prayer and meditation.
Theological and pastoral care training prepares the spiritual care practitioner for this task. A rich pastoral care education includes various stage-based models like:
  • Phil Rich’s formulation of grieving
  • Judith Herman’s stages for trauma recovery
  • James Fowler’s identification of five “stages of faith”
  • Paul Pruyser’s work on ministerial diagnosis.
In addition, the team at Caron is trained:
  • To be mindful of learning styles and cultural and religious frameworks which inform the expectations and struggles of each person and family.
  • Howard Gardner’s theory of multiple intelligences and the DSM’s CFI are key resources.
  • Each spiritual care clinician has their own identity, formation, and belonging. They are accountable for understanding how this informs their experience of the spiritual care encounter, attending to projection, transference, and counter-transference as these occur.
As is the case with other target areas:
  • Identified spiritual care concerns may be mild, moderate, or severe.
  • In certain instances, strengths are identified rather than areas of need or focus.
  • While not equating to formal diagnoses of other disciplines, spiritual care findings often correlate with medical and psychological diagnoses identified by other practitioners – and should.
 
TIP 2
Formulate spiritual care assessments using the ASAM Criteria dimensions, and increase compatibility and integration with other practitioners in the multidisciplinary care team.
 
Treatment assignments, designed collaboratively with the patient, become part of the written care plan. Spirituality is also a focus area in their family program, and throughout the treatment continuum: in preparation dialogues and in next steps after residential care.
Examples in Six Dimensions
In reporting findings to the treatment team, the spiritual counselor writes to one or more of the six ASAM Criteria dimensions.
Dimension 1, Acute Intoxication and/or Withdrawal Potential
Exploring an individual’s past and current experiences of substance use and withdrawal.” The discipline of spiritual care attends to tremors, eye contact, and ability to focus, and even emotional elements of withdrawal like homesickness. Some patients will invite comment in this area; others merit no observation on Dimension 1. Consider a patient in early withdrawal, whose emotions are characterized by fear and loneliness, perhaps having “burned bridges” and sought treatment multiple times previously. This Dimension 1 lamentation, with aspects of fear and loneliness, constitutes an aspect of their spiritual assessment or “diagnosis.”
Dimension 2, Biomedical Conditions and Complications
Exploring an individual’s health history and current physical condition.” Spiritual care attends to the chart and patient’s presentation, and explores how biomedical conditions contribute to the patient’s self-understanding and negotiation of the challenges of existence. A patient with chronic migraines sees their unrelenting pain not only as a medical affliction, but as a cause for despair. Other examples of particularly significant Dimension 2 presentations might include HIV positive status, an amputation, or a history of cancer.
Dimension 3, Emotional, Behavioral, or Cognitive Conditions and Complications
Exploring an individual’s thoughts, emotions, and mental health issues.” What is the patient’s suffering? How does their suffering affect their connection to self, others, the natural world, and to the transcendent – the “God of their understanding?” Dimension 3 is often the most significant area of findings for spiritual assessment. Shame is a frequent challenge for those with use disorders in Dimension 3, and religion, culture, or spiritual outlook often layer this with a narrative of brokenness that seeks forgiveness or redemption. Grief, trauma, and life meaning or purpose are also central to this Dimension. Multiple keywords may apply, for example faith and trust, grief, or woundedness and healing (trauma). It is helpful not only to identify areas of focus but to provide insight into severity and staging.
Dimension 4, Readiness to Change
Exploring an individual’s readiness and interest in changing.” The discipline of spiritual care explores change in varied terms including fear, developmental processes, ritual theory, religious or spiritual conversion, and 12 step recovery. Appropriate findings here are based on the data described in an interview summary and might include observation of patient’s difficulty with surrender in part or whole, fear in relation to specific issues like care planning, or an inability to conceive of a new paradigm.
Dimension 5, Relapse, Continued Use, or Continued Problem Potential
Exploring an individual’s unique relationship with relapse or continued use or problems.” The spiritual counselor helps identify obstacles and risk factors for the achievement or maintenance of a sustained recovery. Apathy and self-reliance are frequent concerns. The patient’s cultural or religious context may contribute positively or as caution. This dimension may simply highlight findings in other areas, which present the greatest concern, but simple redundancy should be avoided.
Dimension 6, Recovery/Living Environment
Exploring an individual’s recovery or living situation, and the surrounding people, places, and things.” The discipline of spiritual care may be especially interested in the network of relationships or meaningful attachments and their status. Distrust, alienation, and resentment are frequent keywords. Examples would be marital discord, strained parent-child relations, hostility or risk in friendship and work settings, and the loss or reduction of any sense of “home” and “belonging.”
 
TIP 3
Spiritual Treatment in Action
 
1. Documented Action Steps. Beyond spiritual “diagnosis,” a compelling area of spiritual interest involves action steps toward identified treatment goals – what are often called clinical “interventions.” At Caron, the initial assessment includes a “disposition” which summarizes any assigned interventions, recommendations, and collaborative engagement of the multidisciplinary team. This might include suggestions for specific approaches to prayer or meditation, reading or writing assignments, art projects, attendance at Chapel or other services, etc.
In the same way interventions can become “boiler plate” in other disciplines, there are core spiritual care practices that frequently are proposed. These often include:
  • Breathing and other mindfulness practices
  • Specific readings from classic recovery texts
  • Observance of customary faith practices (e.g. Sabbath)
  • Grief processing is often aided by the writing of therapeutic letters
  • Resentments in recovery are often processed through AA’s “fourth step” columnar exercises.
The items mentioned above are supported as “evidence-based” in the classic sense.
There is also historic evidence provided by the witness of faith traditions, recovery communities, and the archetypal role of the priest/minister/shaman in our diverse human heritage. Prayer, meditation, ritual, calendar, study, mentorship, and more structured spiritual roles and rites of passage are all tools that can contribute meaning, hope, help, and transformation in the journey of recovery.
2. Contextualization. The spiritual care professional can aid in grounding identified treatment goals within the context of a client or family’s cultural, religious, and personal thought-world.
  • While mindfulness exercises in the generic sense appeal to many, others may be interested in the meditation practices of their family of origin faith experience.
  • A learning style limitation or preference may suggest music or collage as better methods over reading or letter-writing.
3. Collaborative Care. It is important to recognize that significant interventions should be brought to the attention of the primary counselor, and often also the psychologist and unit coordinator – possibly through case consultation beyond documentation in the chart.
  • Any follow-up intention or scheduling should be noted.
  • The spiritual counselor is a regular attendee at treatment team meetings, so that progress towards the fulfillment of action plans and larger objectives can be assessed and the treatment plan updated on an ongoing basis.
  • The treatment plan is then a ‘living’ document, rather than a snapshot, which may quickly lose relevance.
TIP 4
Respecting the Spiritual in Your Context
 
Caron’s deployment of a spiritual care team as an integrated component of residential addiction treatment makes a comprehensive program like this possible. Satisfaction surveys indicate spiritual care content adds significant value to the patient’s perceptions of treatment. Caron’s outcome measures consider an individual’s overall health and wellness, which includes spirituality.
1. Depending on your level of care and other factors, there may or may not be possibilities for full-time spiritual care providers as a component of treatment.
2. The factors raised here, though, and the associated skills for spiritual assessment and treatment planning, are ones that may be beneficial.
3. Consider who may be functioning in this kind of role in an informal or supplemental way. Often there are specific providers who incorporate spiritual aspects in their mental health or medical evaluation and treatment.
4. There may even be administrative and support staff who are providing a spiritual care component not easily recognized. It may have no “footprint” in the medical record.
In whatever way spiritual issues are addressed in your setting, the next time someone mentions “that guy” or “that woman” who “does the spiritual stuff,” don’t disregard the role they may be able to play in assisting your clients to wellness and flourishing. Respect them. The thought may be a great one after all!
References:
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA, American Psychiatric Association, 2013.
Fowler, James. Stages of Faith: The Psychology of Human Development and the Quest for Meaning. 2nd ed. New York, NY: HarperCollins, 1995.
Frank, Arthur. The Wounded Storyteller: Body, Illness, and Ethics. 2nd ed. Chicago, IL: University of Chicago Press, 2013.
Gardner, Howard. Frames of Mind: The Theory of Multiple Intelligences. 2nd ed. New York, NY: Basic Books, 2011.
Herman, Judith. Trauma and Recovery: The Aftermath of Violence-from Domestic Abuse to Political Terror. 1R ed. New York, NY: Basic Books, 2015).
Mee-Lee D, Shulman GD, Fishman MJ, Gastfriend DR, Miller MM, eds. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. 3rd ed. Carson City, NV: The Change Companies®, 2013.
Pruyser, Paul. The Minister as Diagnostician: Personal Problems in Pastoral Perspective. Philadelphia, PA: Westminster Press, 1976.
Rich, Phil. The Healing Journey through Grief: Your Journal for Reflection and Recovery. New York, JY: John Wiley & Sons, 1999.

SOUL

I read an article on April 24 by Julie Pace, Associated Press White House Correspondent. I was intrigued by her report that President Trump “acknowledged that being Commander-in-Chief brings with it a “human responsibility” he didn’t much bother with in business, requiring him to think through the consequences his decisions have on people and not simply the financial implications for his company’s bottom line.”
Here, everything, pretty much everything you do in government involves heart, whereas in business most things don’t involve heart,” he said. “In fact, in business you’re actually better off without it.” (I added italics)
Yes, President Trump is so right …..”everything…..involves heart”.
  

 

 

  • “Heart” is what the staff on the United Airlines flight forgot about (or lacked) when Dr. David Dao didn’t want to give up his seat on the plane, concerned about getting back home to see his patients the next day. If you missed the video of his being dragged up the plane aisle:  United Airlines and Dr. Dao
It took United Airlines too long to get President Trump’s message that “everything involves heart”. United CEO Oscar Munoz eventually said the airline won’t allow law enforcement officers to haul seated paying passengers off its flights again “unless it is a matter of safety and security.”
(Don’t get me wrong. There are always two sides to the story and I fly United whenever I can.  But if United’s culture was ‘person-centered’, there would have been an easy fix to the problem.  For example- ask if anyone else, less concerned about their seat, would give up their seat for $1,000, $2,000 or whatever it took.  Even $10,000 would have saved United millions in lost image, revenue and stock price.)
 

 

 

  • “Heart” is what the flight attendant on American Airlines forgot about when he grabbed the stroller from the distraught and crying mother carrying 15-month-old twins.
“What we see on this video does not reflect our values or how we care for our customers,” the airline said in a statement. “The actions of our team member captured here do not appear to reflect patience or empathy, two values necessary for customer care. In short, we are disappointed by these actions.” (I added italics)
Heart, patience and empathy.
You would think addiction and mental health professionals would be the first people to know about heart, patience and empathy. However it hasn’t been too far back in behavioral health treatment history that we were more focused on rule breaking, behavior control and sticking to our policies. We did this:
  • Discharged people for having a flare-up of addiction and drank alcohol or used other drugs.
  • Heavily confronted clients with profane language, punishments and re-traumatizing practices to strip a person of their defenses.
  • Blacklisted clients – barring them from treatment for months, after three poor outcomes in the program.
  • Used physical restraints and leather straps to tie down psychiatric patients to their beds.
Heart, patience and empathy.

Until next time

Thanks for joining us the start our 15th year of Tips & Topics.  See you in late May.
David

Questions about addiction, treatment and criminal justice; culture change; Stump the Shrink

Vol. #15, No. 2

Welcome to May edition of Tips and Topics. We’re glad you could join us.

David Mee-Lee M.D.

SAVVY

Earlier this month, I had the opportunity to present to a mixed audience of criminal justice teams and treatment providers. The focus was on engaging mandated clients into accountable, sustainable positive change to reach the goals everyone wants: increased public safety, decreased crime and safety for children and families. Because of the mix of important stakeholders there were apparent clashes in mission, attitudes, policies and procedures.

How do you marry into one coherent approach the perspectives of judges, prosecuting and defense attorneys, probation and parole personnel, law enforcement, court coordinators and case managers, treatment providers and not least of whom, clients, participants and their families?

In the process of training and talking together, there were many issues raised explicitly or implicitly in the questions, attitudes and dilemmas voiced.

TIP 1

Here are questions that highlight conflicting perspectives on what is “addiction” and addiction treatment……and my attempts to answer them.

Q 1. Is addiction really a disease or isn’t it just willful misconduct?

I can certainly understand the difficulty of embracing the American Society of Addiction Medicine’s (ASAM) definition: “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.”

ASAM Definition of Addiction

The behavioral manifestations (and often “bad” behaviors and acts) of this brain disease are so egregious, in-your-face threatening public safety, that it can seem nothing short of willful misconduct needing punishment.

But I would encourage those doubtful about addiction as a brain disease to speak with recovering physicians, lawyers, judges, pilots and any other person who has been afflicted with addiction. Ask them about the dangerous, reckless and unfathomable things they did when in the throes of addiction. Why would a physician who has spent hundreds of thousands of dollars in medical school and countless hours of study, internship, residency training and daily practice jeopardize his license and career to get high on fentanyl, or drink before seeing patients or while on emergency call?

How does it make sense to lose family, finances, health and even face death in willful misconduct, to use a legal or illegal drug to get high, if it isn’t a brain disease which results in individuals chasing after whatever will activate the brain reward system or provide relief?

Q 2. If they don’t stop using, treatment is fine; but at some point enough is enough and you have to kick them out of drug court and lock them up?

If you just look at the behavior of a person with addiction, you may see a person who lies, cheats, breaks laws and appears to lack good moral values.

  • An understandable (but counterproductive) reaction of society is to punish such antisocial behaviors and approach a person with addiction as “a bad person” to be punished.
  • The productive attitude to achieve public safety and real lasting change is to “realize that good people can do very bad things, and the behaviors of addiction are understandable in the context of the alterations in brain function.”

Q 3. If you do individualized treatment, won’t participants scam the system? If we don’t treat them with all the same expectations, won’t they all try to get around the rules as much as they can?

If you think “individualized treatment” means just allowing participants to pick and choose what parts of the program they will participate in; and not have any expectation of accountability to follow a treatment plan, then I can understand your concern.

But..

“individualized treatment” is about collaborating on a treatment plan that matches the specific needs of the participant, makes sense to the participant, and therefore has the best chance to actually work and succeed.

Treatment isn’t about rules, phases, behavior control and punishment. It is about holding a person accountable for changing their beliefs, attitudes and lifestyle such that they are:

  • Better parents – if getting their children back is what they want.
  • Better citizens – if getting out of jail or off probation is what they want.
  • Less impulsive and out of control- if not getting arrested is what they want.
  • Mentally stable, sober and in recovery – if getting housing or a job or happiness is what they want.
  • Better workers or partners – if keeping a job or relationship is what they want.

Q 4. These people have criminogenic thinking and antisocial behavior. How will they change if you are soft on them in treatment? Don’t they need to know who’s the boss?

Helping people change their thinking and behavior only has lasting, sustainable results if the person is an actual participant in the process. Good treatment isn’t being “soft” on people; it is expecting good faith effort to work on thinking and behaviors that are pro-social at a pace which brings actual change, not passive compliance.

The judge, treatment court, probation and parole, and any mandating agency certainly has the power of the “boss”; and should use that power:

  • Not to prescribe and define the treatment e.g., level of care, length of stay, numbers of AA meetings etc. That is outside their scope of practice.
  • To enact graduated sanctions for lack of good faith effort in treatment as evidenced by passive compliance, active or passive non-adherence to individualized treatment plans. Partnership with treatment providers ensures treatment is accountable and not “soft”.

SKILLS

In the September 2014 edition of Tips and Topics, we covered in more detail problem- solving courts. Tips & Topics September 2014

TIP 1

Questions about dealing with substance use and positive drug screens

Q 1. Using illegal drugs is criminal behavior. How can we just let that go without consequences? They picked up the drug and used.

If a participant uses substances while in treatment – legal or illegal drugs – you don’t just “let that go”. Using substances for a person with addiction is not good and indicates a poor outcome in treatment just like getting suicidal is a bad outcome for a person with major depression; or a spiking high blood pressure is a poor outcome for a person with hypertension.

The “consequences” of poor outcomes is to assess what went wrong and change the treatment plan. If you believe addiction is an illness characterized by loss of control of impulses and cravings to use drugs against ones better judgment, then yes, they did pick up the drug and use….but:

  • The person with severe suicidal depression also picked up the razor blade to slash their wrists; or the bottle of pills to overdose.
  • The addicted smoker also lit up the cigarette to deal with the craving to use.
  • The morbidly obese person ate those extra calories against their better judgment.

Q 2. If they get a positive drug screen they need more than a tap on the wrist and “treatment that is all unicorns and rainbows.” (Said one workshop participant with disgust).

Yes, using substances when you resolved not to use; or are in treatment to achieve abstinence and sobriety needs more than a tap on the wrist. It requires the participant to take responsibility to learn from what went wrong and change their treatment plan in a positive direction. If they aren’t willing to do that, then they aren’t in treatment and should be counseled about the apparent need for some kind of sanction:

  • Not for having used, which is a natural vulnerability for people with addiction
  • But for not doing treatment in good faith and being out of compliance with court orders or agreements to do treatment.

Q 3. I’m OK with cutting them some slack early on in treatment if they use and get a positive drug screen. But if they are further along their phases and haven’t used for months, then shouldn’t they be sanctioned for any use?

People with addiction can establish abstinence for short or long periods of time depending on a variety of factors. But just like any other chronic illness, flare-ups and reactivation of the disease process can occur at any time, regardless of the length of stability.
For example:

  • The person may be triggered by a sudden loss of a relationship by death or divorce and use even if they have months and years of sobriety.
  • A flare-up of co-occurring chronic pain or depression and suicidality or trauma could trigger substance use.
  • The participant may have started to get overconfident after many months of abstinence and sobriety and even start thinking that maybe they don’t even have addiction. They start attending support groups less; or try having “just one drink” that then blossoms into full relapse mode.

It doesn’t mean substance use is excusable early on in treatment phases, but later use is willful misconduct needing punishment. Any substance use in addiction treatment is not a good outcome. But the approach is the same for early or later use:

  • What went wrong that you picked up a drink or drug again?
  • What can you learn from this bad experience and do something differently in a positive direction?
  • What people, places and things can you address to decrease the chance of a future flare-up?
  • Choosing to not do treatment will show up as disinterest in changing your treatment plan in a positive direction; and/or lack of follow through in active, adherent services. Then a sanction is needed.

References and Resources:

  1. “A Technical Assistance Guide For Drug Court Judges on Drug Court Treatment Services” – Bureau of

Justice Assistance Drug Court Technical Assistance Project. American University, School of Public Affairs, Justice Programs Office. Lead Authors: Jeffrey N. Kushner, MHRA, State Drug Court Coordinator, Montana Supreme Court; Roger H. Peters, Ph.D., University of South Florida; Caroline S. Cooper BJA Drug Court Technical Assistance Project. School of Public Affairs, American University. May 1, 2014.

  1. Critical Treatment Issues Webinar Series, Bureau of Justice (BJA) Drug Court Technical Assistance Project at American University Feb. 10, 2016 – May 3, 2016 https://www.youtube.com/watch?v=AuUEP52z1Xk
  1. Mee-Lee D, Shulman GD, Fishman MJ, Gastfriend DR, Miller MM, eds. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. 3rd ed. Carson City, NV: The Change Companies®, 2013. Application to Special Populations – People in Criminal Justice Settings

SOUL

On May 22, 2017, Ford Motor changed its CEO. Mark Fields, who had been with Ford for 28 years was replaced by Jim Hackett, an outsider who had only been at Ford for about a year. (Sometimes, just because you’ve have been in the business for decades doesn’t mean you have the most innovative ideas.)
Ford Executive Chairman, Bill Ford, said the “switch” was aimed at remaking Ford’s:

  • Legendary hierarchical culture
  • Expediting decision-making
  • Pursuing a cohesive vision for the future
  • Improving day-to-day operations

(USA Today, May 23, 2017 Money section page 2B)

What could justice teams and treatment providers take from these aims as they create more effective partnerships for public safety and lasting positive change?

  • Facilitating accountable pro-social thinking and behavior can’t be a top down, hierarchical court mandate or a provider’s push for treatment compliance.
  • When a flare-up of drug use destabilizes a participant’s treatment progress, good treatment and court decision-making must rise above a knee jerk sanction or suspension from treatment.
  • All stakeholders must come together to pursue a cohesive vision for the future of criminal justice reform and improved treatment outcomes that serve public safety and recovery oriented systems of care.
  • Communication between court teams and treatment teams must improve beyond cookie-cutter treatment compliance reports to meaningful progress reports on whether the participant is actually changing and growing.

The article quoted AutoPacific analyst Dave Sullivan: “Any time you go to a company like this, the culture is not gonna change overnight. It’s been set in stone for a hundred years.

It hasn’t been 100 years since Drug Courts started. But it feels like there is still a lot of stone. However if you resonate with any of the thoughts for a new direction, the stone is breaking down and the culture is already changing.

STUMP THE SHRINK

Here is a question from a Mental Health Specialist at the Department of Corrections in Oregon:

Q: “I am assessing an individual who is non-compliant with their probation/parole and has missed UAs (drug urinalysis) in addition to many other noncompliance issues, but has not admitted to using substances. I have always been taught that we do not consider a missed UA to be a positive UA when diagnosing and/or determining appropriate level of care (LOC). Would the American Society of Addiction Medicine (ASAM) agree with this?”


My response
:

The issue is less about the technicality of designating a missed UA to be coded as a “positive” UA result. Rather, the focus should be on assessing the individual’s Dimension 4, Readiness to Change. If the client is missing urine testing and other treatment meetings and strategies, the first consideration is to determine whether the client is even interested in treatment and whether s/he thinks there is an addiction problem needing treatment.

If s/he is ambivalent or not interested in attending, and there are no unstable problems needing containment and structure, then any treatment should focus on motivational enhancement that could be done in an outpatient Level 1 setting.

If there is instability threatening safety or their ability to access services, then the assessment and placement would be based on the needs of those issues, not just on missing drug testing.

In summary, the level of care placement depends on what issues, in which dimensions need services, the dose and intensity of which can only safely be delivered in which level of care? In that sense missing drug testing is indicative of broader issues rather than just legalistically considering that miss as a “positive” UA.

Compliance, adherence, Stump the Shrink on treatment courts, Biopsychosocial

Vol. #15, No. 4

Welcome everyone to the July edition of Tips & Topics (TNT).  Glad you could join us.

David Mee-Lee M.D.

SAVVY, SKILLS & STUMP THE SHRINK

You may have heard people described as either “lumpers” or “splitters”. Lumpers look at a certain topic and like to lump information together into as few categories as possible to keep it simple. Splitters like to dive deeply into a topic and tease apart more of the details into a variety of split categories.
Usually in Tips and Topics, I split apart SAVVY, SKILLS and STUMP THE SHRINK to tease apart some knowledge content, assessment, treatment and administrative skills, and challenging questions readers have sent. This month however, I lumped them all together because the comments and questions that drive the content for this edition encompass all three categories.
  • The first two questions/comments are follow-ups from the June edition of Tips & Topics and the article on rethinking discharge categories in substance use disorders treatment. If you missed it, here is the link:  Tips & Topics June 2017
  • The second set of questions/comments arose from the recent Annual Training Conference of the National Association of Drug Court Professionals (NADCP) held in National Harbor, Maryland July 9 -12, 2017.
TIP 1
Distinguish compliance from adherence when considering discharging people from treatment.
Compliance:
  • Merriam-Webster’s dictionary defines ‘comply’ as follows: “to conform, submit, or adapt (as to a regulation or to another’s wishes) as required or requested.”
  • Compliance names and labels participants based on participant behavior.
  • Compliance and following the rules assumes that actual treatment and change is happening. It also assumes that increasing compliance by the person means a good prognosis and successful long-term recovery.
  • However compliance often means “doing time” in a treatment setting rather than “doing change.” It doesn’t necessarily mean treatment has actually been successful.
Adherence:
  • Adherence has quite a different meaning from compliance in various dictionary definitions. According to one dictionary, adherence is to “stick as if glued, maintain loyalty, as to a person; or follow without deviation” (Ogden, 1999, p. 221).
  • Merriam-Webster’s defines “adhere” as “to hold fast or stick by or as if by gluing, suction, grasping, or fusing; to give support or maintain loyalty; to bind oneself to observance.”
  • Treatment adherence allows for treatment plans to be individualized to the specific needs and strengths of the client, not tied to a “one size fits all” program rules and phases.
  • If the treatment plan makes sense to the participant and helps them get what they specifically want, they will more likely stick to it and hold fast.
  • Compliance (versus adherence) with treatment allows a participant to “go through the motions” in a program, not being held accountable for working on whatever is needed to change attitudes, thoughts and behaviors to advance public safety.
 
Question No. 1
David-
I read your TNTs all the time and I definitely agree with you about not discharging patients from treatment. When we have discharged patients, sometimes they die from overdoses.   But what do you do with the person who cannot stop using alcohol, cocaine or illicit benzodiazepines? We offer further treatment but they don’t cooperate. They miss appointments. Do you discharge them then?
 
Judy Dischel, M.D.
Stanley Street Treatment and Recovery
386 Stanley Street
Fall River, Massachusetts
My first response to Judy
Hi Judy:
Thanks for writing and it is a dilemma when patients are hard to engage into treatment. If the person is in imminent danger of overdosing then you have the right and obligation to commit them against their will until stable e.g., someone who has intense cravings, will not agree to treatment . You assess they are very likely to continue to use in a dangerous life-threatening manner over the next few hours and days (not weeks or months, as that is not imminent.)
But if there is not imminent danger, and they are not interested in treatment, then the next intervention to try is to see if there is any leverage from family, significant others or anyone who has power in the person’s life e.g., supports them financially or in their living situation; or an employer; or partner and love relationship.
By working with any significant others, it might be possible to intervene and get a person into treatment to receive motivational enhancement therapy backed up by the leverage of the significant other. If there is no leverage, then basically you have to “Serenity Prayer it” as there is only so much you can do. We are dealing with a deadly disease that sometimes wins, even when we have done all we can.
Hope this helps a bit. No magic answers I’m afraid.
David

 

Judy’s first response
Still, would you kick them out of treatment while you’re saying the Serenity Prayer?
My second response to Judy
Judy, it isn’t a matter of kicking them out of treatment. If the person isn’t changing their treatment plan in a positive direction, even if in tiny steps, then they are not doing treatment, just “doing time” and are choosing not to accept treatment.
Think of it this way: if the patient is not interested in changing their treatment plan in a positive direction when their outcomes and progress are poor (e.g., using substances but not interested in doing something different to learn from that use), then the person is not doing treatment and is “kicking themselves out of treatment”. So you would discharge them (if not in imminent danger) since they are not interested in treatment.
If patients just sit there and don’t do anything different, then you are, in effect, saying to people that it is OK to sit in a program and not do treatment. So I wouldn’t want them to blame you for “kicking them out”, but rather they have decided they are not interested in doing an improved treatment plan. They have a right to be uninterested in treatment and so leave.
It may sound like semantics, but it puts the responsibility on the person to do treatment or choose not to do treatment, which is their right and OK for them to leave.
Hope this helps, but let me know if not.
David
Judy’s final response
Perfect, David, I hate letting people go from treatment, given the dangers, but they do seem to have an adverse affect on others. I really appreciate your time in responding to me.
Judy
Comment from Scott Boyles, LAC, MINT Trainer
Scott Boyles is a long time colleague and friend and is a licensed addiction counselor and the National Training Director for Train for Change Inc. His career has included inpatient and intensive outpatient counselor, clinical director and director for over three decades in the behavioral health field. Scott has passion and expertise in system change approaches to support implementation and use of evidence-based practices. For over two decades, he has been a consultant and trainer, with a focus on the ASAM Criteria, individualized treatment planning, clinical documentation, and motivational interviewing strategies.
His comment relates to the June article on rethinking discharge categories in substance use disorders treatment.
Hi David,
Great article! Raising awareness around Discharge Category (DC) terminology seems like a unique and powerful lever in driving systems change, amongst other things. One of the other classic DC terms, “Received Maximum Benefit,” was the ultimate in implying poor compliance, but not poor enough that we could use “Discharge at Staff Advice”.
 
Or sometimes “Received Maximum Benefit,” actually meant “we kept them for the whole program and they just never changed”, cool part is we got paid anyway…
Thanks,
Scott
My response to Scott
Thanks, Scott. Yes, we thought about putting in Received Maximum Benefit, but wondered if that was still in wide use. Your explanation was quite apt (and funny/cynical) because it captures the all-too-often practice that treatment is all about getting clients to comply with the rules, regulations and phases of the program.
David
Scott’s response
A program reacted to my comment about the Maximum Benefit discharge category when I was training a couple weeks ago in Oregon. The provider explained to me their Criminal Justice contract measured and expected an 80% completion rate based on a fixed length of stay in the program. This is a legitimate and unfortunate truth in their argument for the impossibility of having a variable length of stay (LOS).
 
Contracts and business models are another prong of the system that also drives the “old” measures and discharge categories. Maybe you could do a future piece in TNT on contracting (what’s the product and how is the quality measured?); and business models to support the variable length of stay, person-centered, partnership model.
Take care,
Scott
My Further Comments
Scott is right. Even if counselors and clinicians recognize the need to move to person-centered, collaborative and individualized treatment, the system issues often work against what we know creates lasting, sustainable, positive change.
Here are a few examples:
  • Administrators more focused on filling beds or treatment slots to stay profitable.
  • Contracts and so-called quality measures which require an 80% completion rate.
  • Such expectations perpetuate a program, fixed LOS model rather than expecting measures to track engagement across a flexible continuum of care, with a focus on improvement in function, rather than compliance with program behavioral rules.
TIP 2
Recognize that sanctions and incentives, punishment and reward belong to a narrow behavioral modification approach to addiction treatment.
Here are three questions arising from the NADCP conference earlier this month. They point to Drug and other Treatment Courts’ focus on behavior modification as the primary treatment approach in addiction. The American Society of Addiction Medicine (ASAM) describes addiction as a brain disease that certainly has behavioral manifestations. But behavior modification is just one possible tool in what should be a wide variety of recovery-oriented treatment tools to attract participants into lasting positive change.
Question No. 1
Hi,
I just attended the NADCP Conference with Dr. Mee-Lee and after reviewing my notes I never got a chance to ask him a question – if you could pass along this email to him that would be helpful, thanks.

We talked a lot about sanctions, discharge or suspending – as well as individualized treatment plans and the difference between “doing time” and “doing change.” I think individualized treatment is crucial to the client getting anything out of treatment (I won’t say success because I am aware that treatment doesn’t necessarily correlate with success from this disease)…. But for a while, our court was doing general sanctions (for example: missed therapy = 1 day in jail, missed urine screen = positive test and loss of clean time, missed curfew = 8 hours of community service, etc.).  
 
Then, it started to shift more towards individualized sanctions (for example: person X was late for a urine screen but ended up taking one later so the judge said it was confirmed negative so no loss of clean time, when person Z lost their clean time with the same scenario…. Or person X relapsed for the 4th time but because they are honest and upfront about it they don’t go to jail. But person Z had a positive screen and won’t admit to use so they will go to jail for lying).
Do you think this damaging? We previously tried to remain consistent with sanctions for specific things but then it became more individualized and then the group compares themselves out to one another. Or they say “It’s not fair because I’m telling the truth that I didn’t use, the cup was just positive” and it’s hard to verify this so we have to go by the lab…. Any thoughts?
Also, you mentioned Discovery, Dropout Plans… I am really interested in seeing some examples of these and how they differ from Recovery, Relapse Prevention plans. Since you mentioned that some folks never stopped using long enough for a Recovery, Relapse Prevention plan, I feel like this might be a really great thing to incorporate for folks who are more ambivalent.
 
Thanks for addressing this. I think it’s really important discussion to bring to my team.
Lanier Meeks Yi, MA, NCC
Arlington County Drug Court Therapist
Phone: 703-228-5214
My response to Lanier
Thanks, Lanier for these more in-depth questions. Here are some thoughts and suggestions:
1. When you were doing the “general sanctions” that were more formulaic, standardized and predictable (e.g., missed therapy = 1 day in jail) it can seem to be fair and consistent rules. One problem is that this places all the emphasis on compliance with rules and regulations predicated on a behavior modification approach to “treatment”.
2. If the goal of treatment is to improve attitudes, thinking and behavior and address all of the specific aspects of a participant’s functioning which interferes with public safety and reoffending behavior, then treatment is more complex than reward, punishment and behavior modification.
3. You may remember the importance of assessment of biopsychosocial severity and function using the common language of six ASAM Criteria dimensions to determine needs/strengths in behavioral health (The ASAM Criteria 2013, pp. 43-53).
1. Acute intoxication and/or withdrawal potential
2. Biomedical conditions and complications
3. Emotional/behavioral/cognitive conditions and complications
4. Readiness to Change
5. Relapse/Continued Use/Continued Problem potential
6. Recovery environment
4. When you recognize each person has different strengths and vulnerabilities, then it’s obvious each participant needs an individualized treatment plan to achieve successful outcomes.
E.G. if one person has post-traumatic stress on Dimension 3 and chronic pain on Dimension 2, their treatment needs will be different from another person’s priorities. E.G. Another person may have great difficulty with cravings to use on Dimension 5 and no supportive friends on Dimension 6. Their plan is quite different. A one-size-fits-all behavioral modification sanction plan doesn’t translate into lasting change.
5. Your shift to “individualized sanctions” seems like the right direction, however the “individualization” is based on criteria such as, complying later with a missed drug test, or admitting a mistake and being honest etc. This type of individualization can be too subjective leaving the team vulnerable to sanctioning one participant because they weren’t honest enough or fast enough. This then sets a tone of having all participants focused on who can get around the system more craftily than the next person.
6. Effective individualization is based on the specific unique needs of each participant. Each person is responsible for good faith effort in working on their own treatment plan with adherence, rather than focused on compliance with rules and regulations.
What then is fair for every participant? It is not what sanction they receive for the rule they broke. Rather fairness is that everyone is sanctioned for the same reason. That reason? When a person is not working in good faith on their individualized treatment plan which is designed to improve function and public safety. That is the distinction.
7. If there is a missed therapy day or drug screen, right away you assess what went wrong (e.g, participant overslept or used a substance and was afraid to be tested.) Learning from that poor outcome, the person fashions a new and improved treatment plan to wake up on time, or how to resist cravings to use. If they work to make changes in a positive direction, then no sanction is necessary. Only when someone is not interested in changing their treatment plan in a positive direction, is it then that they receive a graduated sanction.
8. The focus now is not on comparing one individual’s sanction with another, looking for uniformity and “fairness. ” Rather the attention is on what the participant is working on with effort and accountability.
9. Lanier asks if it is “damaging” to have “individualized sanctions” metered out in the the way she described? For example: person X was late for a urine screen but ended up taking one later so the judge said it was confirmed negative so no loss of clean time, when person Z lost their clean time with the same scenario…  I do think both “general sanctions” and your new direction draw attention away from holding participants accountable for adherence to their own treatment plan. It keeps participants’ focus on rules and regulations, compliance and concern with sanctions rather than on demonstrating real change in attitudes, thinking and behavior and pro-social functioning.
10. As regards Discovery, Dropout Plans for a start look at Tips & Topics June 2003:
A “discovery”, dropout prevention plan can use strategies like:
  • “Ask two old timers at an AA meeting why they think you may have an alcohol problem simply because you got two DUIs. Report back to group” or….
  • “Keep a log of all the times you are late with your curfew. See if you parents are on your back more or off your back when you are late”.
Also, see Tips & Topics February 2010:
Tips & Topics February 2010
Question No. 2
Dr. Mee-Lee;
This is a follow-up to our discussions at the “Meet the Expert” ASAM Criteria roundtable last day at the NADCP annual conference.

By way of re-introduction, I am a former prosecutor who is currently working on a project to determine compliance with the requirements of Pennsylvania’s DUI statute. That law requires that each DWI offender undergo a preliminary screening and, if warranted [repeat offender, BAC > .16], a full drug and alcohol assessment prior to disposition of the underlying criminal case. In the course of the review, we reviewed the process of collaboration/consultation between the criminal justice and treatment systems.

During our discussions, I raised concerns expressed by both judges and probation/parole officers present at the table, regarding the quality of status reports provided to them by the treatment providers. Our statute provides that the sentencing order require the defendant to “participate in and cooperate with drug and alcohol addiction treatment”.   The statute also requires the treatment program to report periodically to the assigned parole officer on the offender’s progress in the treatment program. The treatment program shall promptly notify the parole officer if the offender: (1) fails to comply with program rules and treatment expectations, (2) refuses to constructively engage in the treatment process, or (3) without authorization, terminates participation in the treatment program.  

Our state also has confidentiality provisions that provide that information released to the criminal justice system [judges, probation officers] Is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following”: (1) whether the client is or is not in treatment; (2) the prognosis of the client, (3) the nature of the project, (4) a brief description of the progress of the client and (5) a short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
These regulations are given as the reason for the very general descriptions in treatment providers’ status reports such as “client is compliant with the treatment plan.”
You indicated that you may be interested in further discussing the issue in a future edition of your “Tips and Topics”.

If you need any additional information, please don’t hesitate to ask.
All the best,  
Jerry Spangler
Pennsylvania Department of Drug and Alcohol Programs.  
My response to Jerry
Yes, Jerry, I have heard from many judges and probation/parole officers their dissatisfaction with the quality (or lack of quality) of status reports provided to them by the treatment providers.Regarding your confidentiality provisions list and its 1-5 criteria, here is more detail on what treatment providers could provide which would not violate confidentiality, yet provide more meaningful status information:
Our state also has confidentiality provisions that provide that information released to the criminal justice system [judges, probation officers] Is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following”:    
“(1) whether the client is or is not in treatment”
  • This should encompass a report as to whether the client is actively adhering to an individualized treatment plan designed to improve attitudes, thoughts and behaviors that increase public safety and enhance lasting accountable change.
  • Just sitting in groups or handing in an AA attendance log is not being “in treatment”.
  • The status report can indicate if the participant is working in good faith on doing treatment and change or just “doing time” complying with rules, phases and program-driven behavioral expectations.
  • If a treatment provider works with a client to engage them, yet the client continues to passively comply instead of actively work on changing, then a graduated sanction should be discussed with the participant and the treatment court team.
” (2) the prognosis of the client”
  • The status report should indicate if the client is changing in attitude and function, working on that person’s unique mix of strengths and vulnerabilities.
  • If the participant is not working in good faith on actual positive, lasting change, then the prognosis is shaky.
  • This should be discussed with both the participant and court team. This expresses that the client has not yet demonstrated sufficient change in function to decrease public safety risk.
  • If the participant is working hard on improved function, this predicts a better outcome. That information should be shared in a status report also.
“(3) the nature of the project” 
  • Does “nature of the project” refer to the highlights of the treatment plan without the need for intimate confidential details? If so, then the status report should outline those highlights – e.g., the client is working with his ambivalence about the severity of his substance use; or the client is exploring how strong are her parenting skills given she wants to get her children back.
” (4) a brief description of the progress of the client” 
  • Progress is measured not by the client attending all groups and complying with urine drug testing. Progress is measured by whether the client is actually changing in function, attitudes, thinking and behavior towards recovery and public safety.
  • Details on every up and down of a client’s progress is not necessary or useful. But the status report should be clear about whether the client is making progress towards positive change that is sustainable.
“(5) a short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse” 
  • If flare-ups of addiction have occurred (like any poor outcome in any illness) the next step is assessment as well as a change of the treatment plan in a positive direction, learning lessons from the relapse.
  • If the client has learned what went wrong, changed their treatment plan in a positive direction, then that information is what the status report should reflect.
  • If the client is not interested in changing in a positive direction and learning from the flare up, the client is now not doing treatment. This should be in the status report and be discussed for a possible graduated sanction.
I hope it is clear that providers’ status reports such as “client is compliant with the treatment plan” are inadequate, incomplete and need improvement. Concerns about confidentiality does not explain, justify or excuse such flimsy status reports.
Question No. 3
Hello Dr. Mee-Lee,
I was lucky enough to attend two of your wonderful workshops at the National Association of Drug Court Professionals conference and got so much out of each. I’m a therapist in a Drug Court.
I have a few questions for you if you have the time and I certainly understand if you don’t.
My first question is about our policy with high and low creatinines. We changed labs a few years ago and now every random urine drug screen has creatinine levels. We’ve been told the normal range is 20-300 mg/dL. For a level below 20, we give a warning letter for the first time and consider the second and all subsequent lows a positive drug screen test, which can mean jail, returning to a lower phase, change of sober date, 60/60 (60 AA meetings in 60 days), etc. For a high, above 400, we give a warning on the first test result; do daily urine drug screen tests for a week on the second test result above 400; and consider a third and all subsequent highs positives with the typically tough sanctions.

I’ve read and attended workshops and corresponded with Paul Cary, the major proponent of creatinine sanctions. As far as I can tell, he cites only one study for the lows and none for the highs. We certainly have clients who water-load to avoid detection of use and may have clients who supplement with creatine. However, many of our clients with highs and lows have no positive urine screens before or after the highs or lows.
 
Do you have any thoughts on this problem? I have many clients who appear to be really working a recovery program who are terrified about getting highs or lows. I also wondered if you have a toxicologist who you’d recommend my corresponding with on this subject?
My other question is about Vivitrol (trade name for extended release, injectable naltrexone), which we use with many of our alcohol and opioid clients. Sometimes the judge orders the client to take it-for a year-when the client doesn’t want to. What do you think about that?

All my best and thanks again for your extraordinary service on behalf of clients everywhere.
TD
Therapist in a Drug Court
My response to TD
Before I respond to TD’s important questions, here is some information on creatinine levels. Since I am not expert on urine drug screening tests and interpretation, I turned to Dr. Google. If you are an expert and I got it wrong, please let me know.
  • Creatinine is a waste product of creatine, an amino acid contained in muscle tissue and found in urine in relatively constant quantities over a 24-hour period with “normal” liquid intake. It is filtered out of the blood by the kidneys and some amounts are normally secreted into the urine.
  • Therefore, urine creatinine can be used as an indicator of urine water content or as a marker identifying a specimen as urine.
  • A normal result is 20-300 mg/dL in urine.
  • Creatinine level varies based on a person’s size and muscle mass. Below normal creatinine levels indicate that a person has been drinking excess fluids. Such a reading is a red flag in drug tests because it signifies that the person tested has attempted to tamper with the results by disguising other active by-products that would have otherwise been detected.
  • In other words, the creatinine levels determine whether or not a person is trying to cheat on a urine drug test. Most laboratories now perform advanced screening procedures that verify whether there has been adulteration or dilution. In the case of the latter, when the urine sample is too diluted, the results are normally labeled as “inconclusive.”
  • Why Is Creatinine Being Analyzed in Urine Drug Tests? The accuracy and reliability of urine drug test results depend heavily on the validity of the urine specimen.
  • When the specimen is pure and free from adulteration or substitution, those who rely on the results of the analysis can be assured the reported outcome is precise.
  • Adulteration or tampering with the specimen in order to alter the drug test results to produce a false negative is a known practice among drug users. A common way to do is by adding some products such as bleaching agents or detergents to the urine sample.
  • Another method is to conceal the metabolites or by-products of the ingested drugs by consuming excessive amounts of fluids or taking diuretics in an attempt to “flush” out the metabolites and “dilute” the urine.
  • The best way to check for “dilution” is to analyze some urinary characteristics such as creatinine levels.
Another resource:
ASAM has developed the “Appropriate Use of Drug Testing in Clinical Addiction Medicine” document to provide guidance about the effective use of drug testing in the identification, diagnosis, treatment and promotion of recovery for patients with, or at risk for, addiction.
 
TD, here are some thoughts and suggestions:
1. Urine drug screens and creatinine levels are laboratory tests for addiction, like any other lab test in assessing the severity and treatment for any health condition.
2. Lab test results have to be interpreted in the context of the participant’s history, gender, current health conditions and signs and symptoms. Lab test results do not stand alone, and should not be the final answer on a person’s health and well being.
3. Creating sanctions based solely on a lab test result is against good clinical practice in tracking the progress in any disease and health condition.
4. When you say “I have many clients who appear to be really working a recovery program who are terrified about getting highs or lows.” This is a good example of what happens when the focus is on compliance, rule breaking and sanctions rather than on demonstrating positive, sustainable and lasting change (recovery).
5. Even if a client does attempt to tamper with a drug test, the treatment provider should look as much at themselves as the client.
  • What type of culture and treatment atmosphere have we created such that clients feel the need to play games and cheat, rather than be honest about any flare-up or relapse?
  • Do we offer this explanation? While substance use in treatment is never good, if it does happen, it is important to raise that and get help. This is exactly like a depressed person who becomes suicidal. We teach them to reach out rather than hide the depression flare-up.
  • Have we created a ‘gotcha’ attitude to urine drug testing and a ‘police state of affairs’, rather than a treatment healing environment where we expect progress in treatment rather than perfect abstinence?
6. For a toxicologist with expertise about lab tests and addiction recovery, I suggest you contact the American Society of Addiction Medicine and contact any of the members of the Expert Panel who developed the “Appropriate Use of Drug Testing in Clinical Addiction Medicine”.
7. As regards Vivitrol – “Sometimes the judge orders the client to take it-for a year-when the client doesn’t want to.”
  • This is an example of a judge or any court personnel working outside their scope of practice.
  • In addition, the best predictor of good outcomes is the quality of the therapeutic relationship. This means agreement on goals and agreement on strategies and methods, within the context of a safe, trusting working relationship.
  • What if the participant doesn’t agree with the goal of abstinence or the method (medication)? You do not have an alliance. The likelihood of a good outcome is very low.
  • Thus the problem is not only the wrong treatment strategy for the wrong participant, but it is assessed and prescribed by the wrong person working outside their scope of practice. Good intentions don’t produce good outcomes if the alliance and treatment are out of alignment.
References
Adherence. (n. d.). In Merriam-Webster online. Retrieved from https://www.merriam-
American Society of Addiction Medicine (ASAM) “Appropriate Use of Drug Testing in Clinical Addiction Medicine” https://www.asam.org/quality-practice/guidelines-and-consensus-documents/drug-testing
Compliance. (n. d.). In Merriam-Webster online. Retrieved from https://www.merriam-
Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies.
Ogden, J. (1999). Compliance versus adherence: just a matter of language? The politics and poetics of public health. In J. D. Porter & J. M. Grange (Eds.), Tuberculosis: An interdisciplinary perspective (pp. 213-234). London: Imperial College Press.
Williams IL, Mee-Lee D (2017): “Coparticipative Adherence: The Reconstruction of Discharge Categories in the Treatment of Substance Use Disorders” Alcoholism Treatment Quarterly. Vol. 35, Issue 3, June 2017 Pages: 279-297. Published online: 16 Jun 2017, Pages 1-19 http://dx.doi.org/10.1080/07347324.2017.1322432

SOUL

Forty years ago this year, psychiatrist George Engel introduced his Biopsychosocial model as a holistic alternative to the prevailing biomedical model that had dominated industrialized societies since the mid-20th century.
Earlier this month, I watched two tennis players in the finals matches of Wimbledon who by tennis standards are “old” – Venus Williams at 37 going for her sixth win and Roger Federer at 35 going for his 8th championship.
I watched Federer win the all time record of 8 Wimbledon tennis tournaments and accomplish his 19th Grand Slam title. I also saw five-time Wimbledon winner, Venus Williams, lose the second set of the finals 6 – 0. Watching them both, “biopsychosocial” crossed my mind.
Although Venus worked hard and was so close to winning the first set and looking like she was headed for victory riding with confidence, she couldn’t win even one game in the second set.
Both players work hard with their physical fitness (Bio). Both have disarmingly calm temperaments and positive outlooks (Psycho). Both have very supportive families and loved ones (Social).
What was the difference between those two champions with such longevity and success in tennis? Who could blame Venus for the impact of two psychological blows?:
  • A month earlier on June 9 an officer at the scene of a fatal car accident was seen telling Venus Williams: ‘You kind of violated his right of way’.
  • The tennis star was at an intersection in Florida when she apparently caused a crash. Jerome Barson, 78, was killed; his wife Linda left with ‘disfiguring injuries’ in the accident.
  • After losing the first set, this same physically fit, socially-nurtured and supported champion could not muster the psychological confidence to win a single game.
The power of the emotions and psychological vulnerability, I suspect, undid Venus that day.
Federer: “Previously I always thought it was just tactical and technique, but every match has become almost mental and physical – I try to push myself to move well. I try to push myself not to get upset and stay positive, and that’s what my biggest improvement is over all these years. Under pressure I can see things very clearly.”
(“Five lessons in success from tennis champion Roger Federer”)
Finding the right balance of bio-psycho-social goes a long way to a happy healthy life – even if you don’t win at tennis.

Until next time

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

November 2017

Vol. #15, No. 8

Welcome to the November edition of Tips & Topics (TNT). To all of you in North America, I hope you had a great Happy Thanksgiving. Wikipedia says that Thanksgiving is also celebrated by some of the Caribbean islands, and Liberia. But I don’t have any Tips & Topics readers there.

David Mee-Lee M.D.

SAVVY, SKILLS & STUMP THE SHRINK

I frequently receive questions from readers that I answer under a section we call “Stump the Shrink”. Of course I only put in the questions I know the answers to. This month I’m combining Savvy, Skills and Stump the Shrink to include some of the recent questions you may be interested in.
TIP 1
Address client complaints in a person-centered, not counselor-centered manner
Question:
Dr. Mee-Lee, I have a question regarding changing counselors in a residential treatment setting. A person receiving services has stated that she feels that her counselor hates her. She talked with the supervisor and requested another counselor. It was denied. The counselor then gave the person receiving services a book regarding resistant clients in treatment. How would you suggest that a situation like this be handled in a more person-centered manner? Thank you for your time in this matter.
Jan, Minnesota
My response:
Hi Jan:
Thanks for your question. Here are some thoughts:
1. You said the person spoke to the supervisor, but did the person first speak directly to the counselor to share their concern? In any conflict between clients and counselor or staff member to staff member, it is best to have the person talk first at the lowest level of involvement. Then pull in the next level up of authority if the conflict is not resolved. So the client would be encouraged to first talk to the counselor before the supervisor gets involved.
2. If the person said, “I already tried talking to the counselor and it didn’t go well, which is why I am coming you”, the supervisor, then the next step is for the client, counselor and supervisor to meet together so the supervisor can observe how the counselor responds. The supervisor may see that the request for a change is appropriate or if not, they can all discuss why a change would not be helpful and how to work on the conflict in future sessions.
3. If the counselor gave the person a book regarding “resistant clients”, as in this case, that signals to me that the counselor puts all the blame on the client, which would concern me about the counselor’s competence (and maybe even that of the supervisor) though I would need to hear all sides of the decision-making. The 2013 edition of Motivational Interviewing doesn’t even use “resistance” any more because clinicians should be looking as much at their contribution to so-called “resistance” as blaming the client.
Here’s a quote from page 197: “…our discomfort with the concept of resistance has continued to grow, particularly because it seems to place the locus and responsibility for the phenomenon within the client. It is as though one were blaming the client for “being difficult.” Even if it is not seen as intentional, but rather as arising from unconscious defenses, the concept of resistance nevertheless focuses on client pathology, under-emphasizing interpersonal determinants.”
(Miller, William R; Rollnick, Stephen (2013): “Motivational Interviewing – Helping People Change” Third Edition, New York, NY. Guilford Press.)
Hope this helps, but let me know if not.
Thanks.
David
In the February 2007 edition of Tips & Topics, I wrote about conflict and a conflict resolution policy. If you don’t have such a policy where you work, here is one to consider:
 
 
TIP 2
Engaging youth in treatment and using ASAM Criteria levels of care
Question:
Good Morning!
I took a refresher course in ASAM Criteria this past weekend. I was compelled to reach out. Strange how my 10 years in the field has added a “reality” lens to my use of the Criteria. Dealing with insurance companies and limited availability of resources has surely effected my clinical impressions.
 
Working in Portland, Oregon you would think we have great resources, we do – for adults. However, for insured adolescents there is almost nothing. I work with these families. I have a few clients in my outpatient practice who could use Level I (ASAM Criteria Outpatient Services) or Level 2.1 (ASAM Criteria Intensive Outpatient Services) levels of care. It turns out, I am their ONLY source of treatment. I carry my CADCII as well as an LCSW, but I CANNOT meet the needs for clients who need a higher level of care.
 
Any thoughts?
 
Also, what is my responsibility (ethically) working with teens who have no interest in decreasing their use? I am engaging in Motivational Enhancement Therapy (MET) with these folks but I feel a bit stuck.
 
Thanks for your guidance,
Beth Rossi, LCSW, CADCII
Hillsboro, Oregon
My response:
Hi Beth:
Thanks for staying up on The ASAM Criteria and sounds like you are doing some good work with adolescents and their families. While you may not have a lot of access to residential levels, from an ASAM Criteria perspective, clients only need 24 hour treatment in residential if they are in imminent danger* and life threatening risk to self or others or of running behavior with severe consequences like fire setting or prostitution etc. Unless a client is in imminent danger, residential levels should not be used to “break through denial” or just get them away from their environment. Such treatment ends up focusing on behavior control for a young person not interested in learning about prosocial behavior change and recovery. The focus of behavior control treatment is on adolescent rule breaking and loss of privileges and setbacks in the phases of the program rather than on treatment and recovery.
So one question I would have for you is what are the clinical reasons you think your adolescent clients need a more intensive level of care than you can provide?
As regards working with teens not interested in decreasing their use, that is normal for most clients who are motivated more for getting people off their back or avoiding some consequence they don’t like e.g., limiting their curfew, being sent to a foster home or juvenile hall. So the focus of treatment you do is “discovery, dropout prevention” not “recovery, relapse prevention”** using as you are doing MET and Motivational Interviewing. You help the teen discover, at a pace that makes sense to them, a connection between drug use and the consequences they don’t want. Also you want to keep them engaged to not drop out. It is hard to help someone if they are not there!
Here is an example of “discovery” motivational work for a teen who doesn’t think he has a drug problem because “I can stop any time I want”; and certainly doesn’t see anything wrong with hanging with his drug using friends:
Treatment Plan Strategies:
1. Jordan will gather all the data he can from school, family, legal history to prove he doesn’t have an addiction problem.
2. Jordan will demonstrate he doesn’t have a substance use problem by just stopping all use; and continue hanging with his friends to see how well he does with abstinence as measured by random urine drug screens.
So long as the teen is willing to try these “discovery plans” and is adhering to them, you keep working with them. If a client doesn’t show up or doesn’t follow through on a treatment plan you collaboratively agreed upon, then you could be “enabling” the client. By that I mean, that if outcomes are not going well, and the teen keeps getting into trouble with their substance use or behaviors, the next step is to assess what is not working and change the treatment plan in a positive direction. It is “enabling” If the client is not held accountable to change the treatment plan in a positive direction and you just continue to see the client. The client gets the message that there is no real expectation to change or take responsibility for treatment.
Any changes to the treatment plan can be a small incremental step e.g., “OK I will stay away from Harry who is the hardest person I have trouble saying “no” to. But I’m not giving up all my friends.” That is a change in the client’s treatment plan in a positive direction so treatment should continue. That is progress and you keep going. But if the client does not see anything s/he will do in a positive direction, then just keeping the person in treatment is enabling. The client has the right to choose no further treatment and then you let the consequence happen.
Hope this helps, but let me know if not.
Thanks.
David
* Imminent Danger (The ASAM Criteria 2013, pp. 65-58) – Three components:
1. A strong probability that certain behaviors (such as continued alcohol or other drug use or addictive behavior relapse) will occur.
2. The likelihood that such behaviors will present a significant risk of serious adverse consequences to the individual and/or others (as in reckless driving while intoxicated, or neglect of a child).
3. The likelihood that such adverse events will occur in the very near future, within hours and days, rather than weeks or months.
  

** I first wrote about “discovery, dropout prevention” and “recovery, relapse prevention” plans in just the third edition of the first year of publication of Tips & Topics – June 2003. If you’d like to read more on that, here’s the link:

Beth’s response:
Dr. Mee-Lee:
I really appreciate your feedback. You have given me numerous points to consider. What is my role for these clients? Therapist or addiction counselor, usually BOTH roles apply.
 
I guess for some reason I am fearful that parents/guardians will have expectations that I can decrease/prevent substance abuse in their teen. Having worked in residential facilities in the past and knowing that parents sometimes think treatment = abstinence. Now that I am processing it, I realize I am placing some high expectations on MYSELF!
 
I am currently working with a family whose daughter was in imminent danger and I could not get her treatment until she made a suicide attempt (after running away with drug use and prostitution). Now she is in treatment in another state and we are engaging in weekly sessions via telephone. Her progress is limited.
 
I feel that some of my adolescent clients need 2.1 level of care and I do not have the time in my schedule to provide this amount of client contact/treatment.
 
Maybe I am looking at the ASAM Criteria too literally? I do not need to place someone AT a facility just to place them using the Criteria. I need to be more flexible in my thinking! ?
 
Thanks again!
Beth
 
 
My second response:
Yes, Beth, with your training you are actually able to do integrated co-occurring disorders work, which is what a lot of clients need but can’t obtain very well.  For most youth, motivational work is going to be where to start- once any imminent danger situations have been stabilized.  I wonder if your client ,who is in residential treatment, is actually receiving motivational work; or whether she is expected to be interested in sobriety and recovery when she might not be.  That might be contributing to what you said is happening: “progress is limited.”
You are in a good position to do that motivational work once any imminent danger activities are stable.
All the best,
David
 
References:
1. Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies.
2. Miller, William R; Rollnick, Stephen (2013): “Motivational Interviewing – Helping People Change” Third Edition, New York, NY. Guilford Press.

SOUL

As I write this, I am on a plane en route to India to conduct three days of ASAM Criteria training. Making this training happen has been a labor of love for both the organization in Pune, (not far from Mumbai or previously, Bombay) and for me as well. They have very limited resources, yet the Executive Director has been passionate and single-minded about introducing The ASAM Criteria to India.  I couldn’t let her commitment over the past two years go unsupported.

When they finally found enough resources to conduct the training, it was a rush to match my limited availability with their window of dates too. That made getting an Indian entry visa a time-pressured, tense process: completing a complicated visa application (three times to get errors correct); photos; several approval processes, some requiring

more documentation, explanatory phone calls, waiting…….more waiting, more documents and explanation – all of this to just enter the country for a week to do an ASAM Criteria training to physicians.

Once all the documents were declared accurate and the complete, the tension shifted to the Embassy’s processing the application. Would the visa come on time to make the trip? Why did the tracking update information on their website stay stuck for days on “Under Process at Embassy”? All I want is to do a 3-day training in India, I am not wanting to immigrate; or steal any resources; or terrorize the country.
In the process, I expanded my empathy for the millions applying for a visa to enter the USA. Getting an Indian visa was not life and death. The worst that could happen is the training got postponed.  However for many seeking asylum and safety in the USA, it is literally life and death. And they are not waiting just for a few days or weeks. The wait is often years, maybe decades!
I am so grateful to hold a passport to two wonderful countries – my country of birth, Australia; and my country of choice, the USA.  Coming and going so freely with passports many would die for trying to get them, is easy to take for granted.
My Indian visa experience reminds me that freedom to come and go is to be treasured.

Until next time

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

David

January 2018

Vol. 15 No. 10 
In this issue


India ASAM Criteria Training
Transcendental Meditation
5 hearts

David Mee-Lee M.D.


SAVVY

In late November/early December, I made a quick trip to India to do a three day training train on The ASAM (American Society of Addiction Medicine) Criteria. I was in Pune, about 95 miles from Mumbai (formerly known or as Bombay). In November’s SOUL section I spoke about the bureaucracy of getting a visa to train in India.   Tips & Topics November 2017

Since this was India’s first introduction to The ASAM Criteria, I wanted to share a brief Q&A with Ranjana Pavamani, the driving force behind bringing this training into reality:

1. Who you are and why do you have such a passion for bringing The ASAM Criteria to India?
I am Ranjana Pavamani, Executive Director of IC&RC IADCC (International Certification and Reciprocity Consortium (IC&RC) and International Alcohol and Drug Counselor Certification Trust for India). I come from a pioneering background where my father, the late Dr. Vijayan Pavamani,
pioneered Drug Rehabilitation and Suicide Prevention for South East Asia In 1971 under The Calcutta Samaritans.
Over time, I felt this intense desire to work as a Drug Counselor, and I realized that the experience of working with my father would be a bonus or would expand, with additional formal training. In the 1990s, there was no formal training in Asia, to my knowledge. I was told about an Institute in Florida willing to accommodate me for Drug Counseling Training and I attended for a year. I returned to India at the end of the year and in 1999 onwards, began my endeavor to train counselors on addiction.
I do feel passionate about the ASAM Criteria, as it structures a precise assessment of a patient suffering with addiction/mental health Issues. Using the ASAM Criteria 6 assessment dimensions and the continuum of levels of care gives a person a chance of recovery, as opposed to forcing someone into a 21-day program. They, perhaps, may not need that length of stay or a 24-hour treatment setting.
The ASAM Criteria delivers excellent patient-care matching, which saves a lot of time and money. It enlightens the fact that recovery is very possible and the chances of getting out of addiction and leading a normal life are huge, with the guidance of the ASAM Criteria. I recommend that more and more medical and non-medical Institutions should use the ASAM Criteria for addiction treatment and recovery.
2. What is the mission and activities of the IC&RC International Alcohol and Drug Counselor Certification Trust for India?
In 2010 we began our efforts to establish an International Credentialing service for Drug Professionals, which we pioneered in the Indian subcontinent and established by 2012 called The IC&RC IADCC. You can see more about us on our website: IADCC
We worked with a department of the Ministry of Social Justice and Empowerment in the government of India called NISD (National Institute of Social Defence), which umbrellas 900 Drug Programs. They receive support from the Government of India. My father, Dr. Vijayan Pavamani was one of the founders of this department.
We then went on to work with those Drug Programs interested in International Credentialing and also with some of them that were privately-run Drug Programs.
3. Who came to the three days of ASAM Criteria training and how did you decide who should be invited?
On November 30th to December 2nd, 2017 in Pune, we had a small group of 16 doctors who were administrators in their hospitals in several states from all over India to take the ASAM Criteria training.
Three years ago, when we were organizing our syllabus for students to get our credentials, I came across the ASAM Criteria. On studying it, I realized that we needed someone from ASAM to teach us about it. We sent an email to the American Society of Addiction Medicine, and then someone responded that there is Dr. David Mee-Lee who could be interested in training on the ASAM Criteria to those interested in India.
In our quest to promote the ASAM Criteria amongst the Drug Programs, a psychiatrist in Punjab asked me if we could deliver this training for Medical Practitioners. On this request, we began to request doctors who were working with addiction patients to take this training. We were requested to deliver this training and so we did!!
4. How do you think the training went and what are your Next Steps?
Our trainer was none other than Dr. David Mee-Lee for whose training we received excellent reviews for all those three days.

Here is our group:

If you want to see more photos:
Our next step is implementation of the ASAM Criteria in India. We hope that a few ambassadors of The ASAM Criteria would be available to mission their time in India to help with the implementation of The ASAM Criteria for a few medical Institutions.
Yours sincerely,
Ranjana Pavamani
Executive Director
The IC&RC International Alcohol and Drug Counselor Certification Trust for India
While I had the opportunity to introduce something new to India, the USA, along with many other countries, have long looked to the ancient wisdom of India for health and spiritual guidance in our fast-paced society. In February 1968, fifty years ago, the Beatles travelled to Rishikesh in northern India to attend an advanced Transcendental Meditation (TM) training course at the ashram of Maharishi Mahesh Yogi.
TIP 1
Note one recent study on Transcendental Meditation Program’s Impact on the Symptoms of Post-traumatic Stress Disorder of Veterans.
Current treatments for post-traumatic stress disorder (PTSD) are only partially effective. The purpose of this study was to determine whether an extensively-researched stress reduction method, the Transcendental Meditation (TM) technique, can reduce the PTSD symptoms of veterans.
The findings of the 46-patient study were published online December 29, 2017 in the journal Military Medicine. Results indicated that TM practice reduced PTSD symptoms without re-experiencing trauma.
  • After 1 month of TM practice, all 46 veterans with PTSD responded.
  • Because of the magnitude of these results and dose-response effect, placebo effects are unlikely explanations for the results.
  • Major limitations were the absence of random assignment and lack of a control group. Those who self-selected to enter this study may not be representative of all veterans who have PTSD.
  • But when taking into account these results and all previous research on the TM technique in reducing psychological and physiological stress, the evidence suggests that TM practice may offer a promising adjunct or alternative method for treating PTSD.

TM has been extensively researched for other disorders like hypertension, heart attacks and other

cardiovascular disease; depression, insomnia and stress-related conditions.
For more on this research:  Evidence on the benefits of TM
Reference:
“The Transcendental Meditation Program’s Impact on the Symptoms of Post-traumatic Stress Disorder of Veterans: An Uncontrolled Pilot Study”
Robert E Herron, Ph.D., MBA Brian Rees, M.D., MPH, MC, USAR (Ret.)
Military Medicine.
 

David Mee-Lee M.D.

How to move systems from programs to people.
Reframing “resistance” in systems change.
Soothing the customer.
When to increase the level of care intensity.

Vol. 10, No. 3 June, 2012

Welcome to the June edition of Tips and Topics (TNT) and to all the new subscribers. You can see nine years of back issues of TNT on The Change Companies’ website and download any of the previous editions.

Senior Vice President
of The Change Companies®

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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®

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April 2011 – Tips & Topics – april-2011-tips-topics

TIPS & TOPICS from David Mee-Lee, M.D.
Volume 9, No. 1
April 2011

In this issue

— SAVVY –The 3 Ps to Understanding the Big Picture of Healthcare
— SKILLS –Clinical Implications of the 3 Ps
— SOUL –Celebrating anniversaries
— SHARING- Some readers’ comments
— Until Next Time

Welcome to the start of the 9th year of publishing TIPS and TOPICS (TNT).  It was April 2003 when I started this experiment which has blossomed into a widely-read and appreciated resource (at least that’s what many readers tell me – the others don’t say anything- they just don’t read TNT!)

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June 2011 – Tips & Topics – june-2011-tips-topics

TIPS & TOPICS from David Mee-Lee, M.D.
Volume 9, No.3
June 2011

In this issue

— SAVVY   Top 10 reasons to use the ASAM Criteria
— SKILLS  How close your services are to the spirit/use of the ASAM Criteria
— SOUL   R&D – not doing the same old thing
— Until Next Time

Welcome and thank-you for joining us for the June edition.
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March 2011 – Tips & Topics – march-2011-tips-topics

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

Volume 8, No. 11
March 2011

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

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

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

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May 2011 – Tips & Topics – may-2001-tips-topics

TIPS & TOPICS from David Mee-Lee, M.D.
Volume 9, No.2
May 2011

_________________________________
In this issue

— SAVVY – Teaching tips that work
— SKILLS –Practice these teaching techniques
— SOUL – Tornadoes and dodging bullets
— SHAMELESS SELLING – Tips from the TNT book
— Until Next Time

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August 2011 – Tips & Topics – august-2011-tips-topics

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

Volume 9, No. 5

August 2011

_______________________________________

In this issue
— SAVVY – A new definition of addiction from ASAM
— SKILLS – What the new definition means to you, your program and systems

— SOUL – Charley horse
— SHARING- Readers’ comments

— Until Next Time

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May 2010 – Tips & Topics – may-2010-tips-topics

TIPS and TOPICS from David Mee-Lee, M.D.

Volume 8, No. 2


May 2010

In this issue

SAVVY   Assessment Issues in Co-Occurring Disorders
SKILLS   What does the client want?  Understanding retention and resistance
SOUL A recovering Speeder
SHARING SOLUTIONS Innovations from Readers
Until Next Time

Thank-you for joining us for this month’s edition of TIPS and TOPICS.

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

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

In this issue

-SAVVY: Psychiatric diagnosis gone wild!

-SKILLS: Working with People, not diagnoses

-SOUL: My favorite meals

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

-SHARING SOLUTIONS: Readers share their experiences with aging

-Until Next Time

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

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October 2007 – Tips & Topics – october-2007

TIPS & TOPICS
Volume 5, No.6
October 2007

In this issue
— SAVVY and STUMP THE SHRINK
— SATIRE
— SOUL
— SHAMELESS SELLING
— Until Next Time

Thanks for joining us for the October edition of TIPS and TOPICS (TNT). Welcome to all the new readers.

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September 2007 – Tips & Topics – september-2007

TIPS & TOPICS
Volume 5, No.5

September 2007

In this issue
— SAVVY and SUCCESS
— SKILLS
— SOUL
— SHAMELESS SELLING
— Until Next Time

Welcome to the September edition of TIPS and TOPICS (TNT). I hope your vacation time was as successful as mine. Or if you didn’t have a vacation, maybe this is something to be learned from the Australians and Europeans.

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July/August 2007 – Tips & Topics – julyaugust-2007

TIPS & TOPICS
Volume 5, No.4
July/August 2007

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

Welcome to a combined July-August edition of TIPS and TOPICS (TNT). In August I am leaving the warmth of summer in California to enjoy family and friends in wintry Australia.

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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.

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December 2005 – Tips & Topics – december-2005

TIPS & TOPICS
Volume 3, No.6
December 2005

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

Happy New Year! By the time you read this, for most it will be 2006. I hope you receive the best gift of all this year – good health. Welcome to all the new subscribers who have joined us since last month. You can browse back issues of TIPS and TOPICS by going to the homepage of www.DMLMD.com . Click on ‘Read Back Issues’. There is also now a printable version of each edition.

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September 2005 – Tips & Topics – september-2005

TIPS & TOPICS
Volume 3, No.5
September 2005

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

A significant number of new readers are joining us this month, so welcome to you. Thanks too, to all of you who have been with TIPS and TOPICS for many months and even years. I appreciate the many comments and messages of appreciation you send me.

(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…)

January 2005 – Tips & Topics – january-2005

TIPS & TOPICS
Volume 2, No. 9
January 2005

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

Welcome readers!

Happy New Year! Actually January is nearly over and it seems 2005 is already in full swing.

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May 2003

Vol 1, No.2
In this issue


SAVVY | SKILLS | SOUL | STUMP THE SHRINK

David Mee-Lee


 

WELCOME!

Welcome back to this second edition of TIPS and TOPICS.

The response to the first edition was very positive and satisfying. If you are receiving TIPS and TOPICS for the first time, thanks for signing up along with over a hundred of your colleagues. For a few of you with whom I have had professional contact in the past, I took the liberty of sending this along to you this month. If you would like to keep receiving it, I’ll be happy to send it. But if you are overwhelmed with information already and would rather not receive TIPS and TOPICS free each month, then I totally understand if you unsubscribe (see Unsubscribe link at the very end).

Thanks to all of you who wrote and expressed appreciation and gave feedback. It seems TIPS and TOPICS has already filled a need for many of you. I hope this edition will also be as useful to many.

SAVVY

Over the past month, I was asked to consult about two patients. Between them, both had been hospitalized in acute care medical and psychiatric units five times in the past six months. They were admitted for depression, suicidal feelings and ideation. One had a serious overdose and one even had electroconvulsive therapy (ECT). Alcohol and cocaine were the drugs involved. One of the consultation questions asked of me was this: What should be the focus of treatment given the patient’s poor follow through with treatment, “denial”, and multiple readmissions in a period of months?

In both cases, the substance dependence was correctly recognized as an important element in the patient’s history and treatment needs. However, in both cases, the clinician’s major emphasis was on the mental health problems – partly because those were the most acute presenting symptoms. Very little assessment of the substance use was done to tease apart to what degree the psychiatric symptoms were a result of the addiction problem; or to what degree the symptoms were truly a co-occurring disorder. Both programs were not very savvy about addiction treatment, let alone integrated dual diagnosis treatment.

Tips:

  • If a person is suffering from depression or any other psychiatric presentation, and is actively using alcohol and/or other drugs, specific assessment of both the mental health and substance use is needed. Is there a mental health problem where substance use may be attempts to self medicate the psychiatric disorder? Is this a substance use disorder in which the mental health symptoms are a result of addiction illness? Or is it a true dual diagnosis?
  • It is necessary to understand the difference between Substance Use Disorders and Substance-Induced Disorders. They are both under the category of Substance-Related Disorders (See DSM-IV Text Revision, 2000). This can help tease apart some of these assessment dilemmas.
  • If a person is in an early stage of readiness to change (notice I am downplaying the use of the term “denial”) and demonstrates ambivalence or lack of understanding about addiction, this is an active treatment issue. It is not a reason to exclude a person from treatment, or to provide only passive education about addiction.

SKILLS

Given the prevalence of co-occurring mental and substance-related disorders (dual diagnosis) it is good that both mental health and addiction treatment clinicians are so much more aware about dual diagnosis. However, awareness without clinical savvy can lead to knee-jerk over-reactions. Addiction treatment professionals too quickly can refer a client for a psychiatric evaluation without taking even a little time for more careful assessment and gathering of history data. Mental health professionals similarly can often rush to medicate symptoms before determining if they are looking at a substance-induced disorder or a true dual diagnosis.

Tips:

  • A Substance-Induced Mood Disorder, for example, “is distinguished from a primary Mood Disorder by considering the onset, course, and other factors. Substance-Induced Mood Disorders arise only in association with intoxication or withdrawal states, whereas primary Mood Disorders may precede the onset of substance use or may occur in periods of sustained abstinence.” (Page 405 DSM-IV Text Revision)
  • Take the history and timelines to check the relationship between substance use and addiction problems and the appearance of mental health problems. Not all mood swings are Bipolar Disorder – it could be that the person is using uppers and downers, stimulants and depressant substances. Not all heavy drinking is alcoholic drinking – it may be that the client is drinking at night until he passes out, in an attempt to deal with the severe insomnia of Major Depression.
  • Even after four weeks following detox, people can still have problems with depression, anxiety and mood swings etc. While we want to give people the benefit of medication if necessary, there is also a period of psychosocial adjustment after detox. If an individual has few (if any) positive recovery tools to deal with stress or discomfort- (e.g. dealing with cravings or mood swings) mental health symptoms can still be present after detox. These symptoms may be a part of normal addiction recovery and not positive proof that a co-occurring mental disorder exists.

If you want to learn more about these assessment dilemmas, you can check out the Home Study Course: “Dilemmas in Dual Diagnosis Assessment, Engagement and Treatmentat Professional Psych Seminars, www.psych sem.com.

SOUL

I am writing this section on Mother’s Day at 6:30 AM in a basic, but comfortable tent cabin in Yosemite National Park. What a privilege to be able to drive under four hours to such a place of astounding beauty. But last night, in an incongruous juxtaposition of experiences (sorry for the fancy words) we were in a lodge lounge packed with people cheering on the Sacramento Kings in the NBA Playoffs. If you are not a basketball fan, you would not know that the Sacramento fans are the most loyal and noisy fans in the USA. The Kings lost in double overtime. The prospects look bleak. Chris Webber, the King’s star player, is out for the rest of the playoffs with a torn cartilage in his left knee.

Two games ago, the Kings looked on track to take it all and win the championship this year. Frank Sinatra said it all in his gritty song “That’s Life” – “riding high in April, shot down in May”. In those final minutes of the game, the battle with the Dallas Mavericks seesawed between victory and defeat. Participating in the emotion and passion in the room, you would have thought the most important event in the world was a basketball game. Many of you didn’t even know the game was on, couldn’t care less and won’t ever care.

Outside, the sky is perfectly blue; the air crisp and clear; the sheer granite rocks tower all around us. One can look across the meadow to see Yosemite Falls pounding over the rock face. Half Dome stands huge, tall and impressive. Beside Yosemite’s picture-postcard beauty, we are here to meet up with our college freshman son on a geology class field trip. He gets to hike this grand National Park for two days- and for college credit!

In my view, there’s nothing wrong with the emotion and passion of a tight playoff game. And in the battles over budget cuts, competing theories of treatment, and advocacy for our various rights and noble initiatives, there’s nothing wrong with emotion and passion. But budgets come and go. Theories and rights rise and fall in importance, and basketball games will be forgotten next week. The grandeur of Yosemite, the emotion and passion around our mother and family remain way beyond April and May. I remind myself and perhaps you too, about priorities, perspective and permanence. What really is important? What do you really want for you, your family and the people we serve?

STUMP the SHRINK

Question:

Dr. Mee-Lee:
“I am reviewing a document and they have used the term “substance related” disorder and said they got it from the ASAM material. Is that the official new term? I had just heard two weeks ago that the term was “substance use” disorder. I have been in the field 22 years and have been through a number of these changes and don’t like the former term as it seems to refer to “related” disorders but not necessarily inclusive of substance use directly. Please advise if you have any insight to the “official” terminology. Thanks!”
Jane (real person, but not real name)

Answer:

Dear Jane:
“As regards the term “substance-related disorders”, we are using the language of DSM -IV. Substance-Related Disorders are made up of two categories: Substance Use Disorders (Substance Abuse and Substance Dependence); and Substance-Induced Disorders (Substance Intoxication and Substance Withdrawal and a whole host of other Substance Induced Disorders like Alcohol Induced Depression; or Amphetamine Induced Psychosis etc.) So it depends on the patient and their presentation as to what their diagnosis is. In the ASAM Patient Placement Criteria, we use all of the terms depending on what the history and assessment reveals. In other words, the term “substance-related disorders” is not replacing substance use disorders. ” Substance-Related Disorders” is the overarching DSM-IV chapter for both addiction disorders and for psychiatric disorders induced by substances. These substance-induced disorders are psychiatric disorders that are “related” to the substance, but are not the specific addiction or Substance Use Disorder (Abuse or Dependence). Check out the DSM and it should make sense, but let me know if not.”

Until next time

I would welcome any Success Stories on implementing any of the TIPS and TOPICS, or any questions to Stump the Shrink! Send those along. Just tell me how much identifying data you are comfortable with my sharing in this ezine. All the best until next time.

David.

April 2003 – Tips & Topics – april-2003

Why I started this Ezine!
>> Clinicians have ongoing clinical questions that need answers!

I have been training and consulting for over 25 years, but fulltime for nearly the last seven years. I travel the country & get repeated requests for answers to questions on the American Society of Addiction Medicine (ASAM) Patient Placement Criteria and other topics. People ask about books, videos and audio learning materials they can obtain. They want help to implement and apply knowledge and skills presented in one or two-day workshops. An Ezine is one way to answer those common questions and requests more efficiently.

>> To help people apply new-found knowledge!

Budget deficits are hitting almost every state. Attending a workshop can change one’s knowledge and skills immediately. However, fewer can afford to take the time and funds to learn onsite at a workshop. Continual learning is essential, but a challenge to achieve without some ongoing prompting, supervision or assistance. An Ezine is a vehicle to provide supplements and support to previous workshop attendees, or to those who have so far been unable to get to an onsite training.

>>Because I want to make a difference in our field!

Out of sight, out of mind! I want my work to make a real difference in providing, managing and funding person-centered services. An Ezine is a channel available to stay in touch and keep making positive changes in our work. It is a way to feed “Tips and Topics” to healthcare providers sincerely interested in applying concepts and skills to change( for the better) the way we serve people in behavioral health.

What to expect from the Ezine
>> You will receive it once a month.
Please forward it to other interested individuals. Suggest that colleagues sign up on my website.

>> It will be a relatively brief communication.
While, on occasion, I may excerpt or include material from other sources (appropriately referenced of course), most material will be original and be focused on practical tips and topics in the following areas:
— implementation of the ASAM Patient Placement Criteria;
— providing and documenting individualized person- centered services;
— clinical and systems issues to do with co-occurring mental and substance-related disorders (dual diagnosis);
— ways to engage, empower and collaborate with people in getting what they want and changing what they want.

>> There will be 3 Sections: SAVVY, SKILLS, and SOUL
Each section will hopefully imrpove who we are as professionals and as people – it’s not just about “doing”, but also about the “being”!
“Savvy”- to improve our knowledge, wisdom and practical grasp of topics;
“Skills” to focus on tips to improve practical competence;
“Soul” to enrich a person’s total self – both yourself and others;
>>From time to time, I will add in “Successes” & “Stump the Shrink”
In “Successes”, I’ll share what has been working for you and others in the practice of “doing” and “being”.
In “Stump the Shrink”, I will focus on questions and dilemmas you and others face in the “real world. ” I’ll try to answer them; or perhaps I’ll be stumped for a good answer.

>> YOU CAN EXPECT THE NEXT ISSUE TO BE MUCH SHORTER.

So enough introduction. On with it!

September 2006 – Tips & Topics – september-2006

TIPS & TOPICS 
Volume 4, No.5
September 2006

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

Welcome to the September issue of TIPS and TOPICS. If you are receiving this in October, it is because we have been playing catch-up all month. Hopefully you will actually receive the October issue in October!

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July/August 2006 – Tips & Topics – julyaugust-2006

TIPS & TOPICS
Volume 4, No.4
July/August 2006

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

Welcome to the summer edition of TIPS and TOPICS. (For the Southern Hemisphere readers, it’s the winter edition). August has been a month of stimulating international travel. The rich cultural experience and still vivid images makes writing about clinical behavioral health issues an anticlimax. So this edition of TNT is going to be a version of “What I did on my summer holidays.”

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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…)

June 2006 – Tips & Topics – june-2006

TIPS & TOPICS
Volume 4, No.3
June 2006

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

Welcome to the June edition of TIPS and TOPICS (TNT). We won’t call it the June/July issue even though you are receiving it in the first few days of July. You will however receive a combined July/August edition sometime in August – as is our custom in the summer.

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July 2003 – Tips & Topics – july-2003

TIPS and TOPICS
Vol 1, No.3
June 2003

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

WELCOME!

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

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June 2003

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


SAVVY | SKILLS | SOUL | SUCCESS STORIES

David Mee-Lee M.D.


SAVVY

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

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

Tips:

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

Here are a few references for that:

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

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

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

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

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

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

SKILLS

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

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

Tips:

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

>>”Ask two old timers at an AA meeting why they think you may have an alcohol problem simply because you got two DUIs. Report back to group”. or
>> “Keep a log of all the times you are late with your curfew. See if you parents are on your back more or off your back when you are late”.

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

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

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

You can respond several ways.

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

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

A SPECIAL NOTE:

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

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

SOUL

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

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

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

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

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

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

SUCCESS STORIES

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

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

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

Until next time

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

All the best…

David

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

Learn more about the Supervisor Intensive. Click here.

August/September 2003 – Tips & Topics – augustseptember-2003

TIPS and TOPICS
Vol 1, No.5
August- September 2003

– SAVVY
– SKILLS
– SOUL
– STUMP the SHRINK
– SUCCESS STORIES
– Until next time

WELCOME!

I have been in summer vacation mode, so this August edition of TIPS & TOPICS is a little later than usual. In fact, since this is already September, I’ve decied to give myself a break and give you less mail to read. So this is now an expanded August-September edition which has the usual sections, with two additional sections that appear periodically – “Stump the Shrink” and “Success Stories”.

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October 2003 – Tips & Topics – october-2003

TIPS and TOPICS
Vol 1, No.6
October 2003

In this issue

– SAVVY
– SKILLS
– SOUL
– SHAMELESS SELLING
– STUMP the SHRINK
– Until next time

WELCOME!

A TIPS & TOPICS reader recently asked about information on adolescent treatment. I realized that many of you are working with youth and adolescents, and we have not addressed your needs specifically thus far. So for everyone who works with adolescents, or has ever been an adolescent, this edition is for you.

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December 2003 – Tips & Topics – december-2003


TIPS and TOPICS
Vol 1, No.8
December 2003

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

WELCOME!

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

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November 2003 – Tips & Topics – november-2003

TIPS and TOPICS
Volume 1, No. 7
November 2003

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

WELCOME!

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

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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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March 2004 – Tips & Topics – march-2004

TIPS and TOPICS
Vol 1, No.11
March 2004

In this issue
– SAVVY
– SKILLS
– SOUL
– Until next time

WELCOME!

Recently I was training on the ASAM Criteria. I was surprised by some fundamental misunderstandings even from people using the criteria for many years. As you may know, I have been involved with, and chaired the development of the Patient Placement Criteria (PPC) for the Treatment of Substance Related Disorders of the American Society of Addiction Medicine (ASAM) since its beginning in the late 1980’s. For those of you who do not know the ASAM PPC, these are consensus criteria that match people with substance use problems to the appropriate level of care within a broad continuum of services.

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February 2004 – Tips & Topics – february-2004

TIPS and TOPICS
Volume 1, No. 10
February 2004

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

WELCOME!

On February 11, 2004 there was a press release from Join Together- a project of the Boston University School of Public Health- that had convened a national policy panel in the summer of 2002. Their task was to address the quality of treatment for substance use disorders. The panel’s primary recommendation called for a fundamental change in the payment system for treating drug and alcohol disorders – that payment should be based on the results achieved; that purchasers of treatment services should reward results.

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January 2004 – Tips & Topics – january-2004

TIPS and TOPICS
Volume 1, No. 9
January 2004

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

WELCOME!

It is already moving towards February. I know it is clichéd to say, but I can’t believe how fast the year is racing by. I hope you are as busy (in the productive sense) as I am. But I also hope you have more balance in your life than I have at present. I have already broken my New Year’s resolution for more balance. By declaring this here I am putting myself on notice to check the balance-meter more often and more effectively.

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October 2004 – Tips & Topics – october-2004

TIPS & TOPICS 
Volume 2, No. 6
October 2004

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

Welcome readers!

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

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April 2004 – Tips & Topics – april-2004

TIPS and TOPICS
Vol 2, No.1
April 2004

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

WELCOME!

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

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June 2009 – Tips & Topics – june-2009

TIPS & TOPICS
Volume 7, No.3
June 2009

In this issue
— SAVVY
— SKILLS
— SOUL
— STUMP THE SHRINK
— SUCCESS STORY & SHARING SOLUTIONS
— Until Next Time

Welcome to the June edition of TIPS and TOPICS. I’m glad you could join us.

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May 2009 – Tips & Topics – may-2009

TIPS & TOPICS
Volume 7, No.2
May 2009

In this issue
– SAVVY
– SKILLS
– SOUL
– SHAMELESS SELLING
– Until Next Time

Welcome to the many new subscribers who joined us this month for your first edition of TIPS and TOPICS. Thanks to all who have expressed appreciation and sent along nice feedback.

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February 2009 – Tips & Topics – february

TIPS & TOPICS
Volume 6, No.10
February 2009

In this issue
— SAVVY
— SKILLS
— SOUL
— STUMP THE SHRINK
— SUCCESS STORY
— Until Next Time

Welcome to all the new readers who joined us this month and to our long-term readers as well. I understand we all receive a lot of information in our inbox each day; I appreciate your taking the time to look this edition over.

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May 2008 – Tips & Topics – may-2008

TIPS & TOPICS
Volume 6, No.2
May 2008

In this issue
— SAVVY
— SKILLS
— SOUL
— STUMP THE SHRINK
— Until Next Time

Welcome to the many new subscribers to TIPS and TOPICS (TNT). Just a reminder: there are 5 years of Back Issues you can read or download. Simply click on “Read Back Issues” on the homepage of www.DMLMD.com. Coming soon – a revamped website with a Search function to search by topic.

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March 2008 – Tips & Topics – march-2008

TIPS & TOPICS
Volume 5, No.11
March 2008

In this issue
— SAVVY
— SKILLS
— SOUL
— SHAMELESS SELLING
— As a RESULT of your FEEDBACK
— Until Next Time

Welcome to March’s Tips and Topics (TNT), especially to the many new subscribers. As usual we are running late, so this March edition will likely get to you in early April. It is after all, free, so I guess you get what you pay for!

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February 2008 – Tips & Topics – february-2008

TIPS & TOPICS
Volume 5, No.10
February 2008

In this issue
— SAVVY
— SKILLS
— SOUL
— STUMP the SHRINK
— SURVEY FEEDBACK
— Until Next Time

In February, many of you celebrated Valentine’s Day, the traditional day on which lovers express their love for each other. So this edition will take a slight twist away from the purely clinical world. Sigmund Freud talked about the need for a balance of love, work and play to be happy, healthy and content. So this month we’re all about —-love.

Also, a huge votes of thanks to the over 125 people who took the time to provide Feedback on my website (and TIPS and TOPICS, TNT). See at the end who are the three winners of the random drawing.

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