November 2022

Dr. Ken Minkoff on “Welcoming” and “Skills-based learning” when serving people with complex needs; 70th birthday and 50th wedding anniversary and Thanksgiving week

In SAVVY, guest writer and psychiatrist, Ken Minkoff, M.D., highlights the importance of designing services expecting to see people with co-occurring mental health, substance use and other complex needs. But most importantly, organizing ourselves and services in a welcoming manner in everything we do.

In SKILLS, Dr. Minkoff addresses another important principle in helping people with complex needs, what he calls “Adequately supported, adequately rewarded, skills based learning for each condition.” As simple as you may think this needs to be, it needs to be even simpler!!!!

In SOUL, I reflect on what would have been my wife’s 70th birthday, our 50th wedding anniversary. Thanksgiving Day is an opportunity for pain or joy.  I choose to make it a week of Thanks and Giving.

savvy

On October 25, I watched a live streaming of Dr. Ken Minkoff’s keynote presentation at the 2022 Minnesota Association of Resources for Recovery and Chemical Health (MARRCH) Conference. Ken is a longtime friend and colleague whom I have heard many times, but not recently. His message is still fresh and even more relevant today as it has been in years past.

I asked Ken to guest write about two highlights of his presentation that deserve more attention in serving people with complex needs: “Welcoming” and “Skills-based learning”.  The content is Dr. Minkoff’s that I tweaked to fit Tips and Topics’ format.

You can see the video of his Keynote – Integrated Systems and Services for People with Co-occuring MH/SUD on YouTube

  • If you want to hear Dr. Minkoff talk about “Welcoming” start at Minute 32.  You’ll enjoy his demonstration on what to actually say to welcome people with complex needs. 
  • To hear Dr. Minkoff talks about “Skills-based learning”, start at Hour 1.02. It’s worth hearing him explain this if you can’t listen to the whole presentation.

Tip 1

Design services in all settings with the expectation that the people you see will have co-occurring mental health, substance use and other complex needs.

It is important to recognize that people with co-occurring mental health and Substance Use Disorder (SUD) conditions (and other complex needs) are an expectation in ALL settings, so that we ALL need to be in the co-occurring “business”.   That is what is meant (and what the Amercian Society of Addiction Medicine (ASAM) is developing in the coming 4th edition of The ASAM Criteria) when we say that “all programs (SUD and MH) need to become co-occurring programs”:

  • Organizing themselves to provide the very best integrated interventions,
  • To the people with co-occurring needs they are already serving,
  • Within the resources and mission they already have.

Tip 2

“Welcoming” is not just being nice. It is organizing everything we do to have a welcoming manner towards the people you serve with all their complex needs.

What is the first step?  The first principle is to build this expectation of “co-occurring” in a welcoming manner into everything we do. After all, we are serving these clients anyway. The more we organize ourselves to welcome them exactly as they are, the better they will do, and the more fun we will have.

Welcoming however is not just about being nice. We’re all nice (at least most of the time, J).   Welcoming builds on the organized practice called “customer service”, where you learn exactly what to say (and what not to say) not just to the easy customers, but to the ones you might find more challenging.

Tip 3

Here is what “Basic Welcoming” sounds like.

So we start with what I call: Basic Welcoming:  In an SUD setting that might sound like this:  “Hi there, welcome to our program. You’re one of those folks who has lots of issues.  Not only do you have addiction, but it seems like you might be hearing some voices, you’re walking with a cane, you just lost your housing, your family wants nothing to do with you, and you’re in trouble with the law.  

You know you’re the kind of person we most love to be engaging, because you’re the kind of person who might be having the hardest time. We know it couldn’t have been easy for you to show up here today. Thank you for coming. 

You’re in the right place.  We’re glad you’re here.  We know our job when we meet you is not to control you or perfect you or refer you…..Our job is to get to know you, inspire you with hope, and help you connect to us and trust us, and anyone we find along the way, to help you with all your issues so you can have a happy, hopeful, beautiful life.”

Nothing in that speech is rocket science: What we ask ourselves is: How well organized are we by policy, procedure, and practice so that when folks like this come to our door, everyone knows that’s what they are supposed to say, saying it from the heart looking people right in the eye.

Tip 4

Consider now “Intermediate Welcoming”.

What intermediate welcoming looks like: 

  • What if we had a rule that said we never trash talk about the people we’re serving, based on their comorbidity, or anything else for that matter, even when they are not listening…..any more than we would use racial slurs behind people’s backs.  
  • We all know how easy it is when we’re frustrated to start labelling people as “sociopathic, borderline, med-seeking, manipulative.”  
  • Sometimes we write it in the chart, and we’re amazed that the person acts like they don’t want to work with us.  

How we frame people in our minds affects how we are with them, and how they are with us.

Tip 5

What is “Advanced Welcoming”?

Finally, here’s what we might call Advanced Welcoming:  

  • What happens when someone comes to us reporting symptoms we wish they didn’t have?  What if someone in our SUD program tells us they are can’t go to group because they are having trauma flashbacks, or hearing voices?  
  • What if someone in our SUD program (or any program) comes to our door smelling of alcohol and unsteady on their feet?  How do we make it our most important business in that moment to have that person feel really happy that when they were in crisis they had the good sense to come to the people who are paid to help them.
  • The opposite of “Advanced Welcoming” is to think our job is to tell them that they belong somewhere else; or their behavior is inappropriate and we need to get them out of there as soon as possible, when they are likely to land in jail, or on the streets or worse.

skills

Another important principle in helping people with SUD and other co-occurring and complex needs is what we call “Adequately supported, adequately rewarded, skills based learning for each condition.” That principle is much simpler than it sounds.

Tip 1

Our job is not just to tell people what to do, and ask them to promise to follow our recommendations.

Do you promise to be med compliant?”.

  • Success as treaters is more than just telling people the rules and creating consequences if they don’t follow them.  
  • After all, if they all knew how to do all this already, they probably wouldn’t have to be in our program.  
  • Or to put it another way, if everyone we admit follows all our rules, we are admitting the wrong people.

Tip 2

Teach people the skills they need to succeed for each condition.

Our most important job in treatment is to combine our recommendations with TEACHING PEOPLE THE SKILLS THEY NEED TO SUCCEED FOR EACH CONDITION. There are four types of skills that apply for both SUD and MH: 

  • Self-management skills for taking medications.
  • Self-management skills for managing cravings and symptoms. 
  • “Asking for help” skills for taking medications (working with your prescriber).
  •  “Asking for help” skills for managing cravings and symptoms (from peers, family/friends, or professionals).

It’s not just: “don’t drink, go to meetings, ask for help” for people with addiction. 

  • It’s how do you develop the skills to not use when everyone in your environment is offering to share drugs with you, and you are lonely and depressed?  
  • What do you do when you go to 12 Step meetings – do you talk about your mental health meds, or not?  
  • How do you ask for help when you’re having a hard time?  

Similarly, for people with mental health needs:

  • How do you learn to take your meds as prescribed, even when your friends want to borrow them?  
  • How do you work with your doctor as a partner, not a supplier? 
  • How do you ask for help to manage your MH symptoms when they are scary and you feel ashamed?

Tip 3

Teaching people skills, particularly when they have co-occurring challenges, is not just giving a lecture.

Teaching skills to people who have co-occurring challenges, is about:

  • “Structured and supported” learning in small steps – practice, role play, and repetition. 
  • It’s showing people what to do and helping them to do it, whether in 1-1 or group.  
  • Further, it’s about rewarding progress not punishing failure, as the best practice for teaching.  A round of applause for ONE DAY of success in learning any new skill, just like you get a round of applause from a room full of people for being sober just one day (or even less).

Tip 4

As simple as you may think the skills teaching needs to be, it needs to be even simpler!!!!

To guide us in how simple this needs to be, there are Skills Manuals we can use. I recommend because it teaches simplicity “Overcoming addictions: Skills training for people with schizophrenia” – By Thad Eckman, Ph. D., Lisa J. Roberts, Andrew Shaner, M.D.

This is a skills manual that is not just for people with schizophrenia but for everyone who is having trouble with new skills, which is just about everyone. 

  • Ten pages on how to refuse drugs offered by a friend. 
  • Ten pages on how to refuse drugs offered by a dealer.  For example When you see the dealer, walk fast. Don’t smile. Don’t start a conversation.  If the dealer offers you drugs, don’t say yes – say these other things. If the dealer gives you a freebie don’t put it in your pocket; throw it to the ground and walk away quickly.
  • The manual provides guidance for both 1-1 skills training and for role playing in groups. Lots of fun either way.   

When you read this, it seems simple minded, but these authors are experts. What are they teaching? – As simple as you may think this needs to be, it needs to be even simpler!!!!

Brief Bio – Kenneth Minkoff, M.D.

Dr. Minkoff is Vice President and Chief Operating Officer Senior at ZiaPartners, Inc., a behavioral health system consultation firm in Tucson, AZ.  He is Board-Certified as an addiction psychiatrist and community psychiatrist.  

The vast majority of Dr. Minkoff’s work (with Dr. Cline, as ZiaPartners, Inc.) relates to helping systems reorganize themselves within limited resources, at every level, to better meet the needs and inspire the hopes of individuals and families with complex and co-occurring issues that need help. 

soul

As I write this today, November 20, we would have been celebrating my wife’s 70th birthday.  In 20 days time, the celebrations would have continued for our 50th wedding anniversary…..yes, we married quite young in those days and even younger by today’s mode. In February, I updated readers on my grief process three years after losing my wife to a sudden illness.

So today is a day of memories of so many birthdays and anniversaries together.  It is not a day of morbid grief or deep pain, but in this week of Thanksgiving, a grateful looking back at the decades of companionship, family-building and fun travel. I and my three children are thriving and our close connection and communication sustain us.  We live as if Marcia is still with us….just not in the ‘physical’.

In the USA, Thanksgiving Day is a prime time for families to be together, whether that be your biological family or your family of choice.  For some, there will be mixed feelings and emotions. For others, full joy and connection. Whatever it is for you, may I suggest that by the Law of Attraction, you will get more joy out of the time together if you focus on any happy times and memories together rather than on your differences, resentments, hurt and pain. 

It’s not about being fake – there must have been a couple of happy times to reminisce about. It is not a time to discuss: 

  • “Fake news” or the midterm elections; and winners and losers.
  • How they always favored your sibling over you.
  • Why do you have that girlfriend or that boyfriend; or why don’t you have a partner or children or a job or….
  • The economy, culture wars, banned books in schools, Pro Life or Pro Choice, red or blue states and Presidential candidates.

Check out this 3 minute YouTube by Kyle Cease How Enlightened Families Argue.  It will give you some tips (not really).  But it might lighten your mood.

So for today and this week, I will remember the happy times together, knowing that more and more of those memories will show up making this week truly a week of Thanks and Giving.



October 2022

Clients who don’t want inpatient treatment – What to do; Individualized, accountable care; Right turns on red.

In SAVVY, STUMP THE SHRINK and SKILLS, Amber asks a couple of questions about what to do when clients are recommended for inpatient treatment but decline and only want outpatient services. This edition explores how to meet the client where they are at, but also hold them accountable to the outcomes of whatever plan they agree to work on, even in outpatient services.

In SOUL, I am grateful for the “Right turn on red” law and ponder why we can’t have an “everybody wins” attitude to lots of challenges and problems.

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September 2022

Brief But Spectacular take on telling the whole story; Solutions Journalism; COVID and Things are always working out for me.

Welcome to the September edition of Tips and Topics from Australia.

In SAVVY, watch David Bornstein make the case for Solutions Journalism to activate people to be powerful players in a participatory democracy.

In SKILLS, be part of telling the whole story, not just focusing on the problems. “It is as if your parents were always criticizing you about what you were doing wrong and never letting you know where you have possibilities to grow.”

In SOUL, I have adopted more robustly the attitude of “Things are always working out for me”. A number of events on my Aussie trip would seem to contradict that. But as I reflect on the events midway through my trip, and my week of COVID, I’m sticking with my story.

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August 2022

Jaclyn’s story about a mother and son in her own words – Applying the therapeutic alliance to any relationship; What is ‘young’ anyway?

In SAVVY, SKILLS, SHARING STORIES & SOLUTIONS, I depart a little from our usual format to let you enjoy and learn from a mother’s story about how she applied the principles and practices of the therapeutic alliance to restore her relationship with her son. Not only did it rebuild the relationship but it empowered Leo to reach his full potential.

In SOUL, I am choosing to focus more on the joy of living than on my biological age. Even though I hit 73 this month, I don’t feel anywhere near that. How about you?

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July 2022

How smart are you about SMART Recovery and its Family & Friends Program? Wisdom on coming together from social media

In SAVVY, we all know about AA and other 12-Step programs. But Joe Gerstein, Founding President of SMART Recovery, gives us an update on this complementary alternative community mutual assistance organization started in 1994.

In SKILLS, Joe explains how SMART Recovery runs and what skills and goals are the focus; as well as how the Family and Friends Program is integrated with CRAFT [Community Reinforcement And Family Training].

In SOUL, I share some of my favorite quotes and images from social media that helped me think about how to come together in an era of division and information bubbles.

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June 2022

Helping families with addiction – Residential treatment is not the gold standard; Intervention, Tough Love or CRAFT?; Exercise training is hard work. How do those athletes do it?

In SAVVY, STUMP THE SHRINK and SKILLS, I share a colleague’s request for recommendations for a residential program on behalf of a family affected by addiction. The family wanted their son in long-term residential treatment. But is residential treatment the gold standard? We have to use the whole continuum of care to give long-term, life long addiction treatment if necessary.

What should be done for a son who the parents are financially supporting and who doesn’t follow through with treatment?

In SOUL, I recently started strength and core exercise training. Better late than never, but it is hard. I have a new found admiration for all those athletes who workout everyday to reach their peak performance

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May 2022

Pandemic Parenting: Do you have Parental Burnout?; Strategies to help with Parental Burnout; 13 million pounds of discarded soap.

In SAVVY, an online survey of 1,285 working parents was conducted between January 2021 and April 2021. Earlier in May, the researchers from Ohio State University published their report, Pandemic Parenting: Examining the Epidemic of Working Parental Burnout and Strategies to Help.

In SKILLS, after describing what Parental Burnout is, the report went on to provide some strategies to help parents deal with burnout. So whether you are a parent yourself, or helping parents cope, the report has strategies for you.

In SOUL, In 2008, Shawn Seipler was staying at a hotel in Minneapolis and wondered what happens to all the unused hotel room soap? This got me thinking about what would be the ‘wasted hotel soap’ of the healthcare industry? What better systems could we build that could save as many lives as 13 million pounds of discarded soap?

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April 2022

My three career bridge-building targets; Where to start in helping people change; 50 years for Elon Musk and me.

Welcome to the start of my 20th year of writing Tips and Topics. The first edition was published April 2003.

In SAVVY, this edition of Tips & Topics begins the 20th year of publication. I look back at what I’ve written before in three areas of bridge-building: Addiction as an illness – the general public and health care in general; Addiction and mental health – Co-Occurring Disorders; Justice and Treatment teams.

In SKILLS, it requires skillful bridge-building to attract people into lasting, accountable change, and cross the bridge from expecting compliance to treatment to collaborating in person-centered care planning: Start with what the person is at Action for, not what you are at Action for; Hold the participant accountable to their goal and track their engagement, good faith effort and outcomes.

In SOUL, this year is 50 years since I graduated from medical school and started my career. See my ASAM Educator of the Year award photo and video bio. Elon Musk is 50 years old. I’ve had a good career, but find out what drives Elon and what someone who was one year old when I started my career has achieved.

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March 2022

What to report to Probation and CPS; Dilemmas about drug testing; Client-centered doesn’t mean client anarchy; Win, lose and win

In SAVVY, SKILLS and STUMP THE SHRINK, treatment providers can be confused about their role when clients are referred by Probation, Child Protective Services and other mandating agencies. Focus on improved function and skills, not compliance with assignments and phases in a pre-determined program. How to be “client-centered”.

In SOUL, increasingly I make no distinction between ‘wins’ and ‘losses’. A ‘win’ is an opportunity to discern what works and what doesn’t; and a ‘loss’ is an opportunity to discern what works and doesn’t.

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February 2022

What I didn’t know about growing up Black in America; I thought I pulled myself up by my bootstraps, but….; the 3 year anniversary of losing my wife.

In SAVVY, I learnt a lot from three African American young people. I was aware of some of their experiences but others were totally new to me. Rethinking the terms “microaggressions” and “cultural competence”.


In SKILLS, being person-centered and focused on the individual in their social context addresses siloed initiatives and projects. I thought I pulled myself up by my own bootstraps. But a look at my generational history exposed the myth of meritocracy.

In SOUL, it is three years since the sudden loss of my wife. Current thoughts on my process in Work, Love and Play.

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January 2022

Could you learn something from Buddha? Check out some of his quotes and how to apply them; Using joy to focus on where to put my energy.

In SAVVY and SKILLS, Suzan Dalia shares Quotes by Buddha that will change the way you think….if you apply them. She suggests some ways to apply them.


In SOUL, anything or anyone who doesn’t bring joy to your life; and doesn’t think you are a joy in their life, doesn’t deserve your time or energy.

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December 2021

“Rat Park” and Vietnam – research focuses on the role of environment in addiction; Assess people’s social environment; Educator of the Year Award

In SAVVY, two research studies from the 1970s remind us of the role of the environment in the development and continuation of addiction. Access Michael Pollan’s episode on Science Friday to hear about three plant-based compounds from the three major categories of psychoactive drugs– uppers, downers, and what he thinks of as outers.

In SKILLS, do you focus on your clients’ families, their social communities, their sources of human contact and support? Assessing their social environment is as important as their mental and physical health assessment.

In SOUL, David Mee-Lee, MD, DFASAM, Named ASAM’s Educator of the Year. What that means and how it feels.

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