September 2023 – Vol. #21, No.6

Welcome to the September edition of Tips and Topics and National Recovery Month.

In SAVVY, a guest writer shares her recovery journey and the role of processing trauma in moving into true joy.

In SKILLS, Leah highlights tools and treatment models that are working for her as she explores practices for dealing with intense emotions in healthier ways.

In SOUL, recovery is a process, not an event. In fact, it is a relationship process – a relationship with yourself and others. Leah shares some heartfelt insights she has discovered over the past year.

David Mee-Lee, M.D.
DML Training and Consulting

SAVVY

September is National Recovery Month “to promote and support new evidence-based treatment and recovery practices, the nation’s strong and proud recovery community, and the dedication of service providers and communities who make recovery in all its forms possible.”

In SOUL two years ago, Katie shared her heartfelt recovery story.

This month, Leah has agreed to share her wisdom garnered not just from her lived experience, but from her passion for training, speaking, writing, and researching at the nexus of trauma, behavior change, and the legal system. She comes from a professional background in education and the courts. Leah is a Statewide Treatment Court Coordinator who focuses on coordinating training and education for over seven hundred multi-disciplinary professionals.

The behavioral health and justice services fields are increasingly savvy about the role complex trauma, event trauma, interpersonal trauma, intergenerational trauma, Adverse Childhood Experiences, brain injuries, and systemic oppression play in the development of and recovery from addiction, mental health challenges and involvement in the justice system. Over the past year, Leah and I have collaborated on exploring questions like these:

• What is the balance between digging deep into past trauma and continuing counterproductive coping adaptations and focusing on living joyously and optimistically in the present?

• If trauma (in the broadest sense) is baked in on a cellular level affecting people’s fight or flight triggering responses, what is the mix of psychotherapy, body work and corrective experiences needed to allow a person to live unshackled from the past?

• How can a person with a history of trauma cultivate peace when there are physical, emotional, social and spiritual challenges swamping them?

Leah recently summarized some of her conclusions to such questions. The content in SAVVY and SKILLS is Leah’s. I have edited and formatted it in collaboration with her to fit Tips & Topics. Leah also shares from her heart in SOUL.

If you would like to contact Leah, this is her e-mail: leahelsbernd@gmail.com 

Tip 1

To achieve joy and serenity in the Here & Now, there is no getting there without processing the trauma.

The most important thing I've learned in the last year regarding the role of processing trauma in moving into true joy is that there is no escape hatch, no magic switch, no bypass. The only way out is through.

Once I emerged from decades of absolute denial, I still continued to try literally every single strategy available to me short of hard drugs, cutting, bulimia, and suicide to avoid dealing with my actual emotions, including rigid hardcore positive focus.

Ultimately, I learned that when trauma is baked in on a cellular level affecting a person’s fight or flight triggering responses, those most deeply suppressed and painful emotions have to be processed compassionately by the self, ideally in the company of a skilled therapist. This allows reintegration of disowned and exiled parts of oneself and a shift into authentic peace and joy to occur naturally.

When we try to convince ourself that I am or should be feeling joy and peace when you really don't feel that, this is brainwashing ourselves. It can become just another mechanism to bypass having to process these painful emotions, which are the true drivers of compulsive avoidance behaviors.

Tip 2

Awareness of one’s knee-jerk reactions to triggers is a first step in processing trauma.

A sense of self-trust and internal safety may take a long time to develop, as one becomes aware of their knee-jerk reactions in response to triggers. Early on in their recovery processes people often don’t realize that they even have choice in how they respond to their triggers; or that they’re even having a trauma-response.

As this awareness grows:

  • Self-shaming atrophies, and skills for diffusion, redirection, and naming those triggers develop. 
  • Only then can someone begin to truly connect with others in relationships.
  • Only in developing safe relationships to oneself and others can real healing start to happen.

Tip 3

For helping professionals to effectively facilitate their clients move towards joy, an important responsibility is to do their own internal work.

  • They can model self-compassion and self-emotional and experiential validation to clients who are struggling.
  • They can feel and show their clients genuine care, compassion, and unconditional acceptance.
  • They can meet their clients where they are with their support, resources and services.
  • I believe the most important responsibility helping professionals have in helping clients move towards joy is to first learn self-compassion and to validate one's own experiences and emotions. When helpers do their own internal work:

SKILLS

Leah goes on to offer some SKILLS Tips to process trauma.

Tip 1 

Use a variety of tools and treatment models to address the biopsychosocial impacts of trauma.

Meditation, Journaling, Internal Family Systems, Somatic Processing, acupuncture and Eye movement desensitization and reprocessing (EMDR), have all been powerful tools in my personal healing journey.

Without being prescriptive, meditation in any form (sitting silently, guided, moving) helps one feel their greater connection to everything in existence. It helps you witness your mind as it goes about its important daily work of trying to keep you safe and alive, helping to dispel the myth that “I am my mind.”

Journaling or reflective writing is a powerful tool for many people who can best organize and make sense of their observations of their own mind and their experiences by cataloging and synthesizing them on paper. However it is accomplished, self-reflection without judgement is the key beneficial factor.

Internal Family Systems, Somatic Processing, and EMDR are all more in depth treatment modalities that I encourage you to explore more deeply. They are supported to aid in the healing of trauma by extensive research, but each warrant a more in-depth discovery process than can be undertaken here, should the interest arise in you.

Tip 2

Healthier practices for dealing with intense emotions may build slowly at first, but the momentum does eventually lead to an exponential progress curve over time.

Along the way, while attending to this deep work, there is an absolutely critical need for:

  • Practicing positive psychology.*
  • Developing awareness of your triggers.
  • Directing one's focus deliberately towards what you want in life.
  • Moving steadily towards a healthier lifestyle.

But it's also critically important that these practices:

  • Do not themselves become mechanisms for bypassing painful suppressed emotions.
  • Do not help the person continue to stay in their fantasy rescue thinking, which is a habitual/residual protective adaptation that was developed in response to feeling completely powerless at the time(s) they experienced trauma as a child.

Momentum in learning to utilize healthier practices for dealing with intense emotions may start to build excruciatingly slowly. But it's been my experience that the momentum does begin to compound eventually, leading to an exponential progress curve over time.

* “Positive psychology is a scientific approach to studying human thoughts, feelings, and behavior, with a focus on strengths instead of weaknesses, building the good in life instead of repairing the bad, and taking the lives of average people up to “great” instead of focusing solely on moving those who are struggling up to “normal” (Peterson, 2008).

SOUL

I am not recovering from a mental or addictive disease. But as the joke goes, I am a recovering psychiatrist in long term recovery from the stereotypical medication-prescribing MDeity. In fact, I have been accused of being a social worker not a psychiatrist.

Social Workers are taught to be more person-centered and to understand people in the context of social, economic and cultural institutions and interactions. Psychiatrists are only just beginning to pay more attention to social drivers and determinants of health.

A lot of what I learnt about Recovery came from on-the-job training with addiction counselors in long-term recovery when I was assigned to an inpatient addiction treatment team. I was assigned to that team not because of my exquisite knowledge about addiction, but because they couldn’t get anyone else to work on that team.

Recovery is a process, not an event. As Katie wrote in her recovery story, her path into and through recovery involved relationship with others and with herself. So Recovery is a relationship process.

Leah shares some heartfelt insights she has discovered over the past year. They could help you and/or those you serve.

“Only in developing safe relationships to oneself and others can real healing start to happen. Finally, as this happens, and the internal compass is gradually reoriented to it being safe to feel good in oneself, in relationships, and in the world generally, true vibrational shifts begin to occur, and thereby changes in one's frequencies of attraction begin to occur.”

What I hear Leah saying as I ponder the hours of collaboration we have had on the recovery process is this:

  • Recovery is a personal and an interpersonal healing process.
  • This takes honest, sometimes tumultuous exploration of trauma to know that you are safe in just being your authentic self and in relationships and the world.
  • As that personal and interpersonal safety grows in recovery, you experience real shifts in outlook and attract more and more joy, peace and optimism.

Leah goes on:

“As a result of my personal journey, I believe there is only one faith needed for inner peace; the faith that you will not abandon yourself emotionally ever again, no matter what emotions you feel; that ALL parts of you are acceptable and that your WHOLE self is inherently worthy of unconditional love. This radical self-acceptance blooms over time into emotional self-efficacy and authentic present-moment experiencing of good feeling emotions without fear of "the other shoe" dropping all the time. I believe that this deep inner peace is foundational to being able to experience true and lasting joy.”

Couldn’t have said it better myself.

Until Next Time

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

David

August 2023 – Vol. #21, No.5

Welcome to the August edition of Tips and Topics and to all the new subscribers.

In SAVVY, I recommend you watch William Miller highlight the What and Why of some of the new changes in Motivational Interviewing (MI). I highlight how MI helps you be a more effective agent in helping people change and grow.

In SKILLS, listen to Scott Miller on Mike McGee’s podcast talk about how to use feedback to identify where you might need a coach rather than an overall supervisor. The coach is expert in a particular skill that feedback measurement has identified you as falling short.

In SOUL, Dr. James O. Prochaska, a pioneer in the field of psychology who revolutionized the science of behavior change died on July 9, 2023, at the age of 80. How do you say good-bye to such an icon?

David Mee-Lee, M.D.
DML Training and Consulting

SAVVY

Motivational Interviewing (MI) has had a huge impact not just initially on the addiction treatment field but increasingly on general healthcare and even in fields beyond healthcare. The first edition was published in 1991 and the 4th edition, “Motivational Interviewing - Helping People Change and Grow” is just out now this month. Who better to give an overview of the major changes in this new edition than William Miller, Ph.D., co-author with Stephen Rollnick.

You can watch (I highly recommend it) that free webinar if you go to The Change Companies website, click on Webinars and you will see the MI webinar and also one on the upcoming new 4th edition of The ASAM Criteria. (An interesting bit of trivia is the the first edition of The ASAM Criteria was published also in 1991 and both MI and The ASAM Criteria’s 4th editions are out this year too).

You can also go directly to the MI webinar. 

Dr. Miller started with the What and the Why of changes in the 4th edition. But I was especially interested in his information on what the research says about what it takes to be an effective therapist. Then he showed how MI overlaps with those characteristics and supports the development of those skills.

Tip 1

The therapist’s skills affects the outcomes of treatment far more significantly that what therapy model you believe in and practice

At minute 18:44 of the webinar, Dr. Miller summarized research on outcomes and comparisons between different schools of therapy. He said:

  • It is now well documented that when "different" bona fide therapies are compared with each other, there is usually no clinically meaningful difference in client outcomes.
  • Whereas therapists' outcomes do vary significantly.
  • Therapist factors account for far more variance in outcome than do treatment methods.

In other words, you may think your favorite model of therapy is far superior to someone else’s model of care. But actually there’s not a lot of difference. The real difference depends on what the therapist is good at, not what model they are using.

Reference: Wampold, B. E., & Imel, Z. E. (2015). “The great psychotherapy debate: The evidence for what makes psychotherapy work” (2nd ed.). Routledge.

Tip 2

These therapist factors and skills determine who does better in treatment.

At minute 19:44, Dr. Miller reviewed the therapist factors that are responsible for who does better in treatment. Here are the clinical skills that the research says really matter:

  1. Accurate Empathy
  2. Positive Regard
  3. Genuineness/Congruence
  4. Acceptance
  5. Focus
  6. Hope
  7. Evocation
  8. Offering Information and Advice

Reference: William R. Miller & Theresa B. Moyers (2021). “Effective Psychotherapists – Clinical Skills That Improve Client Outcomes” Routledge.

Tip 3

Motivational Interviewing overlaps and supports the therapist factors that make for more effective ouctomes in helping people change and grow.`

At minute 20:36, Dr. Miller explains what key elements and foundational concepts of MI overlap with the essential therapist factors effective in helping people change.

  1. Accurate Empathy - Foundational in MI
  2. Positive Regard - Affirmation
  3. Genuineness - Not emphasized before 4th ed.
  4. Acceptance - Key element of MI spirit in MI
  5. Focus - Focusing is a key process
  6. Hope - Evoke hope, support self-efficacy
  7. Evocation - Evoking is a key process in MI
  8. Information/ Advice - Included in MI

Tip 4

Motivational Interviewing helps you do better in whatever treatments and models of change you are using, both inside and outside of healthcare.

At minute 23:14 Dr. Miller explains that MI is not meant to be done instead of other treatments. It cuts across all kinds of treatments and helping models. In fact, while it started in the addiction treatment field, it is now commonly combined with other treatments as a way of doing whever else you do.

At minute 25:17, Dr. Miller reviewed all the ways MI is a way of doing:

  • Cognitive behavior therapy
  • Health care
  • Diabetes and nutrition education
  • Preventive dentistry
  • Social work
  • Case management
  • Probation supervision
  • Sports coaching
  • Education
  • Leadership

SKILLS

Last month I reviewed several issues to do with Feedback Informed Treatment (FIT). As it happened, my friend and colleague Michael McGee, M.D. also focused on FIT in his July 29, 2023 podcast with Scott Miller (no relation of William Miller, but one of a handful of mentors who have taught me so much).

So in addition to the William Miller webinar, I highly recommend listening to Dr. McGee’s interview with Scott Miller, Ph.D. There’s even a transcript of the interview so you can read and listen and not miss a thing. Mike McGee summarizes below some of what he discussed with Scott Miller, but better to hear it from “the horse’s mouth” on the podcast. (I have re-formatted what Dr. McGee wrote and put it in Tips & Topics format.)

FIT began about 30 years ago, like Motivational Interviewing. Most clinicians actually decline in efficacy over the years. More education doesn’t help. What helps to improve outcomes is getting feedback. But not just getting feedback, but actually doing something with the results. Discussing the results with clients.

Tip 1 

To improve your clinical skills, get a coach who can help you with repeated deficits in your practice that you may be blind to.

There is a psychological tendency towards complacency when we reach a certain level of proficiency, a tendency to “let it be.” To becomes clinical masters, we need to counter that tendency. By intentionally getting feedback, we can identify non-random errors in our practice that we may be blind to.

What deliberate practice requires is not supervision, which has not been shown to improve outcomes, but a coach; someone with skills that can help you address identified deficits. The way to find a coach is to be proactive and reach out and ask experts who you feel might be able to coach you.

Tip 2

You don’t need an overall supervisor. You need a coach who is expert in a particular skill that feedback measurement has identified you as falling short.

There is the need for deliberate practice, which can be difficult. This requires dedicated time. Therapy time is not necessarily practice time, it is a performance. Deliberate practice might be working with a coach to practice a particular skill, such as empathy, trying it in a practice session with your coach, and getting feedback on your work from your coach, and then trying it again. It is intentional, focused work to hone specific clinical skills that are identified from client feedback.

Here’s what Scott Miller says:

“What deliberate practice requires is a coach. A good model for this is to look to Olympic athletes because most of these elite athletes don't have one overall coach and they don’t pick them from a pool of potential coaches. Instead, championship figure skaters have an equipment coach, a dance coach, a choreography coach, an upper body strength, a lower body strength coach. They have people who specialize in areas that may be in need of improvement. And therapists also need that.

We don't need an overall supervisor. You don't need the best supervisor. You need someone who is an expert in the area in which you evince shortcomings. And that means measurement.”

SOUL

About 7 years ago, I was at a conference where a trainer was talking about Motivational Interviewing and the Transtheoretical Model of Change. We were instructed to do a “real-play”, not a role-play, with an attendee seat mate.....“real-play” as it needed to be a subject that was real for us in our lives. I happened to be sitting near Jim Prochaska so we were it. I did a real-play with “Dr. James O. Prochaska, a pioneer in the field of psychology who revolutionized the science of behavior change and who died on July 9, 2023, at the age of 80.”

That was one of the last times I saw him up close and personal. I don’t think he would mind my telling you that he was at Action Stage of Change for eating more vegetables and staying healthy so he could be with his grandchildren for as long as possible.

How do you say good-bye to an icon whose work transformed the way I and thousands of other people approach addiction treatment, smoking cessation, weight management, and many other areas of behavior change? I say you say good-bye by:

  •  Embodying in our own lives the compassion, respect, humility and leadership that Jim Prochaska represented.
  • Carrying on the spirit and specifics of the Stages of Change Model that he and Carlo DiClemente championed.
  • Striving to attract more people into behavior change not by coercion, disempowering and demanding compliance but by meeting people where they are at in their various stages of change.

Jim Prochaska, Bill Miller and Scott Miller are mentors and leaders who revolutionized my knowledge and skills for the better. Two of them I can still say “thank-you” to their face. One of them, I wished I had.

Until Next Time

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

David

July 2023 – Vol. #21, No. 4

Welcome to the July edition.

In SAVVY, STUMP THE SHRINK and SKILLS, a reader asks about my thoughts on Feedback Informed Treatment (FIT). It reminded me of how far behind we still are from the rest of healthcare’s Measurement-based Care practices. Check out Jim Walt’s entertaining and informative keynote presentation about golf and what it has to do with Feedback-Informed Treatment (FIT).

In SOUL, I share another joke-with-a-message from Funsteria about cutting off the end of the ham before baking it. How often do you do something because that’s the way it’s always been done?

David Mee-Lee, M.D.
DML Training and Consulting

SAVVY, STUMP THE SHRINK and SKILLS

Earlier this month, Delilah, a student at the Hazelden Betty Ford Graduate School of Addiction Studies, asked me my thoughts on several issues to do with Feedback Informed Treatment (FIT). Her questions have broader implications for the area of Measurement-based care of which FIT is a premier example and method. Here are her questions:

In the Hazelden class we are taking now, we are discussing Feedback Informed Treatment (FIT) surveys. Do you have anything you have written, or have an opinion on Session Rating Scale (SRS) and Outcome Rating Scale (ORS) surveys.

I think surveys are impersonal and generally can be ineffective.

When it comes to counseling and a good therapeutic alliance, isn't asking for feedback by the counselor of the client, better done when the timing is right and in person?

In a person centered approach, wouldn't asking for feedback on how the alliance is going be a natural thing to discuss and get live feedback?

A lot about the surveys seem like a mediocre way to collect feedback, from what is a very personal, often sensitive relationship.

I just wanted to check and see what you thought.

Thank you in advance.

Delilah

Delilah Mahl
Graduate School Student
Hazelden Betty Ford Graduate School of Addiction Studies
Email: DMahl@hazeldenbettyford.edu

Tip 1

Hear Scott Miller, Ph.D. briefly explain FIT and the FIT Alliance Stool. His work has for years changed my whole understanding of measurement and outcomes-driven care.

Go to scottdmiller.com, scroll down to Scott’s most informative FIT TIP 4 minute video. He introduces FIT, ORS and SRS and the FIT Alliance Stool - Improving Outcomes for “at risk” Clients: The FIT “Alliance Stool” April 11, 2023

The FIT Alliance Stool highlights:

The “What?” – Goals, Meaning or Purpose
The “How?” – Means or Methods
By “Whom?” – Client view of the bond and role of the helper
With “Whom?” – Client preferences, values, identity, culture/worldview

Tip 2

Focus on Treatment Outcomes Measured in Real-Time to Guide Treatment.

Delilah said: “When it comes to counseling and a good therapeutic alliance, isn't asking for feedback by the counselor of the client, better done when the timing is right and in person?  In a person centered approach, wouldn't asking for feedback on how the alliance is going be a natural thing to discuss and get live feedback?”

You would think asking for feedback would be a natural thing to discuss; and yes, getting live feedback is the way to do it. The ORS and SRS are indeed done “live” but the timing is at every session in outpatient therapy and every week perhaps in residential settings.

If you provide counseling or therapy, how often has this happened to you?

  • You thought you had a good session with a client, pointing out insightful self-defeating patterns with therapeutic brilliance, only to have them miss the next session or even drop out of treatment?
  • The client sits passively in sessions and you feel like you are doing all the work to get them to talk.
  • The client wants to see you, but they don’t seem to be making much progress or change in their life. You wonder if you have just created a dependent relationship where you are a paid friend?

Whatever real-time feedback mechanisms you use, the goal of such measurement-based care is to guide treatment in the here and now and hopefully avoid these common clinical dilemmas.

So getting live feedback is not left to when the timing is right, but rather a deliberate and routine process at every session. When you accumulate trend data on how the client is doing and the quality of the therapeutic alliance, you can be proactive about what to change in treatment to minimize dropout, increase engagement and improve outcomes.

With treatment of chronic illnesses, changes to the treatment plan are based on treatment outcomes and tracked by real-time measurement at every visit (e.g., blood pressure or blood sugar levels are monitored to determine the success of the current treatment regimen).

It should be no different with behavioral health treatment. How do you know if the client is engaged in a good therapeutic alliance and improving if you don’t actually measure and track the alliance and outcomes?

Tip 3

Practice without real-time feedback is like hitting golf balls and not tracking where they land.`

Ten years ago, in the August 2013  edition, I wrote about this TIP and the importance of real-time feedback to know if what you are doing with clients is effective or not. At the 2013 Annual Conference of the California Association of Marriage and Family Therapists (CAMFT), Jim Walt, a licensed Marriage and Family Therapist, gave a keynote presentation about golf and what it has to do with Feedback-Informed Treatment (FIT).

It is worth watching his entertaining and informative 15 minute presentation.

A few of his points:

  • If your clinical practice is not focused with purpose, you may feel like you are doing good work, but without feedback, you don't really know if you are being effective.
  • When you drive the golf ball, you need immediate feedback on how close you came to the 3 feet circle of the hole; or how far away you were from the 145 yard mark.
  • Based on that real-time feedback, you can know whether you have to apply more force, a better angle or adjust your grip on the golf club to hit your mark.
  • Hitting golf balls with no feedback is meaningless practice if the goal is to be effective and purposeful.
  • Jim Walt talks about how we should relish getting feedback from the client on whether the session we just had hit the mark or not.
  • Even better, candid feedback on how the session was not helpful provides the information the therapist needs to know how to adjust things for the next session.

Tip 4

Questionnaires and client surveys after the fact of treatment are inadequate to measure outcomes and effectiveness of your services.

Delilah said: “I think surveys are impersonal and generally can be ineffective. A lot about the surveys seem like a mediocre way to collect feedback, from what is a very personal, often sensitive relationship.”

I agree. I don’t know if treatment and service providers are still sending out surveys after a person “completes” treatment, asking them a variety of questions about the facilities, staff, food, programming and treatment experience.

If you really want to know how your services are experienced by your clients, the only effective way to have actionable data is real-time feedback and measurement-based care. Based on the immediate feedback – good, bad or indifferent – you now have a chance to collaborate on real-time changes to the treatment and service plan and enhance the therapeutic alliance and results.

SOUL

I have written before about my daily ritual to see what joke Funsteria has come up with to make me laugh. In March 2023, I shared a joke about the bear, wolf, fox and rabbit. If you missed it, take a look because it has a great lesson for your clients.

This month, I have another joke-with-a-message from Funsteria.

A young woman was preparing a ham dinner. After she cut off the end of the ham, she placed it in a pan for baking. Her friend asked her, “Why did you cut off the end of the ham”? And she replied ,”I really don’t know but my mother always did, so I thought you were supposed to.”

Later when talking to her mother she asked her why she cut off the end of the ham before baking it, and her mother replied,”I really don’t know, but that’s the way my mom always did it.”

A few weeks later while visiting her grandmother, the young woman asked, “Grandma, why is it that you cut off the end of a ham before you bake it?”

Her grandmother replied ,”Well dear, otherwise it would never fit into my baking pan.”

How often do you do something because that’s the way it’s always been done? When it comes to being more effective in our work with clients, it’s time to do something different.  Actually ask clients, in real-time, at every session if what we are doing with them is a good fit for them; and if it is working for what they want?

If you don’t ask, you are likely doing the same thing because that’s the way it’s always been done.

Until Next Time

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

David

June 2023 – Vol. #21, No. 3

Welcome to the June edition.

In SAVVY, STUMP THE SHRINK and SKILLS, a reader asks about my thoughts on what stage of change people are who go into treatment. He somewhat disagrees with what he heard at a training: “Rarely will you see a person come into treatment in the Preparation or Action stage of change”. 

In SOUL, at least one reader didn’t ‘get’ the message I was sending last month when I shared Tucker Carlson’s text messages. I believe the wisdom I highlighted is so important, that I’m giving it one more try to explicitly spell out what to do about the polarization in the USA.

David Mee-Lee, M.D.
DML Training and Consulting

SAVVY, STUMP THE SHRINK and SKILLS

Fred Mills asked a question last month that prompts several learning points. He draws on the Stages of Change in the Transtheoretical Model of Change (Prochaska and DiClemente) from Precontemplation (not interested in changing); Contemplation (ambivalent about changing); Preparation (getting ready to change within the next month); to Action (taking active steps to change).

Hi, Dr. Mee-Lee. I was in a training today and the trainer said, “Rarely will you see a person come into treatment in the Preparation or Action stage of change”. I tend to disagree. I know many people who come into treatment are still in Precontemplation or Contemplation stage but I think the majority of people who go through with entering treatment would be at Preparation or Action. Can you offer some thoughts to help me understand?

C. Fred Mills, LCADC, LPCC

Targeted Assessment Specialist

Opioid Use Disorders Project (TAP OUD)

UK Targeted Assessment Program

Prestonsburg, KY 41653

fred.mills@ky.gov

Tip 1

People who go to the trouble of getting into treatment are at Preparation or Action. But they may not be at Action for what we think they should be.

Hi Fred, my experience is that just because people go through the effort of coming to treatment, that doesn’t mean they are at Preparation or Action for Recovery. They may be at Action for getting their kids back; getting off probation; staying out of jail; keeping a job or relationship, but at Precontemplation or Contemplation for stopping drinking or drugging. They will say things like “I have to be here to get my kids back” or “I can stop anytime” or “I don’t think it’s a problem but my boss has it in for me”.

Tip 2

To assess if a client is at the stage of Preparation or Action and for what, listen to what they are actually saying about what they want.

If they really are at Preparation or Action for recovery, then they would say things like “I have a severe problem with alcohol or drugs and I want to stop and I’ll do whatever it takes.” If they really are at that stage, they may not need much formal treatment unless they need immediate withdrawal management or have co-occurring physical and/or mental disorders.

They could start with Alcoholics Anonymous or Narcotics Anonymous or SMART Recovery and some outpatient education about addiction and recovery. 

Tip 3

To engage a person in a self-change process, start with what they are at Preparation or Action for, not what we think they should be at Action for.

In treatment we always welcome a person who comes, but we start with what they really want, what they are at Preparation or Action for, not what we want for them, what we are at Action for. In other words the assessment and treatment plan would focus on what they want (getting the children back) and how we can help then get their children back?

You will no doubt get to the concerns you may have about their drinking or drugging; or the partner they have at home.  As you assess with the client what concerns Child Protection Services has about reunifying with their children, their drinking, drugging or companions will inevitably come up in the assessment conversation.

 Tip 4

The collaborative treatment plan should focus on what the client is at Action for to help them get what they want.

If the client wants their children back, the treatment plan would focus on all the obstacles to reuniting with their children and what the client is willing to do or not do.

  • If the client is at Action for reunification but at Contemplation (ambivalent) about stopping drinking, the “discovery” treatment plan would focus on how to prove there is not a drinking problem rather than just getting the client to comply with abstinence.
  • If the client is at Precontemplation about separating from an abusive partner, the “discovery” treatment plan would focus on how to demonstrate that children would be safe in a home with such a partner living there. 
  • If the client is at Action for recovery, then treatment is easy. Just help them change friends, deal with urges to use, stay away from dangerous places, go to meetings etc. Such a client will happily adhere and work hard. If you get pushback, then they are not at Action for recovery.

SOUL

I don’t like all the polarization in our country....political, cultural, racial, religious and on and on. Being Asian, albeit born and raised an Australian Chinese person, I probably don’t like conflict anyway. It is only going to get worse as the election season heats up for the next year and a half.

So I will address this polarization only one more time for a while and give my message of SOUL last month one more try. The content of what I was trying to say about Tucker Carlson’s January 7, 2021 texts is so important that I am going to spell it out more clearly. This was prompted by a reader’s candid message to me as follows:

To quote a person (Tucker Carlson) who has done so much harm in spreading lies to his listeners is very disconcerting. There are so many professionals that are more knowledgeable about addiction issues that are well respected and trusted than this individual. It makes me start to question your judgment. Please remove me from your list of subscribers. (I didn’t hear back about permission to acknowledge her name, but she is a Licensed Clinical Social Worker. I am also not sure if she even read what I wrote as I wasn’t referencing his addiction knowledge. Maybe she only had time to read the email Subject Headline “Wisdom from Tucker Carlson”)

Here’s the message I was trying to send last month because for at least one reader, ‘Message Sent was not the Message Received’.

If you identify with Republicans and love Tucker Carlson:

To what degree do you agree with the insights on which Tucker reflects in his texts?

  • “.....this isn't good for me. I'm becoming something I don't want to be.”  - Is there hate, violence, a lack of compassion and empathy that is taking us over to become something we don’t want to be?
  • “Much as I despise what he says and does, much as I'm sure I'd hate him personally if I knew him, I shouldn't gloat over his suffering.” – Have we become so divorced from our humanity that we can gloat over the suffering of someone with whom we disagree?
  • “I should be bothered by it. I should remember that somewhere somebody probably loves this kid, and would be crushed if he was killed.”  - To what extent have we so dehumanized those we disagree with that we wish them dead?
  • “If I don't care about those things, if I reduce people to their politics, how am I better than he is?" – Have we so demonized the opposition that we have lost sight of our own humanity and compassion for others?

If you identify with Democrats and do not love Tucker Carlson:

Can you open your heart to see the wisdom that arises from a fellow human being whose words you usually despise?

  • Can we find common ground and areas of agreement to bridge the polarization between the right and the left of the political divide?
  • Can you embrace the self-reflection to take stock of whether hate, violence and lack of compassion and empathy are taking us over?
  • Even the people we think the worst of for what they say and do, can be part of healing. Can we see that they too have a human heart that has the capacity for empathy and caring about those with whom they disagree?
  • Who will reach out first to break down the dehumanizing and demonizing of others that pushes us all further apart?

Years ago, I heard a couples therapist give this great advice: The person who should reach out first to bridge the divide is the one who believes they are the most correct with God, Source, the Universe on their side.

Until Next Time

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

David

May 2023 – Vol. #21, No. 2

Welcome to the May edition of Tips and Topics and to all the new subscribers.

In SAVVY, there is preoccupation with medication as the main and most effective treatment in physical and mental health and addiction. But there are a variety of non-medication lifestyle interventions that can be as effective as medication, if not even better.

In SKILLS, engage with clients to embrace an exercise mindset, use the power of placebo to build hope, and work with families to improve relationship time.

In SOUL, Tucker Carlson, previously a ratings star for Fox News, sent a text message to a producer on January 7, 2021 when he was watching a video of people fighting on the street in Washington. In this age of polarization and demonizing those with whom we disagree, Carlson shares some surprisingly good and insightful advice.

David Mee-Lee, M.D.
DML Training and Consulting

SAVVY

Society, psychiatry and addiction medicine are, in my opinion, too focused on medications as the answer to any ailment. Watch any TV show and you will likely see at least one advertisement for a prescription or over-the-counter medication. Rarely do you see anything promoting lifestyle change.

While scientific advancements in neurobiology, brain function and neurotransmitters have given rise to effective pharmacotherapies, they have also seduced too many into seeing medications as the most important intervention in mental health and addiction.

To balance the scale of therapeutic interventions, this month’s edition highlights some recent findings on lifestyle interventions that can be supportive of what medications do and in some cases, are superior to medication.

Tip 1

Exercise and physical activity can improve anxiety, depression, addiction recovery, and other health outcomes. For depression, exercise may be more effective than counseling and leading medications.

Here are the Headlines:

    • The Addition Of Simple Exercises To Treatment May Improve Recovery From Substance-Use Disorders, Study Indicates

The Washington Post (4/26/23, Reynolds) reports a study “found that incorporating simple workouts such as jogging or weight training into treatment improved the likelihood of recovery from a variety of substance-use disorders, including to cocaine, opioids, cannabis and alcohol.” The study was published online April 26, 2023 in PLOS One. The study’s findings “build on other research, some with animals, showing that exercise changes our brains and thinking in ways that can reduce drug cravings and relapse and might even stave off addictions in the first place.”

    • Exercise For Treating Depression As Effective As Standard Drugs, Psychotherapy, Review Suggests

The Washington Post (3/15/23, Reynolds) reports, “Exercise as a treatment for severe depression is at least as effective as standard drugs or psychotherapy and by some measures better, according to the largest study to date of exercise as ‘medicine’ for depression.” The new research “pooled data from 41 studies involving 2,265 people with depression and showed that almost any type of exercise substantially reduces depression symptoms, although some forms of exercise seemed more beneficial than others.” The review findings were published online February 16 in the British Journal of Sports Medicine.

Researchers are calling for exercise to be a mainstay approach for managing depression as a new study shows that physical activity is 1.5 times more effective than counseling or the leading medications.

    • Exercise Appears To Significantly Decrease Suicide Attempts, Systematic Review Suggests

Healio (4/3/23, Bascom) reports, “Exercise significantly decreased suicide attempts,” investigators concluded in the findings of a 17-study, 1,021-participant systematic review and meta-analysis published online ahead of print in the June issue of the Journal of Affective Disorders.

    • Supervised Exercise Programs May Be Tied To Significant Reductions In Symptoms Of Depression Among Children And Teenagers, Systematic Review Concludes

HealthDay (1/6/23, Thompson) reported, “Supervised exercise programs are associated with significant reductions in symptoms of depression among children and teenagers,” investigators concluded in the findings of a 21-study systematic review and meta-analysis “involving more than 2,400” children. The findings were published online Jan. 3 in JAMA Pediatrics. Additionally, the systematic review “revealed a greater benefit from exercise among children who had already been diagnosed with depression or another mental illness.” Anish Dube, MD, MPH, Vice Chair of the American Psychiatric Association’s Council on Children, Adolescents, and Their Families, stated that “‘in a sense, physical activity itself is similar to an intervention that we would call behavioral activation,’ in which patients engage in meaningful activities to subvert...depressive lethargy.”

Tip 2

For children and adolescents consistent and good sleep supports health, happiness and mental well-being.

    • Study Highlights Importance Of Good Sleep For Adolescents’ Mental Well-Being

MedPage Today (4/5/23, DePeau-Wilson) reports, “Sleep problems throughout the transition from childhood to early adolescence were associated with psychopathology symptoms, highlighting the importance of good sleep for adolescents’ mental well-being,” investigators concluded in a study revealing that “among over 10,000 kids, those with more severe sleep problem profiles had a higher risk of concurrent internalizing symptoms.” The findings were published online April 5 in JAMA Psychiatry.

    • Consistent sleep may be key factor in supporting children’s health, happiness

CNN (3/16/23, Holcombe) reports, “One of the keys to keeping your child happy and healthy is making sure they get enough sleep consistently,” according to a new study published in JAMA Network Open. For the research, investigators “monitored 100 children ages 8 to 12 living in New Zealand,” and “the children alternated between a week of going to bed one hour earlier and one hour later – with one week at normal time in between the two.” Investigators “covered many aspects of well-being, including an assessment of how the children felt physically, and psychologically, in their relationships with parents and peers, and how they felt about school.”

Tip 3

In anxiety, mindfulness can be better than medication and breathing exercises may even be better than mindfulness.

    • Practicing Mindfulness To Relieve Anxiety May Be Just As Effective As Escitalopram, Research Indicates

The Washington Post (1/23/23, Morris) reports, “Practicing mindfulness to relieve anxiety can be just as effective as medication,” research indicates. The findings of a 276-participant study published online Nov. 9, 2022 in JAMA Psychiatry “showed that people who received eight weeks of mindfulness-based interventions experienced a decrease in anxiety that matched those who were prescribed escitalopram.”

    • Breathing Exercises May Improve Mood, Reduce Anxiety Better Than Mindfulness Meditation, Study Says

The Washington Post (3/16/23, Sima) reports, “A study in Cell Reports Medicine showed that just five minutes of breathwork each day for about a month could improve mood and reduce anxiety – and these benefits may be larger than from mindfulness meditation for the same amount of time.”

SKILLS

Tip 1 

Engage clients in embracing an exercise mindset to improve physical, emotional and social health.

    • Exercise mindset, perception can have impact on health outcomes

The Washington Post (3/22/23, Reynolds) reports that a “new study of mindsets and exercise...shows that learning how much we actually move by tracking our steps could help us start thinking of ourselves as active people, which can pay health dividends, even if we don’t start exercising more.” The research suggests that people who “had been given inflated steps responded almost identically to those receiving accurate counts.” Investigators “suspect this signifies that many of us see little subjective difference between 7,000 and 9,000-ish steps, but plenty of difference between 7,000 and 4,000.” The findings were published in the Journal of Medical Internet Research.

Tip 2

Use the power of placebo to retain patients in treatment and improve their sleep.

    • Use Of Open-Label Placebo Alongside Methadone For OUD Tied To Greater 90-Day Retention Rates, Better Sleep Quality Compared With Use Of Methadone Alone, Small Study Indicates

Harvard Medical School’s News & Research explained placebo medication:

“The researchers found that participants who knowingly received placebo pills in addition to standard-of-care methadone treatment were significantly more likely to remain in treatment than were participants who received methadone treatment alone. Participants who received placebo pills also reported better sleep quality.

"The clinical implications of our intervention have great potential impact, as retention in treatment is a serious challenge for the field of addiction medicine,” said Belcher. “We’ve demonstrated it’s feasible to administer a placebo in addition to standard-of-care methadone in a community-based opioid treatment setting without adding a significant burden to clinic procedures, and the low-cost, low-risk nature of this intervention could provide an appealing strategy to target early methadone treatment adherence.”

It had long been assumed that deception or concealment is necessary for placebo effects to occur — “tricking” a patient to believe an inert pill contains active medication. But, a growing body of evidence from randomized controlled trials with irritable bowel syndrome, chronic low back pain, and other conditions has demonstrated that no such deception is necessary for placebo treatment to alleviate symptoms. Additionally, conditioning study participants to placebos by having them pair the placebo with an active medication — thereby potentially associating the placebo with a relief in symptoms that may be caused by the active drug — has been shown to treat symptoms of insomnia, ADHD, post-surgical pain, and more.”

Healio (4/19/23, Rhoades) reports, “The use of open-label placebo alongside methadone for opioid use disorder” (OUD) “was associated with greater 90-day treatment retention rates and better sleep quality compared with the use of methadone alone,” researchers concluded in a 131-participant randomized clinical trial, the findings of which were published online April 12 in JAMA Network Open.

Tip 3

Provide family counseling to improve parent-child relationships and encourage longer family mealtimes.

    • Longer family mealtimes tied to healthier meals for children

MedPage Today (4/3/23, Monaco) reports, “Longer family mealtimes may be one strategy to get kids to eat healthier, according to a randomized clinical trial that found an improvement in the balance of foods eaten at the table.” Results show that “on average, longer family meals induced kids to eat 3.32 more pieces of fruits and 3.66 more pieces of vegetables than those who ate during their regular mealtime duration, the researchers explained in JAMA Network Open.”

    • Teens with closer relationships to parents have lower chance of substance abuse

HealthDay (3/23/23) reports, “Teens who report better relationships with their moms and dads are healthier both mentally and physically and less likely to abuse drugs or alcohol as young adults, according to researchers.” The study also reveals that these teens “reported lower levels of stress and depression, as well as lower use of nicotine, alcohol, cannabis and other drugs.” The findings were published in JAMA Network Open.

SOUL

I don’t watch cable news shows much at all. They usually thrive on berating anyone on the “other side”; and building viewer ratings by whipping up polarizing points of view that demonize and dehumanize people.

Tucker Carlson had a huge following on Fox News before he was let go recently. Reportedly, he “made an inflammatory, racist comment in a text message to a producer about a video that showed a group of "Trump guys" attacking "an Antifa kid," writing in the message that "it's not how white men fight," according to the New York Times.”

The message was sent on January 7, 2021, and Carlson wrote:

"A couple of weeks ago, I was watching video of people fighting on the street in Washington. A group of Trump guys surrounded an Antifa kid and started pounding the living s**t out of him. It was three against one, at least. Jumping a guy like that is dishonorable obviously. It's not how white men fight. Yet suddenly I found myself rooting for the mob against the man, hoping they'd hit him harder, kill him. I really wanted them to hurt the kid. I could taste it."

He continued: "Then somewhere deep in my brain, an alarm went off: this isn't good for me. I'm becoming something I don't want to be. The Antifa creep is a human being. Much as I despise what he says and does, much as I'm sure I'd hate him personally if I knew him, I shouldn't gloat over his suffering. I should be bothered by it. I should remember that somewhere somebody probably loves this kid, and would be crushed if he was killed. If I don't care about those things, if I reduce people to their politics, how am I better than he is?"

I was impressed with the insightful wisdom that arose from Tucker’s text. Here’s what I gleaned from his text that is a good start to decreasing our country’s polarization:

    • “.....this isn't good for me. I'm becoming something I don't want to be.” - The importance of self-reflection to take stock of whether hate, violence and lack of compassion and empathy are taking us over.

    • “Much as I despise what he says and does, much as I'm sure I'd hate him personally if I knew him, I shouldn't gloat over his suffering.” – Certainly we may disagree vehemently with another’s beliefs and priorities. But violence and causing pain and suffering to those with whom we disagree is never justifiable.

    • “I should be bothered by it. I should remember that somewhere somebody probably loves this kid, and would be crushed if he was killed.” - Dehumanizing others is the start of a slippery slope of lack of empathy that can lead to violence and death.

    • “If I don't care about those things, if I reduce people to their politics, how am I better than he is?" – Righteous indignation, demonizing others for their differing opinions pushes us apart.

Self-reflection and concern about what we are becoming; causing no harm; remembering others’ humanity; and empathy can start to bring us back together again. Who would have thought that Tucker Carlson’s texts could spark some healing.

Until Next Time

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

David

April 2023-Vol. #21, No. 1

What to do for a client with a history of addiction who is socially drinking? Twenty years of Tips and Topics. What’s next?

Welcome to the April edition, the start of year 21 for Tips and Topics.

In SAVVY, STUMP THE SHRINK and SKILLS,  two clinical vignettes about clients with a history of moderate to severe Alcohol Use Disorder and three DWIs (Driving While Intoxicated) raise assessment and engagement questions to be considered.

In SOUL, I started publishing Tips and Topics April 2003. On this 20th anniversary, I look back at what the initial goals were; whether I lived up to those; and what’s next for Tips and Topics.

Savvy, Stump the Shrink, and Skills

This April edition of Tips and Topics marks the start of my twenty-first year of writing each month about whatever is on my mind. Much of the inspiration for what goes into each edition comes from readers and subscribers of Tips and Topics….and that is no different this month. A subscriber just sent me this message:

I have two issues that I would like to know your thoughts on. 

1. I am wondering how you think a history of a moderate to severe substance use disorder (SUD) should be treated for diagnosing and treatment? For example, a client reports a history of a moderate alcohol use disorder 3 years ago but the last 12 months he reports drinking socially.

2. Secondly, what are your thoughts on a client who reports 3 driving while intoxicated (DWI) charges 2016, 2017, and the last one 2018. Then reports that during the last 12 months drinking socially? In addition, collateral information indicates concerns about his alcohol use due to the DWIs.

Thank you for your time.

Tip 1

Resist the impulse to jump to conclusions before doing a more in-depth assessment and history-taking.

In these vignettes, it is natural to conclude that if someone is “drinking socially” after a previous diagnosis of moderate or severe SUD or multiple DWIs, that they must be relapsing and heading for trouble. But here are some Assessment and Engagement Questions to consider.

Assessment Questions:

  • Have you been given a formal diagnosis of a substance use disorder or alcohol use disorder e.g., in a medical record; or has any healthcare professional said that you have addiction or are an “alcoholic”? – Just because there is a “history of a moderate to severe SUD”, it is easy to label someone as having addiction without having done a careful diagnostic criteria review. Similarly, while three DWIs would likely indicate a SUD, it is good to check that he met diagnostic criteria.
  • If you were told you have an addiction illness, who gave you that diagnosis and were they trained in addiction diagnosis and treatment? – A physician or other healthcare professional may document that the person has an SUD but may not be skilled in understanding diagnostic criteria and erroneously label someone as having a SUD when it may have actually been a severe substance-induced or substance-related event e.g., a young person who overdosed on alcohol at a party.
  • If the client indicates that he did have a diagnosis of “moderate alcohol use disorder 3 years ago”, it is worth checking on what diagnostic criteria were met back then by reviewing what alcohol related problems were showing up 3 years ago. – This serves to assess how clear the client is that he indeed had an addiction to alcohol and to check if the diagnosis was accurate; or whether it might have been a developmental phase of alcohol use as a young person; or a coping mechanism for other co-occurring issues like trauma, other mental health challenges or even physical health problems like chronic pain.
  • If it becomes clear that the client does indeed have alcohol addiction illness and recognizes that, then review what addiction treatment and/or self/mutual help the client has participated in. – He may have been diagnosed but never engaged in treatment or recovery groups; and may not be knowledgeable about addiction.
  • If the client did have formal addiction treatment, assess what worked and what didn’t work to initiate and maintain sobriety. – Did he get good education about addiction; did he attend regularly; was there continuing care and ongoing monitoring? Or was he simply “graduated” from a program with poor linkage to ongoing care?
  • Whether the client had treatment or not, how long were any periods of abstinence and how did he achieve those? – It is always good to support self-efficacy (the optimism and confidence that a person can change) by complimenting the client on whatever length of abstinence was achieved and to evoke solutions and skills that worked for whatever the period of abstinence. “You didn’t use for 6 weeks? That’s great, how did you do that – who did you hang out with, what did you do with any cravings to use, where were you staying during that time?
  • What does the client mean by “drinking socially”? Is that once a week; or beer or wine with a meal; or drinking just at times of celebrations like birthdays? Does he get drunk, blackouts or has he been told that he behaved inappropriately when drinking?
  • What other drugs besides alcohol does he use; and remember to include tobacco? How much does he gamble?– You want to assess the breadth of his addiction in substance use and other addictive behaviors.

Engagement Questions:

  • Regardless of what others have told you, do you yourself think you have alcohol addiction? If so, why and if not why not? – This indicates what stage of change the client is at and his level of interest in changing or not.
  • Is there any help you need at this point with your alcohol use? If yes, what help do you want; if not, help me understand your thinking.
  • Is social drinking something you want to continue? How will you monitor your drinking so that it doesn’t become a problem in your physical, emotional or social life? – Given his past history with alcohol, you want to engage the client in a “discovery, dropout prevention” plan to discover or not whether he indeed still has a problem with alcohol.

Tip 2

Involving family, friends and other collateral sources in the assessment and treatment of addiction is always important. 

The person suffering from addiction is often the last person to realize how out of control their addiction illness has become. The survival defense mechanism of “denial” serves to solve the cognitive dissonance a person in active addiction faces:

  • How could I be causing all these physical, emotional and social problems and doing this to myself through my substance use or addictive behaviors? It must be my partner’s fault, or my boss, or the police who are harassing me. (Minimization, projection of blame, rationalization).

This is why involving collateral sources, relatives and friends in assessment and treatment is important:

  • To get as accurate information as possible about the frequency, quantity, and effects of drinking on all significant others, including the identified client.
  • To engage and educate significant others about addiction – how it has affected their lives and how they can help or not help to promote recovery for all people affected.
  • To support and assist significant others as they live with either active addiction in their loved one; or learn how to recover with their loved one when and if addiction recovery begins – What boundaries and limits do the significant others have around their loved one’s drinking? How hopeful or discouraged are they? If recovery has begun, how is their loved one reintegrated into a family that adjusted to exclude him or her from family and parenting decisions or even from routine daily activities like family meals?

The Bottom Line:

  • Can a person with moderate or severe Alcohol Use Disorder later socially drink? – Usually once a person has crossed the line into verified addiction illness, it is not likely that a person can return to social drinking free of negative effects on physical, emotional and social functioning.
  • But before assuming that social drinking will inevitably not go well, it is important to verify that there was indeed an accurate diagnosis of a SUD. 
  • Involve significant others in the assessment and treatment of their loved one’s addiction. This is to both assure as accurate information as possible and also to guide significant others on how to help their loved one and themselves.
  • If a person does indeed have alcohol addiction but wants to try social drinking, motivational enhancement therapy and motivational interviewing is needed to engage the client with a “discovery, dropout prevention” plan. The focus is to keep the client involved in treatment and help them discover whether they can safely return to social drinking or not. You may be clear that they cannot, but our work is to have them see and experience that for themselves.

Soul

This edition of Tips and Topics marks the 20th anniversary of publishing what I called back then an “e-zine” – “a magazine published only in electronic form on a computer network.” As I start this 21st year, I reviewed the three original goals that launched Volume 1. No. 1 in April 2003 to see if they are still relevant in 2023.

The first reason I started Tips and Topics was that clinicians have ongoing clinical questions that need answers. I coined STUMP THE SHRINK to highlight the questions I still receive and that prompted even this very April edition. This is still a very relevant goal that underpins Tips and Topics.

The second goal, to help people apply new-found knowledge, drives the SKILLS section. It’s useful to be SAVVY about various topics, but if they can’t be implemented skillfully, the new knowledge soon fades and clinicians fall back to their familiar, and sometimes ineffective practices.

I remember speaking to my therapist soon after completing my psychiatric specialty training and starting a private practice. I was interested in getting referrals of patients wanting psychotherapy not just medication. My therapist said, just let the other psychiatrists know you want such referrals. My rookie, unconfident mentality said “But why would they refer me patients when they would want to keep them in their practice?”

My therapist said “Firstly, not everyone wants to do psychotherapy and are more interested in medication management; and secondly, just because someone has been doing psychotherapy for a long time doesn’t mean they are any good at it.” As I grew in professional confidence and also grew ‘longer in the tooth’, I observed the truth of that for some of my colleagues.

The third reason for publishing Tips and Topics was because I want to make a difference in our field. When I decided over 25 years ago to work for myself from home in full time training and consulting, it was a big risk with a family of three kids to support. In a freelance independent business, your next invitation to train or consult depends essentially on whether you are effective in making a difference in the practices and policies of your audience. There was no guaranteed direct deposit in my bank account every two weeks; no paid sick time or vacation; no health insurance benefits or retirement contributions.

I said that if I couldn’t make it, I could always get a “real” job like being a medical director for a treatment system or some other salaried position. Fortunately, by the ‘grace of God’ and the gratitude of my audiences, I never did have to take that salaried position. That tells me I succeeded in my third goal.

What’s Next?

While these three goals are still relevant and while it still is fun to pull together Tips and Topics each month, you will keep receiving it, if you wish. I don’t send this out unsolicited to random people on mailing lists – everyone in the over 7,300 people on the mailing list should have opted in. If someone else put them on the list unbeknownst to them, they can and should Unsubscribe if they want, just as anyone can do if and when Tips and Topics becomes irrelevant to you.

If you have been a subscriber over the years, you’ll know that the SOUL section is a hodge podge of whatever is on my mind that month. Some readers have told me they read the SOUL section first, not always interested in the SAVVY and SKILLS content. I suspect the SOUL section will become even more hodge podgey as I proceed more heavily into retirement mode…..there are so many interesting insights and ideas that percolate when freed from the daily grind of catching planes, Uber or Lyft, checking into hotels late at night; and all that goes with a busy training and consulting practice.

So stay tuned for some emerging thoughts on ponderings like:

  • What is the balance between digging deep into past trauma and counterproductive coping patterns versus focusing on the Here & Now of living joyously and optimistically?
  • If trauma (in the broadest sense) is baked in on a cellular level affecting people’s fight or flight triggering responses, what is the mix of psychotherapy, body work and corrective experiences needed to allow a person to live unshackled from the past?
  • Is Law of Attraction a law of the universe as fundamental and real like we accept the Law of Gravity as real and fundamental?
  • How can you be at peace when there are physical, emotional, social and spiritual challenges swamping you?

Tips on subscribing and using Tips and Topics

  • Feel free to forward Tips and Topics to whomever you wish. But if you have people you want to invite to subscribe, please have them sign up for themselves at the website where you will see at the top in red the place to “Sign Up Now!” This way they will get into the system more easily. Here’s the link to do that:

https://tipsntopics.com

  • Make sure that the email address you use is one that won’t kick Tips and Topics into Spam or Junk Mail as many work emails are programmed to do. So you may sign up, but never receive it in your InBox.
  • On the right side of the Home Page is a “Search” window in which you can search 20 years of Archives; and also click on any previous edition. Scroll down past the Google-sponsored search findings to the previous editions of Tips and Topics to hopefully see content that is relevant to your search. For example, type into Search “discovery, dropout prevention” and you’ll see all previous editions where I have written about that.

Thanks for reading Tips and Topics and for the comments you send that help me know what speaks to you or not. 

Now on with the next 20 years…..or not.

March 2023 – Vol. #20, No. 12

The bear, wolf, fox and rabbit – a joke that teaches; Feeling good – it’s your responsibility; My son, Taylor’s take on money, career, Dad and the SKILLS and SOUL that drive him.

Welcome to the March edition of Tips and Topics.

In SAVVY, the joke about the bear, wolf, fox and rabbit highlights the need to teach our clients (and ourselves) to be assertive and abandon a “victim” mentality. It’s about taking responsibility for your own happiness.

In SKILLS and SOUL, my son, Taylor writes about his take on a discussion he and I had about how his relationship to money and career and how it was impacted differently by his relationship with his mother versus me. He shares his SKILLS and what drives his SOUL.

Read More

February 2023 – Vol. #20, No. 11

Teen mental health – sadness, suicide and social media; An Uncle’s Wisdom on Love, Work and Play; Some Reflections Four years after I lost my wife.

Welcome to the February edition of Tips and Topics.

In SAVVY, I share some recent news items on teen mental health, especially with teen girls versus boys. Statistics on sadness, suicidal feelings, thoughts and attempts and social media use.

In SKILLS, I reflect on “wisdoms” I shared with my 21 year old niece…wisdoms that I wished I had known at 21 about Work, Love and Play.

In SOUL, my ever evolving grief process and that of my children has been reflections on our past family relationships. They provide an opportunity to remember how life was when Marcia was alive with us. They also allow for healing old wounds that haven’t served us well.

Read More

January 2023 – Vol. #20, No. 10

Responses to the story of the Judge and the Grieving Team; It’s time to retire “graduation” and “treatment completion”; My four words for the year ahead.

Welcome to the January edition of Tips and Topics.

In SAVVY, It’s time to retire terms and concepts like “graduation” “treatment completion” and embrace terms like “transition” and “commencement” after having done an initial piece of work on the path to recovery.

In SKILLS, what to say to Orient Participants to entering Drug Court and about “graduating”. Rename the Graduation or Treatment Completion Ceremony.

In SOUL, my four words to encapsulate the year ahead. What words do you see?

Read More

December 2022

The story of the Judge and the Grieving Team; What does “going high” mean (keep an open mind on these excerpts).

In SAVVY, STUMP THE SHRINK and SKILLS,  this is the story of the Judge and the grieving Treatment Court team. Relapse and a deadly overdose is sad at any time for anyone with addiction. But it is all themore stinging when the participant has been in long-term recovery and then relapses and dies.

In SOUL, I feel sad, confused, and sometimes hopeless about the way we deal with our political differences. But keep an open mind to review what solutions Michelle Obama offers when she explains what “going high” means.

Read More

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.

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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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