January 2020

Frustrations, frustrations – what kind are they and what to do; visioning a new year and decade

savvy, stump the shrink, and skills

I recently received this Stump the Shrink question that presents several SAVVY and SKILLS learning points. (I didn’t share this question because of the reader’s compliments, but it’s nice to know my work is helpful).

Good morning Dr. Mee-Lee!

I am a HUGE fan of yours – just ask any of my staff. I religiously read all of your newsletters, your books and attend any of your trainings that are within a 150 mile radius. I reference your work and tips & topics in my work with clients, students and LMSW clinicians I supervise working toward their LISW. Basically, my point is, there aren’t many situations with clients where I feel completely stumped that you haven’t somehow already provided your insights about. So naturally, when I’m feeling very stuck and unsure about how to move forward with an employee, I thought maybe you would have some understanding and advice.

I started working at this agency a little over 3 years ago. We are an outpatient addiction treatment center and we also provide Medication-Assisted Treatment services. Prior to coming here I worked in another outpatient addiction treatment center- so I have been working in the field of addiction for about 8 years now.

Just within the past 6 months, I accepted the role of coordinator here. This means I no longer run an IOP/EOP program but instead do more managerial work. The issue I am running into has to do with one particular counselor and his style/method of working with clients. He is one that is resistant to motivational interviewing (MI) skill-building or even knowledge and continues to fall back on the self-fulfilling prophecy (as described in my MI book) that clients with an addiction are difficult, resistant and in denial.

I’ve been trying my best to model and encourage alternative approaches (and also I’ll admit to the passive-aggressive e-mail forwards from time to time) but so far nothing has changed. I re-read your Tips & Topics book and even tried to use some of those skills in assessing staff readiness to change, etc; all to no avail. I’m beginning to realize that I’m driving myself more mad than I am getting anywhere with him.

Do you have any suggestions for me? I guess to me it seems that he frankly isn’t receptive to feedback about his clinical work and doesn’t seem to think he’s doing anything wrong or inappropriate. To be completely honest, the less clients he has, the happier he is as he doesn’t seem to want to really work that hard. He doesn’t seem to have passion for his work or that he is genuinely wanting to help clients. He truly reminds me of a client who “does time” rather than “treatment” as he seems to want to come to work, punch the clock, do his “time”, and punch out.

As the clinical leader here I am very passionate about providing a safe, comforting and welcoming environment to our clients. I believe addiction treatment is a lifelong process/lifestyle change and I strive to make every client’s experience here a positive one as they may be more likely to reach out for help in the future that way. So it is hard for me to have a counselor running a program that doesn’t appear to want to do anything to improve his skills or his relationships with clients.

Any advice, suggestions, insight or feedback would be greatly appreciated. I’ve had countless conversations with my director (and even my personal therapist) but I still find myself feeling stuck and frustrated at the situation.

Thank you for your time!

Courtney

Iowa

My response references techniques that I detail more in the SAVVY and SKILLS tips:

Hi Courtney:

Thanks for the high praise. It is gratifying to know that my training and writings are helping and glad that you are applying it to your daily work. As regards your frustrations with the counselor, a good place to start is with a Tips and Topics I did 14 years ago in the October/November, 2005 edition. 

Take a look at dealing with Outer-directed frustrations and see if you can go through the process with this employee to develop a system that he needs to fit into if he wants to stay employed in your agency with a system that values, measures and expects client-centered, evidence-based, best practices including Motivational Interviewing.

The system would be set up to ensure that all employees receive evidence-based practice and best practice training; demonstrate use of such methods successfully as measured by client retention, dropout rates, patient satisfaction as measured, for example by instruments like the Outcome Rating Scale (ORS) and Session Rating Scale (SRS) of Scott D. Miller and Feedback Informed Treatment (FIT).

In other words, think through the process to set up a system that the counselor chooses to work in rather than trying to change him, which is not going well as you have tried so far. If the system defines what quality of work is expected with what results, it isn’t a matter of finding extraordinary people, but rather those who choose to work in that system and can actually perform to measurable standards.

Hope this helps, but let me know if not. You can feed me back what system you come up with after reading that edition and I can see if it would seem to work.

David

Here are the tips that I adjusted to apply to Courtney’s questions:

TIP 1

Identify what kind of frustration you are dealing with in any situation

Michael E. Gerber is an entrepreneurial and small business thought leader who has impacted the lives of millions of small business owners and hundreds of thousands of companies worldwide for over 40 years.

Here is Gerber’s definition of frustration:

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

There are 3 types of frustrations:

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

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

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

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

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

  • Problem: “The photocopy machine keeps breaking down”

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

Courtney’s frustration is not a technological one.

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

  • Problem: Courtney said: I’m feeling very stuck and unsure about how to move forward with an employee… I’ve been trying my best to model and encourage alternative approaches (and also I’ll admit to the passive-aggressive e-mail forwards from time to time) but so far nothing has changed…… I’m driving myself more mad than I am getting anywhere with him…. I am very passionate about providing a safe, comforting and welcoming environment to our clients… I’ve had countless conversations with my director (and even my personal therapist) but I still find myself feeling stuck and frustrated at the situation.
  • When you see yourself as the problem, all your energy is focusing on YOUR need to change.
  • Gerber believes that this self-focus is basically a waste of time. It chews up your thinking and energies which are best spent on analyzing what is getting messed up.
  • Phrased another way – how does this self- directed frustration prevent getting the results needed at your agency/organization?
  • You can make it impossible for yourself to ask the questions necessary to create the right system when you are waiting for yourself to change. (Self-analysis has its time and place, but not here.)
  • Deciding on action steps and taking those steps is a much more productive use of your personal resources and energy.
  • When you get yourself out of the way, you can begin to ask productive questions such as: What kind of program and system do I want to lead? What characteristics define a system I am passionate about? How would I know I have achieved the results of the kind of system I believe in?

Systemic Thinking: When you read Courtney’s Stump the Shrink question, she lists multiple characteristics of the kind of program, system she wants to lead:

  • A program that provides a safe, comforting and welcoming environment to our clients.
  • Where staff value motivational interviewing (MI) knowledge and skill-building.
  • Where team members don’t view clients with an addiction as difficult, resistant and in denial.
  • Where everyone is receptive to feedback about the quality of their clinical work.
  • Where staff are passionate about their work rather than to have the smallest caseload possible; punch the clock; do their “time” at work; and punch out.
  • Where everyone wants to improve their skills and relationships with clients.

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

Courtney’s frustration is partly a Self-directed one.

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

  • Problem: Courtney said she has a problem with one particular counselor and his style/method of working with clients. He is one that is resistant to motivational interviewing (MI) skill-building or even knowledge and continues to fall back on the self-fulfilling prophecy (as described in my MI book) that clients with an addiction are difficult, resistant and in denial….. he frankly isn’t receptive to feedback about his clinical work and doesn’t seem to think he’s doing anything wrong or inappropriate. To be completely honest, the less clients he has, the happier he is as he doesn’t seem to want to really work that hard. He doesn’t seem to have passion for his work or that he is genuinely wanting to help clients. He truly reminds me of a client who “does time” rather than “treatment” as he seems to want to come to work, punch the clock, do his “time”, and punch out…. a counselor.. that doesn’t appear to want to do anything to improve his skills or his relationships with clients.

A similar problem exists in the case of outer-directed frustrations as with self-directed frustrations.

  • When you view someone or something outside as the cause of your frustration, there is the need to change something you cannot control.
  • You cannot make people change to want to improve the quality and quantity of their work; to want to learn and grow as a professional.
  • You can only change those things you do have control over, namely your program and system.
  • Thus while there certainly are outer-directed frustrations, it will not service your efforts to define problems or solutions in outer- directed terms.
  • Success depends on the creation of a system designed to produce a specific result.
  • Whenever your focus is on people, you are forever searching for extraordinary ones to work for you.
  • When you focus on the system, you need only find people who are willing to help you build and use it.

Systemic Thinking: When you consider all the multiple characteristics of the kind of program, system Courtney wants to lead, the questions are not How do I get this counselor to want to learn and improve his skills in MI; view addiction clients differently; be open to feedback; and do more than just the minimum quantity and quality of counseling?

Ask yourself questions like:

  • What is missing in the structure of our program that is permitting counselors to keep working and being paid here, when they don’t uphold any of the values, skills and quality we want to achieve?
  • What system do we need to establish that will attract, nurture, improve and retain the kind of staff we want, so we are not consumed with tolerating poor quality work; passive counselors uninterested in learning, growing and improving their skills and relationships with clients?
  • How could I develop a program and system that moves substandard staff out and attracts and retains high quality professionals and so minimize frustrations?
  • Since I can only change those things over which I have control, what could I change in the structure of our program that will get the only way to get the multiple characteristics of the kind of program, system I want?

– Determining what to change demands that you be willing to look very specifically at what it is about your business, program and system that is not working.

– What is it about your program (not your people or yourself) that generated your original self-directed or other-directed frustration?

– Get specific/concrete in naming your frustration. This then will tell you how to eliminate it by transforming the frustration from a thought or feeling to a condition in the business, program and system that you can do something about.

Courtney’s frustration is largely an outer-directed one.

Stay tuned because next month, we’ll outline more specific steps Courtney can do to deal with her stuckness and frustration using Gerber’s Key Frustration Process to develop systems solutions. 

Reference:

The material above has been adapted from Gerber Business Development Corporation’s Key Frustration Process. Michael Gerber, E-Myth Worldwide Web: http://www.e-myth.com

https://www.e-myth.com/cs/user/print/post/key-characteristics-of-a-great-manager

TIP 2

Note that in the current 2013 edition of Motivational Interviewing there is no such concept as “resistance”

Courtney said: He is one that is resistant to motivational interviewing (MI) skill-building or even knowledge and continues to fall back on the self-fulfilling prophecy (as described in my MI book) that clients with an addiction are difficult, resistant and in denial.

In the Glossary of the current edition of Motivational Interviewing on page 412: “Resistance – A term previously used in Motivational Interviewing, now deconstructed into its components: sustain talk and discord.”

Notice “previously used” means: “Resistance” as a term and concept will no longer be used as in previous editions – “Rolling with Resistance”; “Responding to Resistance”.

Here’s what Miller and Rollnick said on page 197: “…our discomfort with the concept of resistance has continued to grow, particularly because it seems to place the locus and responsibility for the phenomenon within the client. It is as though one were blaming the client for “being difficult.” Even if it is not seen as intentional, but rather as arising from unconscious defenses, the concept of resistance nevertheless focuses on client pathology, under-emphasizing interpersonal determinants.”

What is “sustain talk”?

  • It is “the client’s own motivations and verbalizations favoring the status quo.” (p. 197). The person is not interested in changing anything; I am OK with keeping things the way they are – status quo, sustain what I have already got or where I already am.
  • “There is nothing inherently pathological or oppositional about sustain talk. It is simply one side of the ambivalence. Listen to an ambivalent person and you are likely to hear both change talk and sustain talk intermingled.” (p. 197). “Well maybe I have a drug problem and should do something about it if I don’t want to be arrested again.” (Change talk). “But it really isn’t as bad as they say, they’re just overacting.” (Sustain talk).
  • “Sustain talk is about the target behavior or change” – drinking or drugging, over-eating, gambling; or in the case of Courtney’s counselor, lack of interest in improving skills in Motivational Interviewing; and focused on doing the bare minimum of work.

What is “discord”?

  • “If we subtract sustain talk from what we previously called resistance, what is left? The remainder …more resembles disagreement, not being “on the same wavelength,” talking at cross-purposes, or a disturbance in the relationship. This phenomenon we decided to call discord.” (p. 197).
  • “You can experience discord, for example, when a client is arguing with you, interrupting you, ignoring, or discounting you.” (p. 197).
  • “Discord is about you or more precisely about your relationship with the client – signals of discord in your working alliance.” – Are you on the same page as your client? Are you more interested in abstinence and recovery than they are? Are you doing more work than them about going to AA or taking medication? Or in Courtney’s case, is she more interested in improving Motivational Interviewing skills than the counselor is?

So if you start deleting “resistance” from your clinical and supervisory vocabulary and focus on “sustain talk” and “discord,” you are now in a better position to attract a person into recovery or professional growth than responding to them as a resistant, non-compliant person in denial; or a substandard counselor disinterested in growing professionally.

Reference:

Miller, William R; Rollnick, Stephen (2013): “Motivational Interviewing – Helping People Change” Third Edition, New York, NY. Guilford Press.

soul

What do you do on a non-stop, 14 hour flight from San Francisco, California to Sydney, Australia?

Besides watching movies, sleeping a few hours, listening to crying babies, eating three meals and snacks, and worrying over what I will find in the devastation of the Australian wildfires, of course you write this month’s edition of Tips and Topics; and think about and write in SOUL what is heartfelt at the beginning of a new year and decade.

So here is my list of what I know I want to vision (a verb):

  • Personal and world peace
  • Serenity of the likes of the Serenity Prayer
  • Unity of purpose and meaning if not uniformity of views and ideas (there is power in diversity)
  • Joy and partnership in all aspects of life – love, work and play
  • Compassion and empathy for those different from me
  • Acceptance of who I am myself and who you are in all your glory
  • Teamwork – Together Everyone Achieves More

I didn’t think too hard about that list. It just flowed, so I’m going to trust that these really are my heartfelt priorities.

Those are worthy goals for me this year – flow, trust and heartfelt.

And you?

December 2019

Thinking beyond medication; “Just give me medication”; consumerism and loving yourself

Read More

November 2019

Lessons learned from my journey to India and Japan; travel tips; Laughter Meditation; Sharing Solutions

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October 2019

Two STUMP THE SHRINK questions on passive compliance and substance use while in treatment; customer-focused and friendly

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September 2019

What are social determinants of health? Aging providers and the next generation

Welcome to the September edition of Tips and Topics (TNT). My heartfelt thanks to the many readers who took the time to write and share their support and feelings about the August all-SOUL edition.
This month in SAVVY, the focus is on social determinants of health.
In SKILLS, it is important to assess and include social determinants in treatment planning, not as an afterthought or “discharge planning” task.
In SOUL, a guest contributor asks “how do we capture our faith, skills and experiences in order to share and pass them along to the next generations of professionals?”

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August 2019

All SOUL – grief, loss, and moving forward. Perspectives from my children and me.

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July 2019

Behavior Contracts – the good, the bad and how to move away from them; Surpises about food and the environment

In SAVVY, we focus on the advantages and disadvantages of Behavior Contracts.
In SKILLS, I invite you to delete Behavior Contracts from your clinical toolkit.
In SOUL, I was shocked to learn that that a quarter of the world’s greenhouse gas emissions come from putting food on the table.

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June 2019

What to do about addiction clients with prescribed, potentially addictive medications; Pickleball anyone?

In SAVVY and STUMP THE SHRINK, I respond to a question on what to do about psychiatric prescriptions for benzodiazepines and amphetamines in addiction treatment.
In SKILLS, assessment needs a skilled clinician who is savvy about addiction and mental illness who can evaluate specific diagnostic and treatment questions.
In SOUL, I was introduced to Pickleball and now exercise could actually be fun for me.

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May 2019

Lying and dishonesty in Treatment Courts and what to do; using ACCEPT with dishonesty; update on my grief process.

Welcome to the May edition of Tips and Topics (TNT). A special welcome and thanks to those readers who have been with me from the beginning and wrote to express their appreciation through all the years.

In SAVVY and STUMP THE SHRINK, I respond to a question on what to do about lying and dishonesty in Drug Courts – what is the role of sanctions?

In SKILLS, what is the role of treatment and judges and court teams when participants lie? Using ACCEPT as a structure to guide what to do.

In SOUL, I update where I am in my grieving process. It helps me to reflect and I hope helps you understand grief too.

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April 2019

What to do with poor outcomes: ACCEPT; my top 10 “Unvarnished Truths”

Welcome to the start of the 17th year of Tips and Topics (TNT). Most of you were not a reader from Day 1 when I started writing TNT, April 2003. If you were, please write and let me know.
In SAVVY, I’m introducing an acronym to help think through what to do when a client, patient or participant is not doing well in treatment – ACCEPT © David Mee-Lee 2019.
In SKILLS, what is a poor outcome for your client in addiction treatment?
In SOUL, whether you are thinking about retirement or not, “21 Unvarnished Truths about Retirement” is a worthwhile list from which I highlight my favorites.

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March 2019

Guest writer Tips on Sports Betting; one more SOUL on losing my wife and grief

SAVVY and SKILLS – March is Problem Gambling Awareness Month, which is why this edition comes to you earlier than usual, so you can be aware. Having a guest writer was good for me as I continue in the acute phase of grieving over the loss of my wife a few weeks ago.

SOUL – A bit more on grief and loss this month and then I’ll leave that alone for a while – in Tips and Topics, not my life.

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