TIPS & TOPICS
Volume 5, No.1
In this issue
— STUMP THE SHRINK
— Until Next Time
Welcome to the start of the fifth year of publishing TIPS and TOPICS. The first edition hit cyberspace in April 2003. You can see all previous editions and print them out from the website.
In the January 2004 edition of TIPS and TOPICS, I talked about an addiction medicine physician who was distressed and concerned about the increasing use of “client”, “consumer” and “customer”. He was deeply committed to treating the sick and suffering person with alcoholism and drug addiction. The addiction treatment field had fought long and hard to have medicine, society, health insurance, payers and disability policies recognize alcoholism and addiction as a disease and chronic illness. To this dedicated physician the patients were ill and needed healthcare; not consumers or customers at a supermarket or hardware store who needed to buy butter or light bulbs. It was painful for him to see the shift that consumer advocates and empowerment movements have been promoting.
I decided to revisit these issues in more detail.
- Consider the pros and cons of different terms and the flexible use of those terms appropriate to the situation.
There are strong arguments and sentiments for the use of various terms. There will likely be no consensus because different situations and contexts call for the use of different terms. If you are committed to advancing care for people with substance use problems, I’d encourage you to consider all the issues that different terms emphasize. Don’t worry if I didn’t mention your pet peeve or critical idea. What follows are just some ideas to get you started:
patient 1. Positions addiction as an illness and health care concern; promotes the disease concept and “brain disorder”.
2. Helps society, policy makers, payers, families and those afflicted to eliminate discrimination, stigma, counterproductive guilt and attitudes about willful misconduct.
3. Conveys to people and their significant others that they should comply with treatment in the same way that they should take their insulin or antihypertensive medication; exercise and change their lifestyle and eating habits
1. Over-emphasizes the medical model and robs a focus on psychosocial, cultural, public health and societal factors in etiology and treatment.
2. Encourages people to blame their genetics, neurotransmitters or their family for having a disease instead of accepting responsibility for behavior change.
3. Disempowers people and decreases choice when healthcare professionals tell people they have a disease and need to comply with treatment and the program.
client 1. Allows addiction to still be a health care concern, but conveys a more collaborative process with a person who has sought help with a problem.
2. Brings addiction treatment more in line with mental health treatment where most care givers are not nurses and physicians working in hospitals and medical facilities.
3. Conveys to people and their significant others that they have chosen services and can consult with a professional to help develop a participatory plan for which they are responsible to implement.
1. Dilutes the case for advocacy for parity of health care benefits with other medical illnesses; it allows addiction to be paired with mental illness which also suffers from discrimination and lack of parity.
2. Decreases emphasis on addiction as a chronic illness and hampers adoption of pharmacotherapies and disease management approaches.
3. Conveys to people and their significant others that they can disagree with treatment recommendations that could encourage non-compliance with prescribed treatment.
consumer 1. Broadens thinking about those affected by substance use problems to include the vast majority of people who do not access treatment; or may not have progressed to a more severe level of addiction.
2. Helps society, policy makers, payers, and health care professionals to broaden funds, outreach and services to attract a wider population of people into care.
3. Empowers people to advocate for improved access, quality and affordability of services. Conveys the right and opportunity for more input and choice in treatment.
1. Plays into discriminatory attitudes of health care professionals, policy makers and payers to marginalize addiction treatment and to keep viewing addiction problems as a choice instead of a disease.
2. Health care coverage and benefit plans are already too limited without using terms that encourage further denial of care and resources.
3. Conveys to people and their significant others that their opinions and wishes are more important than the treatment professional’s assessment and treatment plan.
customer 1. Emphasizes that care givers are serving people who choose treatment either because they want recovery; or at least to avoid a major negative consequence. Organizations that want to attract “customers” into recovery will promote quality improvement to welcome people; decrease waiting lists; improve premature discharges and dropout rates; increase access to services.
2. A service mentality promotes collaborative, person-centered services and the use of motivational enhancement strategies. It emphasizes engagement and strategies to attract people into recovery.
3. Conveys to people that they are not a victim of the courts, employers or child protection workers. Since they chose treatment that they could have refused, this is both empowering, but also emphasizes personal responsibility for adhering to a collaborative plan of services.
1. Health care professionals focus on assessment and treatment planning; and with high caseloads and funding restrictions don’t have expertise, interest or time to embrace a service mentality.
2. With so many patients’ lives being devastated by addiction and their choices having led to biopsychosocial dysfunction, it is a disservice to convey a message that they should have choice in treatment.
3. The reality is that many patients would not want treatment if they had not been mandated to attend. So why pretend that they had a choice and are a “customer”. The focus should be more on their compliance with the treatment plan and program. Also, given that they are “in denial” and minimize the severity of their problems, the focus should be more on confrontation, not choice.
Recently I trained about 500 probation officers with a tough job of working with juvenile offenders who aren’t exactly rushing to take responsibility for their actions. I also had a tough job. Each day for three weeks, a group of 30 to 40 probation officers presented for training on Motivational Interviewing. All of them were mandated to attend the training! They weren’t exactly rushing to learn how to engage their probation clients in participatory relationships.
In many addiction programs and less so in mental health, the numbers of clients mandated for treatment can reach 80%, even more sometimes. Even if not formally mandated to treatment, many clients can feel forced into treatment by a family member, supervisor or health care professional. I asked the probation officers what were the feelings and behaviors they noticed in their clients; and what they do that works to engage the minors in that first encounter.
- Tune into what your clients are feeling on that first visit. Identify what methods you use to effectively engage a reluctant client. Here are what probation officers see and do (in no particular order).
How do mandated clients feel?
Fearful, resentful, defensive, unsure, angry, nervous, denying, aggressive, passive, agitated, skeptical, frustrated, uncertain, reserved, depressed, blame others, closed, annoyed, overwhelmed, confused, scared, distressed, anxious, aggravated, ambivalent, manipulated, irritated, ashamed, hostile, intimidated, embarrassed, curious, furious, panicked, afraid, apprehensive.
What methods work to engage clients? Suggestions from Probation Officers:
–> Use a tone of voice that is not threatening
–> Assess from their body language what the client might be feeling
–> Make the client feel comfortable and that you are interested in them; conversation about what the client likes e.g., hobbies etc.
–> Get them to talk about themselves and what they like to do
–> Adopt a posture that is not intimidating; rearrange the desk so you are sitting beside the client or at least not behind the desk
–> Be genuine and convey that you care about the client as a person – “I am here to help you” – Give tools to complete probation; convey compassion – “I understand”
–> Compliment them for coming – it’s a first step; compliment them for appropriate dress and promptness if it is clear they have made the effort to dress respectfully and to be prompt
–> Discuss responsibilities and roles; give them knowledge and not in legalese; “I understand how you feel about all these questions”; use language they understand
–> Use humor to break the ice: Ask “Why are you here? The client may answer: “I don’t know”. You may answer jokingly: “I don’t know either, so let’s go.” But then actually explain to the client why he is here and listen for any misunderstandings.
–> Listen and do not cut them off; let them vent to begin with if necessary. Be respectful and non-judgmental. Be proactive and matter-of-fact to help the client move forward.
–> Create a comfortable climate of respect and dignity; create a relationship explaining expectations; negotiate with the client, but also explain limits and boundaries.
–> Ask open-ended questions -“What is your understanding of why you are here today?” rather than “Do you know why you are here?” The latter closed-end question can be answered in one word ‘yes’ or ‘no’ and doesn’t open up conversation.
You probably do your own version of these. The first principle of Motivational Interviewing- express empathy – is always a good place to start. If in doubt about where to start with a client, start with empathy.
I was surprised to hear on the Today show that if everyone kept their car tires inflated at the manufacturers’ recommended pressure, together we could realize a 6% decrease in gasoline consumption. This would be the equivalent to the output of three oil refineries. If that is true, it gave added meaning to the importance of working together as a team – TEAM = Together Everyone Achieves More.
Governor Corzine of New Jersey was in the hospital for two and a half weeks after being seriously injured in a car crash on April 12. The governor’s SUV was being driven by a state trooper at 91 mph when it was clipped by a truck, lost control, slamming into a guard rail. He fractured his left thigh, broke 11 ribs, his breastbone and other bones in the crash. The Governor was operated on three times; a metal rod was inserted to stabilize his leg. He will likely need crutches or a cane for at least six months. Governor Corzine was not wearing his seat belt. The state trooper driver was wearing his seat belt and walked away unharmed.
Often the little things we do have much greater impact than grand schemes and lofty visions. Grand visions are still important. But who would have thought that a little air in your tires could contribute so much to cleaner air and environmental health? Don’t you think Governor Corzine wishes now that he had taken the five seconds to buckle his seat belt? Not to mention the costs to human suffering, health care and law enforcement of the thousands of times the Governor’s mistake is repeated every day—often with even more tragic consequences.
Gives added emphasis to “an ounce of prevention is worth a pound of cure.” So pump up your tires; buckle your seat belt; and Together Everyone Achieves More.
STUMP THE SHRINK
Our insurance contracts require that we separate the Assessment and the Treatment Planning Session (by the ASAM assessment dimensions). Before leaving the assessment, what can we give our clients in the way of an exercise-worksheet they can use to prepare for the Treatment Planning Session?
I am not sure why an insurance contract would want you to have to separate out the assessment session from the treatment planning session. They usually want you to be as efficient as possible. If you are ready to discuss assessment and treatment planning all at the same time, I would get started as soon as possible on discussing treatment strategies.
Clinically, I recommend that every session, especially the first session, end with some priority-setting based on what the client wants.
Example: If the client wants abstinence and sobriety, there are usually two or three areas obvious from the assessment which the client can start with:
1. attend some AA meetings and see what they are like;
2. track cravings; recall what has worked in the past to deal with them, and again track what works (or not) before the next session;
3. think about which friends to stay away from and start doing that.
Example: The client may be mandated to treatment and only came to the assessment to basically comply, to avoid going to jail or losing their children. They may feel they don’t have a substance problem and can stop any time they want. So then the task before the next session might be:
1. have a diagnostic trial of abstinence and track how well it went and how they did that;
2. if abstinence didn’t go well and they used, then log what happened that they couldn’t keep their plan to be abstinent as a diagnostic trial.
Example: The person may feel they don’t have a parenting problem. The task before the next visit:
1. track all the parenting situations that went well, what they did to not lose their temper, yell or hit their child.
2. if things didn’t go well, observe what happened and discuss what they could have done differently perhaps.
There is always some initial treatment plan that arises directly from the assessment that can jump start the treatment process and the treatment planning documentation process.
Until Next Time
Thanks for starting out our fifth year together. See you in late May.