November 2022

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

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

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

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

savvy

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

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

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

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

Tip 1

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

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

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

Tip 2

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

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

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

Tip 3

Here is what “Basic Welcoming” sounds like.

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

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

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

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

Tip 4

Consider now “Intermediate Welcoming”.

What intermediate welcoming looks like: 

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

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

Tip 5

What is “Advanced Welcoming”?

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

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

skills

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

Tip 1

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

“Do you promise to be med compliant?”.

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

Tip 2

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

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

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

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

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

Similarly, for people with mental health needs:

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

Tip 3

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

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

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

Tip 4

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

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

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

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

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

Brief Bio – Kenneth Minkoff, M.D.

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

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

soul

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

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

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

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

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

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

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