TIPS & TOPICS
Volume 2, No. 6
In this issue
– STUMP THE SHRINK
– Until Next Time
I want to welcome the very large number of new subscribers to TIPS and TOPICS in September- October! You’ll quickly get the gist of the “S” format. When ever any of you have a question or comment, email me. It may be included in “Stump the Shrink.”
Our field can often become absorbed with ‘problems’. If you are doing well, making progress, email me your story for our occasional “Success Stories” section. (Perhaps you have another “S” section suggestion! Email me.) Previous TIPS and TOPICS editions can be accessed on www.davidmeelee.com. Click on “Tips & Topics” on the home page. You always have the option to unsubscribe from the link at the end of each Tips & Topics. I want willing, enthusiastic readers.
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Relapse is one of those common clinical situations where there is a clash in attitudes and practice of addiction treatment professionals and mental health professionals. I have rarely heard of a case- if ever- where an individual in a depression relapse was refused entry to a treatment group, or even discharged for losing control of impulses to cut herself. It is still all too common for a person who used substances on the way to group to be told to return tomorrow when they are sober. Many are still discharged for losing control of their substance use, especially if they’re in a residential program.
- 1. Relapse is a treatment issue which can be assessed and treated. It is not a policy nor an issue of willful misconduct on the client’s part.
While most mental health clinicians would agree with that statement, the addiction treatment field is more ambivalent. There exists such a long tradition of keeping the treatment milieu drug-free. Consequently the relapsing substance user has been neglected much too often. Naturally, if a client brings in drugs to sell or entice others to use with him/her, then discharge is appropriate. You run a treatment place, not a market place! But if people are struggling either with their attitudes about abstinence and/or their skills in controlling substance use, then they need most help when relapse or continued use happens.
“Relapse” in the 2001 Revised Edition of the ASAM PPC-2R
In 2001, Dimension 5 was rephrased as: Dimension 5, Relapse, Continued Use or Continued Problem Potential
New and expanded constructs were provided for Dimension 5. These constructs appear in Appendix C (ASAM PPC-2R, pp 341-353; Gastfriend, 2004 pp 61- 77).
Reference for Constructs:
(2001 Revised Second Edition of the Patient Placement Criteria for the Treatment of Substance- Related Disorders of the American Society of Addiction Medicine (ASAM PPC-2R); Appendix C (ASAM PPC-2R, pp 341-353; Gastfriend, 2004 pp 61- 77)
Why the expanded, revised constructs?
These constructs provide an even clearer focus for assessment of relapse and its treatment. They were informed by, and derived from, several fields of basic and clinical research knowledge: behavioral pharmacology, behavioral psychology, learning theory and psychopathology.
The 4 New Constructs
#1: Historical Pattern of Use
**Chronicity of Problem Use
Question: Since when and how long has the individual had problem use or dependence and at what level of severity?
**Treatment or Change Response
Question: Has he/she managed brief or extended abstinence or reduction in the past?
#2: Pharmacologic Responsivity
**Positive Reinforcement (pleasure, euphoria)
**Negative Reinforcement (withdrawal discomfort, fear)
#3: External Stimuli Responsivity
**Reactivity to Acute Cues (trigger objects and situations)
**Reactivity to Chronic Stress (positive and negative stressors)
#4: Cognitive and behavioral measures of strengths and weaknesses
**Locus of Control and Self-efficacy
Question: Is there an internal sense of self- determination and confidence that the individual can direct his/her own behavioral change?
**Coping Skills (including stimulus control, other cognitive strategies)
**Impulsivity (risk-taking, thrill-seeking)
**Passive and passive/aggressive behavior
Question: Does the individual demonstrate active efforts to anticipate and cope with internal and external stressors, or is there a tendency to leave or assign responsibility to others?
1. Mee-Lee D, Shulman GD, Fishman M, Gastfriend DR, and Griffith JH, eds. (2001). ASAM Patient Placement Criteria for the Treatment of Substance- Related Disorders, Second Edition-Revised (ASAM PPC-2R). Chevy Chase, MD: American Society of Addiction Medicine, Inc.
2. “Addiction Treatment Matching – Research Foundations of the American Society of Addiction Medicine (ASAM) Criteria” Ed. David R. Gastfriend; Released 2004, Haworth Medical Press.
David Gastfriend edited this special edition which represents a significant body of work presented in eight papers. The papers address questions about nosology (def: A systematic arrangement or classification of diseases), methodology, and population differences. It raises important issues to continually refine further work on the ASAM PPC. (To order: 1-800-HAWORTH; or www.haworthpressinc.com)
- 2. Distinguish between Readiness to Change (ASAM Dimension 4) and Relapse, Continued Use or Continued Problem Potential (Dimension 5)
Simply because someone continues to use substances, or suffer with mental health symptoms, doesn’t automatically mean there is a relapse issue to address. The notion of Readiness to Change speaks to where a person’s “heart” is, regarding an interest in changing his substance use, and/or his commitment to improved mental health functioning. Does your client believe they have a substance use or mental health disorder? Is she ambivalent about change or committed to it? Is your client even interested in recovery? Or more invested in staying out of jail, getting her children back, keeping a job or a relationship?
ASAM Dimension 5, on the other hand, addresses a person’s attitudes, knowledge and skills to actually change and cope with substance use and mental health problems. Before 5 comes 4. If a person doesn’t even think they have a substance or mental health problem (Dimension 4), then there is likely to be little interest in preventing continued use, relapse, or in pursuing recovery skills (Dimension 5).
However, an individual might be well aware of his substance use, troubled by his mental health problems and be ready to change (Dimension 4). This person’s challenge resides in Dimension 5. He may be at a loss to know how to prevent continued use, problems or relapse.
If clinicians possess knowledge about Stages of Change, Motivational Enhancement therapies, and building a strong treatment alliance, they are equipped to address issues around Readiness to Change. But relapse assessment and treatment is premature unless a client is ready to change, and at the point of struggling with the “how to change” part.
…Distinguish whether you’re looking at a Dimension 4 or Dimension 5 issue.
…If it’s a Readiness to Change issue, then employ motivational enhancement strategies to engage and attract the person into treatment.
…If you’re seeing an issue of relapse, continued use or potential for continued problems, help your client with whatever knowledge and skills necessary to prevent continued use or relapse.
Q: Clients in early stages of change need relapse prevention strategies – True or False?
Think about this – it could be a trick question!
Check the answer at the end of this Skills section.
- 1. If a person arrives at an individual or group session having used alcohol or some other drug, and/or with recurrence of mental health symptoms, first assess for any immediate needs.
Relapse may have involved heavy use of substances. If a person is so intoxicated and their driving under the influence is possible, then immediate observation is required. Protection for that client’s safety and for others is obvious. It is important to observe this person for signs of physical withdrawal. It might be that an individual shows up so depressed, suicidal, or mentally unstable that acute psychiatric protection is needed.
Relapsing use or psychiatric symptoms do not necessarily render the person incapable of benefiting from an individual or group treatment session. If you rule out any immediate instability, then proceed with assessing what went wrong in the treatment plan. Question yourself on how the treatment plan needs to be modified in collaboration with the client. What went wrong? Where did things fall down?
Addiction clinicians often object to relapsing clients attending group sessions on the grounds that they have drugs in their system, and that they cannot benefit from treatment at that point in time in their intoxicated state.
…If the person is so intoxicated with mental clouding and slurred speech etc., by all means take care of the acute intoxication first.
…If the person is so psychotic or suicidal, then again, by all means take care of the acute need for psychiatric stabilization.
…If such immediate needs have been assessed and ruled out, then the client is considered accountable. Aid them in discovering what went wrong. Work with them to change the treatment plan so they do something differently before the next session.
- 2. If a person has a positive drug screen, first check to see if the person was even trying NOT to use.
Your first clinical impulse might be to view the drug use as a relapse issue and to commence relapse prevention strategies. But why would a person be invested in preventing relapse if they aren’t even trying not to use?
“Why should I stop using, I enjoy drugs and I’m not that bad anyway. I never lost a job like he did. I never lost a relationship like she did. I can control my use now that I know I could lose my job.”
A person can’t have a relapse unless they were in recovery prior to that. The steps to relapse: you first have to think you have a problem with substance use, want to stop, did stop, and got into recovery -from which you then relapse!
But if you use because you don’t think using is a problem (and even using is something you want to do), then you are just using and lapsing, not relapsing.
Back to the trick question
Q: Do clients in early stages of change need relapse prevention strategies?
A person in early stages of change doesn’t think he/she has a substance use problem. They do not need motivational enhancement strategies. What they most need is Discovery, Dropout prevention, NOT Recovery, Relapse prevention.
…We want to keep clients coming back so we can help them discover there is a substance use problem. We don’t want them to drop out and lose the opportunity to help move towards readiness, and lose interest to change.
…When a person has moved towards action for change and has discovered that there is more of a problem than they originally thought, then it becomes time to work on recovery and relapse prevention.
I consider myself focused, goal-directed, tenacious and committed. But if I tried year after year to achieve an important goal, trying 20, 30 and 40 years or more and kept failing, I am not sure I would have energy or faith to believe in myself any more. Add to that yet another year attempting to achieve a goal even more monumental, something never before achieved before in history. I know I would give up, tired from years of trying.
I lived and worked in the Boston area for 17 years. Those were important years in my career and family life. Even a minor sports fan couldn’t help having the Boston Celtics, New England Patriots, and yes the Boston Red Sox, rub off on you some.
As we speak, the Boston Red Sox are competing in the baseball World Series. They’ve had 5 championships in the past 103 years; been in the World Series only four times since they last won in 1918. (Their rival New York Yankees have won 26 championships.)
Two weeks ago, the Red Sox faced painful odds and challenge. They were down 0-3 in a best of seven series with the Yankees. No one in history has ever come back from that kind of situation and won.
At the 0-3 games point against the Yankees, statistics show they should have given up. I had given up, lost faith yet again in the ever disappointing Red Sox. Apparently the Red Sox team did not lose faith like me. They believed in themselves, defied history to come back and win the remaining 4 consecutive games to enter the World Series. And now -as I write- with 3 games to zero against the Cardinals, they are half way to winning it all.
It’s just a game. But this year I learned something from the Red Sox, clichéd as it may sound:
…The importance of believing in yourself; never giving up on your dreams and goals.
…Even when the odds seem way against you, hanging in can defy the odds. It reminded me that the people and systems we work with may sometimes seem hopeless and incapable of changing. Not tiring out, hanging in is so important.
But with team effort you can defy history and do what it takes. Have you seen that poster? Together, Everyone Achieves More (TEAM).
STUMP THE SHRINK
I am interested in the area of adherence and compliance debate that you raised some time ago and the paternalistic attitude of mental health. We often take a too simplistic approach to clients taking on our treatment plan with or without consent i.e. involuntary treatment if client chooses to challenge the treatment recommended by a psychiatrist. There appears to be a superior view of workers in mental health of “I know what’s best for you” and not necessarily fully appreciating all the other things that occur in an individual’s life. Substance use is one such area… A quote a senior person once said to me on the issue of consumer involvement goes as follows: “Would you ask a passenger on a plane about the flying of that plane; or would a better question be to ask of the comfort that person has whilst traveling on the plane?” The message the person was trying to emphasize is that a client/consumer is well placed to talk to their satisfaction with treatment from a comfort position; but are not informed enough to comment on the content of the treatment. Personally I found this challenging in some aspects as I felt it minimized the consumer input to that of only comfort and had a “holier than though” mentality. Maybe you have a comment on this.
As regards the comment about consumers and planes and pilots, I think the analogy breaks down in this way: In a plane, customers go along for the ride and are in no position to necessarily know anything about flying. But with mental health and addiction treatment, the person/consumer IS the plane and we had better get them involved in piloting it and learning about how it works best etc. If your senior person plans to live with the client/consumer/patient and tell them what to do every minute of the day to help them live productively and happily, maybe he can pilot the consumer’s life. But since we have to help clients live THEIR lives, then they need to be the pilot. I think I am getting the analogy right. What do you think?
I think that is a great response to the analogy. Thanks very much.
Until Next Time
Thanks for reading. I’m glad you could join me in TIPS and TOPICS. Got to get back to the game – go Red Sox!
IT’S OVER. THEY WON! -The Editor
Talk to you in November.