April 2003
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In this issue
-- Why I started this Ezine!
-- What to expect from the Ezine
-- SAVVY........
-- SKILLS........
-- SOUL.........
-- STUMP the SHRINK...
-- Until next time......

WELCOME!

This is the very first edition of "Tips and Topics", and marks the beginning of my free monthly Ezine. I know we are all overwhelmed with information, spam and solicitations. So, you might ask, why add to that wave of material?

Why I started this Ezine!
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>> Clinicians have ongoing clinical questions that need answers!

I have been training and consulting for over 25 years, but fulltime for nearly the last seven years. I travel the country & get repeated requests for answers to questions on the American Society of Addiction Medicine (ASAM) Patient Placement Criteria and other topics. People ask about books, videos and audio learning materials they can obtain. They want help to implement and apply knowledge and skills presented in one or two-day workshops. An Ezine is one way to answer those common questions and requests more efficiently.

>> To help people apply new-found knowledge!

Budget deficits are hitting almost every state. Attending a workshop can change one's knowledge and skills immediately. However, fewer can afford to take the time and funds to learn onsite at a workshop. Continual learning is essential, but a challenge to achieve without some ongoing prompting, supervision or assistance. An Ezine is a vehicle to provide supplements and support to previous workshop attendees, or to those who have so far been unable to get to an onsite training.

>>Because I want to make a difference in our field!

Out of sight, out of mind! I want my work to make a real difference in providing, managing and funding person-centered services. An Ezine is a channel available to stay in touch and keep making positive changes in our work. It is a way to feed "Tips and Topics" to healthcare providers sincerely interested in applying concepts and skills to change( for the better) the way we serve people in behavioral health.

What to expect from the Ezine
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>> You will receive it once a month.
Please forward it to other interested individuals. Suggest that colleagues sign up on my website.

>> It will be a relatively brief communication.
While, on occasion, I may excerpt or include material from other sources (appropriately referenced of course), most material will be original and be focused on practical tips and topics in the following areas:
-- implementation of the ASAM Patient Placement Criteria;
-- providing and documenting individualized person- centered services;
-- clinical and systems issues to do with co-occurring mental and substance-related disorders (dual diagnosis);
-- ways to engage, empower and collaborate with people in getting what they want and changing what they want.

>> There will be 3 Sections: SAVVY, SKILLS, and SOUL
Each section will hopefully imrpove who we are as professionals and as people - it's not just about "doing", but also about the "being"!
"Savvy"- to improve our knowledge, wisdom and practical grasp of topics;
"Skills" to focus on tips to improve practical competence;
"Soul" to enrich a person's total self - both yourself and others;

>>From time to time, I will add in "Successes" & "Stump the Shrink"
In "Successes", I'll share what has been working for you and others in the practice of "doing" and "being".
In "Stump the Shrink", I will focus on questions and dilemmas you and others face in the "real world. " I'll try to answer them; or perhaps I'll be stumped for a good answer.

>> YOU CAN EXPECT THE NEXT ISSUE TO BE MUCH SHORTER.

So enough introduction. On with it!

SAVVY........
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As many of you know, I am Chair of the ASAM Criteria Committee and Chief Editor of the Second Edition Revised (ASAM PPC-2R) published in 2001, which included criteria for co-occurring disorders and revamped the six ASAM assessment dimensions. As part of that revision, the dimensions can now be much better applied to assessment of not only substance-related disorders, but also for mental health as well. Here is a reminder of the six dimensions and a few tips on understanding them.

The common language of the six assessment dimensions of the ASAM Patient Placement Criteria can be used to determine multidimensional assessment of severity and level of function of behavioral health disorders.

1. Acute intoxication and/or withdrawal potential
2. Biomedical conditions and complications
3. Emotional/behavioral/cognitive conditions and complications
4. Readiness to Change (formerly Treatment acceptance/resistance)
5. Relapse/Continued Use/Continued Problem potential
6. Recovery environment

Tips:

• Each assessment dimension is not intended to fragment people into separate boxes. The dimensions focus on the severity or function and the kind of services needed for that dimension e.g., detoxification services for Dimension 1; physical health services for Dimension 2; mental health services for Dimension 3; motivational enhancement and engagement services for Dimension 4; relapse or continued use or problem prevention for Dimension 5; and family, friends, vocational, legal, housing, transportation, child care, financial and community services for Dimension 6.

• Dimension 4 assesses and addresses where the person is in their "heart" as regards readiness to embrace and work on abstinence or full mental health functioning. It is not, as some applied in the previous name for Dimension 4, a measure of how big a stick you might have to get them to accept treatment or not.

• If you find a person has a positive drug urine screen, don't be quick to apply relapse prevention strategies (Dimension 5). First check whether the person was even trying not to use. If they are saying something like: "I'm not going to stop smoking weed because it relaxes me and it's natural anyway", then that is a Dimension 4 issue, not a Dimension 5 relapse issue. There is high continued use potential. However, the treatment interventions will be focused on Dimension 4. The work first will revolve around helping the person deal with their readiness (or not) to address their marijuana use.

SKILLS........
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When assessing the severity or level of function (LOF) for each ASAM dimension, it is useful to consider the three H's:

History; Here and Now; and How Worried Now.

The History is important, but never overrides the Here and Now. For example, if by History, a person has had severe alcohol withdrawal with seizures, but has not been drinking Here and Now at a rate or quantity that would predict any significant withdrawal; and as you look at them, they are not shaky or in withdrawal so you are not Worried about severe withdrawal - then there is no significant Dimension 1 severity.

The Here and Now can override the History. For example, if a person has never had serious suicidal behavior before by History, but Here and Now is depressed and impulsively suicidal, you would not dismiss their severe suicidality just because they had never done anything serious before. Especially if you talked with them now and you are Worried that they could not reach out to someone if they became impulsive, then the Dimension 3 severity would be quite high.

Tips:

• To prepare or present the multidimensional severity or level of function profile after initial assessment, first decide what the severity of each dimension is. Do this by reviewing the biopsychosocial data and zero-ing in on the pertinent aspects of the 3H's for each dimension.

• When you present the severity or LOF to team members or a managed care reviewer, state first your severity or LOF rating. Then justify and explain that rating by reciting which parts of the History, Here and Now finding and How Worried Now led you to that severity rating.

• Do not ramble on, reciting every minute detail of the person's history and treatment episodes. Stay focused on a brief explanation of your rating, using the framework of the 3H's to structure your information. For example, you might state: "Dimension 5 is high severity. Even though the client wants to stop using all substances (Dimension 4), he has never had a history of being able to stay abstinent for longer than two weeks. He has never had treatment or experience with recovery groups. Here and now he has intense cravings with few peer refusal and coping skills. As I look at him, he is anxious, craving and I am worried now that he has no internal knowledge, coping skills or ability to prevent continued alcohol use."

SOUL.........
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The other day I was delivering a training on "Keeping the Behavioral Health Team Healthy: Communication, Conflicts and Coping". I shared with my audience some observations of a recent visit to the main Post Office in my hometown. Due to budget cutbacks, the Post Office has shut down some branches creating longer lines and waiting times at the central facility. Let me share my observations from a simple visit to the PO - to illustrate how "crazy" we sometimes make ourselves.

In most of what we do, we are using who we are - our feelings, our centeredness, our reactions - as part of the vehicle and catalyst for change. It makes sense to observe ourselves, to take responsibility to take care of business - keep ourselves healthy to maximize our usefulness to others.

Here are seven ways I increased my stress level that day in the Post Office:

1. I arrived and saw the long line snaking out into the PO lobby and immediately huffed and puffed and rolled my eyes with frustration.
2. I noticed a PO employee walking around in the back behind the PO desk clerks. I started judging them as to why they were not helping service the line. Logically, I knew their job may not have been that of a front desk clerk, but that didn't stop me judging them for not working to reduce the long line.
3. When another PO clerk did arrive, she took forever to log in at her booth and start serving customers. "What does it take to put her stamps and money in the drawer and punch in her password into the computer?" I fumed to myself.
4. A clerk came free, but the next person in line was not watching. The line was slowed up because they had to be waved at, called out to, and signaled to proceed to the next open counter. Again I fumed inside: "Why can't people be watching? Don't they know the line is long and how can you be so out of it to not be ready to immediately proceed as soon as a clerk opens up?"
5. Another clerk came free. This time, the next in line noticed, but sauntered ever so slowly to the booth to be served. I wasted energy analyzing and judging them: "Is this some kind of passive aggressive act - that they would walk so slowly when they know everyone wants the line to move along?"
6. With two people served in quick succession, the line should now be moving along nicely. But could you believe it? The next two in line were talking and socializing, and didn't immediately take up the slack and advance. Another chance to fume inside: "Please watch will you two - can't you see we want the line to feel like it's moving along. Take up the slack and quit talking so much!"
7. Now I finally get my turn. I buy my stamps. Then the postal worker starts reciting their litany of services: Do I want insure the letter? How about Priority Mail rather than regular? Return Receipt Request by any chance? How about other stamps I might need? This was getting worse than a telemarketer interrupting my dinner. "Just give me the stamps and let me get out of here." I smiled all through this - which only added to my stress, as it didn't match what I was thinking or feeling inside. And faking it this time did not make it!

Before you judge me too much, look inside your memory banks and see if you can identify - if not in the Post Office, check how you drive on the road; or how you are in the checkout line of the supermarket; or how you treated you loved ones recently. If you cannot relate in any way, congratulations! ...Celebrate whatever self-care methods you are employing to continue staying healthy and available to those you serve. You may be where I want to be.

STUMP the SHRINK...
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From a real email

"Dr. Mee-Lee:
I am reviewing ASAM and my notes and your handouts from a training you did last summer. I am unable to come up with a good answer for the staff I'm working with and thought maybe you could help. The question has to do with methadone clients. In reviewing the ASAM manual, I did not find what the level of care placement would be for a methadone client who continues to smoke marijuana or drink alcohol, but otherwise is functioning fairly well on the methadone. The ASAM seems to point only to an outpatient level of care unless there are health or emotional issues that warrant an inpatient setting. I guess the bottom line question is, would it be appropriate to rate Dimension 5 as "low" severity when the client is actively using, but functioning well? This has caused much debate among the staff and that is why I thought to ask "the expert"! Any input would be very much appreciated! Thanks Dr. Mee- Lee."
M.H., Project Coordinator.

"Dear M.H.:
Interesting question. If the client continues to drink and smoke marijuana and has no intention to stop, then by definition there is a high potential to continue to use (Dim 5). You could make an argument for not rating Dimension 5 as high severity if there is no imminent danger with that continued use. But just because the client is functioning pretty well, I don't think I could argue for low severity on Dimension 5 as there is almost certainly continued use, especially if he is not trying to stop using.

You could say that he is medium severity, if there is no imminent danger, though I would be inclined to rate it as high severity due to the high potential for continued use. In treatment however, the main dimensional issue is Dimension 4 to work on seeing if he is interested in even considering stopping the alcohol and/or marijuana. So even though I rated Dimension 5 high severity, I would focus on Dimension 4 and watch closely that his continued use in Dimension 5 was not causing any more immediate negative results that could beome dangerous. Hope this helps."

Until next time......
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Well that's it for now. I hope you find these helpful. Feel free to e-mail any comments, successes or questions. I'll address them here as appropriate.
Please provide your name, job title, and agency affiliation, but indicate if you want your identity to be anonymous e.g., initials only or first name etc.
If you haven't visited the website lately, it has been significantly revamped. If you run across any hitches or have suggestions, let us know. I can't guarantee we'll fix or institute them overnight, but your comments are important and we will address them.

Thanks for all you do to help others; and to help me help others too.
David.

Contact Information
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email: info@dmlmd.com
voice: 530-753-4300
web: http://www.dmlmd.com
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