~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ "TIPS and TOPICS" from David Mee-Lee, M.D. Vol 1, No.3 June 2003 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ In this issue -- SAVVY -- SKILLS -- SOUL -- SUCCESS STORIES -- Until next time...... WELCOME! Thank-you for taking the time to read this third edition of TIPS and TOPICS. If you are receiving this for the first time, the April and May editions are on my website, www.DMLMD.com. Certainly feel free to forward TIPS and TOPICS to others who may be interested. SAVVY ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ There is one assessment dimension of the Revised Second Edition of the Patient Placement Criteria of the American Society of Addiction Medicine (ASAM PPC-2R) that potentially has the greatest impact on how we assess, refer and treat people with substance use and mental health problems. It is Dimension 4 - Readiness to Change. In our field, there is increasing interest in strength-based, client-centered, consumer-driven, customer-focused services that empower clients who come to us to use their own (and community) resources to enhance recovery. Despite the rhetoric of person-centered services, unfortunately clinicians' attitudes, knowledge and skills too often create services that are clinician-centered, not client-centered. Many programs and services are designed and dominated by program ideology, referral-source mandates, and funding guidelines. What the client, patient, person, consumer or customer wants- and even needs- are a long second, third or even sixth place concern. Tips: Many of you are already well versed in Stages of Change models and motivational enhancement strategies. But in case you are not, Procahska and DiClemente's Transtheoretical Model would be a good place to start. Here are a few references for that: Prochaska, JO; Norcross, JC; DiClemente, CC (1994): "Changing For Good" Avon Books, New York. Prochaska, JO (2003): "Enhancing Motivation to Change", Chapter 1 in Section 7, Behavioral Interventions in "Principles of Addiction Medicine" Eds Graham AW, Schultz TK, Mayo-Smith MF, Ries RK, Wilford BB, Third Edition. American Society of Addiction Medicine Inc., Chevy Chase, MD. Prochaska, JO; DiClemente, CC and Norcross, JC (1992): "In Search of How People Change: Applications to Addictive Behaviors" American Psychologist, 47, 1102-1114. People in the Preparation or Action stage are ready to change and are actively doing something about it. They really want to be free of the power of substance and mental health problems over their life. They seek recovery. They also want to prevent relapse into drinking or drugging. They want to stop behaviors like cutting himself/herself, or be free of depression or psychosis. By all means, help them develop a recovery, relapse prevention plan. However, if the person presents for assessment because they want to stay out of jail, keep their job or their family, treatment is definitely warranted. But, the individual may first need to discover that s/he has a substance use and/or mental health problem before ever being interested in preventing relapse or getting into recovery. In other words, he/she needs a "discovery", dropout prevention plan; not a recovery, relapse prevention plan! And there is a big difference between the two plans. If you want to educate yourself on the science and skills behind the importance of more person-centered services, check the work of Scott Miller, Ph.D. and his colleagues at The Institute for the Study of Therapeutic Change, www.talkingcure.com. They review decades of outcomes research on how people change. You may be disturbed, yet illuminated on what they find. William Miller, Ph.D. of Motivational Interviewing is the other Miller you will want to read more about.   SKILLS ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Every day we face pressures for efficiency, accountability, documentation and performance. It can feel like we do not have the luxury to assess and treat a person's readiness to change. The courts, child protective services, employers and welfare-to-work can only give so much time for a chance at treatment. There is a lot of pressure from referral sources to assign a person to a set program that expects quick results in a 30 day, 60 day or 12 month program. Is it really practical to ask a client what they want? Is it feasible to provide services individualized around a participatory treatment plan matched to their particular stage of change? These are dilemmas and hard questions. However the outcomes research data and our clinical "gut" tell us that unless the individual is an active participant in treatment, we are unlikely to really help them to change. We want them to do treatment, not time. We want them to have lasting results in public safety, good parenting, productive employment and social independence. Tips: If you ask a person "How can I help you? What do you want help with?"- do you really mean it? They may say something like "I want to be clean and sober", but were just referred by the probation officer or employer. What they really want may be a letter and to stay out of jail or to keep their job; not serenity and sobriety one day at a time. Dig more deeply. Create a therapeutic alliance around what the person really wants, not what they think you want to hear or what you think they should want. Again, they may first need a "discovery", dropout prevention plan; not a recovery, relapse prevention plan. If you already have a set program and treatment agenda that you are unwilling to adjust, better not to ask them what they want. If you do ask, they might actually want you to listen to what they say!   A "discovery", dropout prevention plan can use strategies like: >>"Ask two old timers at an AA meeting why they think you may have an alcohol problem simply because you got two DUIs. Report back to group". or >> "Keep a log of all the times you are late with your curfew. See if you parents are on your back more or off your back when you are late". A recovery, relapse prevention plan may have strategies like: >>"Go to an AA meeting to get two names and numbers and to find a sponsor". or >> "Develop your plan on how not to be late. Ask your group for feedback on how to improve the plan". Can you can see the distinction between "discovery" and "recovery" strategies?   A treatment plan in which a client participates actively solicits the clients' ideas on the problem and the solution. People often have strong ideas about what they think will work, or what they will or won't do. For example: "I don't want to be in groups, or go to AA, or take medication, or go to residential". You can respond several ways. Response #1: "Do it or else you won't get your letter". Or "That's the program" (and I have a bigger stick than you). Response #2: You can educate them on the wisdom of your recommendations. If they understand and accept your views, fine. If they remain ambivalent or unconvinced, you may need to start with their plan. If their plan is imminently dangerous, this society allows us to override a person's opinions and rights. If dangerousness is not a concern, I'd recommend you start with a treatment plan that only includes strategies the person wholeheartedly agrees to do. This will increase both personal effort and accountability. A SPECIAL NOTE: I am pleased to announce the release of a Training Album on this topic I have been discussing. The training module is titled "Enhancing Motivation: How to Engage People into Addictions Treatment". This album contains a CD, Videotape and Companion Guide. Read more about it at the link below. Click here for a time-limited, special introductory offer! SOUL ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Last summer, my family had the privilege of traveling in France, Spain and Italy. Everywhere we went, we continued to be surprised again at how widespread cigarette smoking still is in Europe. As a California resident, (where smoking is not allowed in bars, restaurants and many public places) I was reminded how different cultures and attitudes can be. A couple of weeks ago, I was in Washington, DC., invited to address a joint European Union/USA meeting on treating the difficult patient at the Office of National Drug Control Policy. The night before, I walked into the hotel sports bar for a light dinner. The place was filled with smoke. I had to quickly move to the less atmospheric, but smoke-free lobby lounge. I was surprised to see how different the culture and attitudes can be - even in the USA. In the meeting, we compared and contrasted the Europeans' approach to demand reduction with that of the United States. I was struck again how different we are in culture, attitudes, perspectives and solutions. (Have you ever visited an injection clinic where you can shoot up so long as you bring your own drugs? Clean needles and hygienic clinic supplied!) It is easy to argue and fight with righteous indignation for the causes and concepts we firmly believe. We should not shrink from standing for what we believe is right. But you don't even have to travel to Europe, or from California to Washington, DC to face attitude and culture differences. Just notice if the next client or team member agrees with everything you assess or recommend. What I want and what "the other" wants can often be as different as a smoke-filled room and a crisp, clean morning in Yosemite. Increasingly I want to find effective and efficient ways to achieve results together. Counselor to client. Team member to team member. Care provider to care manager. Administrator to advocate. It starts with me. Was it Gandhi who said: "Be the change you wish to see in the world"? SUCCESS STORIES ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ In the "Skills" section of the first edition of TIPS and TOPICS, I discussed how to organize and present assessment data using the structure of the six ASAM PPC-2R assessment dimensions. One workshop attendee and unofficial supervisee has persevered to discipline himself to stay focused on the client and the assessment. About his presentations to managed care, he writes this: "My denials from Managed Care Organizations have dropped to almost none. I am able to present myself more cogently, briefly and to properly present the criteria to ensure proper treatment. I have been complimented on my presentation by insurance company reps." - Paul Herman, M.Ed., Evaluation Therapist, for a large treatment program with multiple levels of care. Maybe there's hope we could end the game-playing between providers and managed care companies. Maybe providers can prevent the impulse to exaggerate severity to get authorization of care - e.g., the patient is suicidal. Maybe care managers can resist the reaction to minimize severity; or resort to blanket statements like "it doesn't meet medical necessity". I wonder if we could ever start managing care- all of us? It could start with how we organize and present the assessment data. Until next time...... ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Send us any comments or Success Stories on implementing any of the TIPS and TOPICS. Send any questions to Stump the Shrink. (Tell me how much identifying data you are comfortable with my sharing here.) All the best... David P.S. Time is running out to be part of a select group in a 3 day "Supervisor Intensive", train-the-trainers workshop in Davis, CA July 30-August 1, 2003. Learn more about the Supervisor Intensive. Click here. Contact Information ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ email: info@dmlmd.com voice: 530-753-4300 web: http://www.dmlmd.com ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~