David Mee-Lee Training and Consulting

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"TIPS and TOPICS" from David Mee-Lee, M.D.
Vol 1, No.4

July 2003
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In this issue
-- SAVVY
-- SKILLS
-- SOUL
-- Until next time......

If you missed earlier editions, you can read them by clicking the 'Read back Issues' link on the left hand side of my website's homepage: http://www.DMLMD.co mm. Feel free to forward TIPS and TOPICS to anyone who may be interested. Suggest to them they sign up on the website to receive this ezine directly.

I have never yet seen a brochure or program description that says: "We treat everyone as if they are a diagnostic code or case number. We develop treatment plans that are fixed and generic regardless of a person's assessed individual needs." All agencies say they espouse individualized treatment based on the person's unique assessment of specific needs. But then you look at the treatment plan in all the charts and the problem statements all sound the same: "Lacks understanding of disease concept", "Knowledge deficit about addiction", "Lacks positive support environment", "Relapse issues", "Legal problems".

The treatment plans all sound the same too: "Individual therapy, group therapy, Step 1 Workbook, AA meetings, get a sponsor etc". Even the progress notes sound the same in every chart: "Attended group, gave positive feedback to others, gaining insight into his disease, continue current treatment objectives." And there are still some programs that have fixed length of stay programs e.g., 28 days, three months, 24 intensive outpatient sessions.

Do all the patients and clients actually have the same severity of illness? Do they have exactly the same problems? Do they need the exact same strategies to which they respond and progress at exactly the same rate of success? Are they ready to leave after exactly the same length of stay?

Principle No. 4 in the "Principles of Effective Treatment - A Research-Based Guide" published by the National Institute on Drug Abuse (NIDA, 2000) begins: "An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that the plan meets the person's changing needs."
"Treatment plans are living, continuously evolving documents intended to guide treatment interventions and track the patient's progress" ("Patient Records in Addiction Treatment - Documenting the Quality of Care" Joint Commission of Accreditation of Healthcare Organizations" 1992, p.29)
"Each person served is actively involved in, and has a significant role in, the individual planning process and has a major role in determining the direction of his/her individual plan---Planning is consumer-directed and person-centered" (The Commission on Accreditation of Rehabilitation Facilities, CARF, Behavioral Health Standards Manual, July 2003-June 2004, p.60)
Try this experiment!
Go to the chart rack of your program; or review treatment plans that you see in assessments, reports or referral documents. Gather four or five at random and see if you can clearly distinguish the unique treatment issues and strategies of each client, by reading the treatment plan and progress notes. If you can, great! Find what works to make those charts a living, vibrant and evolving treatment guide and share that wisdom around. If they sound much the same, here's an opportunity to recommit to consumer-directed and person-centered services.

Walking the talk on individualized treatment in services and documentation is hard for clinicians and programs - as hard as it is for clients to follow through with attitude, skills and behavior change for any mental health or substance use problem. Here are some tips to tweak and improve what you may already have achieved in making those treatment plans individualized, living, evolving, participatory and person-centered.

At the next individual or group session you have with clients, ask each client at the very beginning of the session: "What do you want to get out of today's session that will help you advance your treatment plan?" If you get a blank stare; or a generic, general comment like: "To improve my self esteem; or gain more understanding about recovery", then you know you are not doing individualized treatment - the person is likely in the program doing time, not doing treatment.

But if they say something like: "I'm supposed to share with group my decisional balance sheet of the pros and cons of stopping drinking and get feedback" - then you are well on your way to person-centered services.
Before you document in the treatment plan any problem statement or treatment issue, ask yourself: What Made Me Say That? If you can answer that question with something more specific that the client said or that your assessment indicated, then write that down as the problem statement or focus of treatment, not the more generic problem that is abstracted back one or two levels.

Example:
If you have an impulse to write: "Lacks positive support recovery environment", ask What Made Me Say That? If your immediate response is: "Well he lives with a drug dealer"- then that may be the problem to write in the treatment plan. Or if your response is: "Her husband beats her up" - then that is the problem to write.
Look at a series of progress notes in a chart, sequenced by date, and read them in order from oldest to most recent. Without looking at the problem list or statement, see if you can get a sense of what problem, treatment issue, knowledge or skills deficit is being helped by the treatment plan and service. Pay attention to these "ifs" with the notes.
If it seems like a disjointed, mish-mash of notes about whether a person attended a group or a session or did not-----
If there are disconnected anecdotes on what was discussed-------
If there is a series of generic statements about continuing treatment objectives that could apply to anyone's chart------ then the living, evolving document may actually be a dying, stagnating record.

Last week, I was flying into Rock Springs, Wyoming in one of those planes where everyone is pleased - those who want a window seat have one; and if you'd rather an aisle seat, you get that too. Same seat. And there are no middle seats to get stuck between the two. The pilot said we were just a few minutes from the airport. At this point on a plane trip, I'm used to seeing houses, roads, car parks, swimming pools -'civilization' in other words. All I saw was desert and barren land, and we were nearly landing.

Now I'm a guy who grew up in (and has lived always in) or near the capital city of my state. And those cities have mostly been the largest city in the state. So visiting towns with populations of 2,000, 3,000 or even 9,000 is quite an experience. I didn't know United Airlines flew into airports where there were no houses around. I am not accustomed to towns where there is one taxi service, no competition, and where the taxi driver can speak to the prevalence of alcoholism in her town. She knows whom and how often she is picking up inebriated patrons. She's on duty for 36 hours at a time. Sleep is not a problem - her next call for a ride might not be for eight hours.

Visiting Wyoming from California is not like encountering a whole new culture. There are even many Californians buying up land in Wyoming, so it can't be too foreign a place to consider. Yet, in many ways, I was out of touch with the culture and thinking of another USA state not that far from my home. We ate lunch during the conference in a restaurant surrounded by the heads of every kind of animal - deer, elk, bear, rabbit, hippopotamus and rhino to name a few. I was the only person in the room with a tie on. Even a judge who attended looked like he had just dropped in from a nearby bar-b-que.

These days there's a lot of talk about cultural competence, and it is important. But I also am reminded that being sensitive to others' way of thinking, history, stigma, marginalized status in society, and a whole host of other factors goes beyond skin color and ethnic background. I realized last week how easy it is to remain familiar with one's own territory and less in tune with others'- geographically, mentally, emotionally, socially and spiritually.

Helping people and tuning into them is what individualized treatment is about - not JCAHO or CARF or State licensure or managed care companies. Rock Springs and Thermopolis, Wyoming reminded me that helping people involves getting to know where they "live" - their perspectives, values, truths and culture.

Thanks for joining us for this month's TIPS and TOPICS. Send us any comments or Success Stories on implementing any of the TIPS and TOPICS; or send any questions to Stump the Shrink. (Tell us how much identifying data you are comfortable with my sharing here.) See you next time.

In the June issue of TIPS and TOPICS, I discussed the subject of Enhancing Motivation and Engaging people into Treatment. If you'd like to enjoy a Cape Cod vacation, and hear more about working with difficult clients, I'll be presenting on that topic at the Cape Cod Symposium in September. There's lots more at these premier annual events- 'big' names, International speakers & sponsors, great topics!

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