January 2004
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In this issue
-- SAVVY........
-- SKILLS........
-- SOUL.........
-- STUMP the SHRINK...
-- SUCCESS STORIES..........
-- Until next time........

WELCOME!

It is already moving towards February. I know it is clichéd to say, but I can't believe how fast the year is racing by. I hope you are as busy (in the productive sense) as I am. But I also hope you have more balance in your life than I have at present. I have already broken my New Year's resolution for more balance. By declaring this here I am putting myself on notice to check the balance-meter more often and more effectively.

SAVVY........
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A colleague once called me an "intellectual scavenger" - meaning that I pick up bits and pieces from others' presentations and writings to use in my own training. I think this was meant in a positive sense and I believe she was right. In this Savvy Tip, I want to share some language or phrases we use that express attitudes (unintentionally perhaps) which are less than desirable. I will reference the originator where I can.

Tips:

• Check whether you want to convey the meaning these words represent.
  
  These may seem too subtle and hair-splitting for your taste, but try these on for size and see what you think.
  
  (a) Treatment compliance versus treatment adherence
  In the literature, significant other parts of healthcare have been using "adherence" long before the mental health and addiction treatment field had their consciousness raised to the implications of using "compliance" versus "adherence" terminology. In this age of empowerment and collaborative service planning, it is not for the expert counselor and professional to develop a plan with which the client must comply. It isn't for the physician to prescribe the medication with which the patient must demonstrate medication compliance. Webster's Dictionary defines "comply" as follows: to act in accordance with another's wishes, or with rules and regulations. It defines "adhere": to cling, cleave (to be steadfast, hold fast), stick fast.
  
  (b) Drug of choice
  I heard Carlton K. Erikson, Ph. D. of the University of Texas in Austin challenge our innocent use of asking people what is their drug of choice- not everybody with an addiction problem is drawn to the same drug or drug class. This comes close to hair-splitting for me, but it made me think. Carlton challenged that when a person, however, has crossed the line into addiction and developed an addictive relationship to a drug, they are not "at choice" with the drug anymore. It isn't their drug of choice, it is their drug of necessity. And he added, for us to think and talk about it as if it is a drug of choice perpetuates that it is willful misconduct that they could choose to do differently.
  
  (c) Clean/ dirty urines versus negative/positive urines
  A participant in one of my workshops some years back was either courageous, concerned enough or both, to let me know that she did not appreciate my use of "dirty urines". Even though we have positive associations to being "clean and sober", she was concerned that using "dirty" instead of "negative" urine drug screen results only added to the stigma of drug users as being dirty. I think there is some merit to that. I now usually stick with positive and negative results rather than dirty and clean urines.
  
  (d) Client, patient, consumer or customer
  I once heard an addiction medicine physician deeply committed to serving the sick and suffering person with alcoholism and drug addiction lament the increasing reference to consumers and customers. To him, the field was forgetting the hard won fight to have medicine, society, health insurance, payers and disability policies recognize alcoholism and addiction as a disease and chronic illness. These are patients who are ill and need healthcare; not consumers or supermarket or hardware store customers who need butter or light bulbs. It was painful for him to see the shift that consumer advocates and empowerment movements have been promoting.
  
  We can get so consumed with being politically correct that we forget to be human and real. It's a bit like a doctor who is so worried about being sued for malpractice that he or she can't be warm, spontaneous and real with a patient. However, words can reveal and shape attitudes that are almost subliminal and insidious. I raise these so you can choose whether you wish to change your use of these terms or not.

SKILLS........
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I don't know how many of your referrals are mandated to attend treatment by the courts, child protective services or an employer, but some programs tell me it is close to 80% for them. In the client's mind, they are there to comply and jump through whatever hoops you construct so they get their treatment completion letter. Here are a couple of Tips to encourage the client's doing treatment, not doing time.

Tips:

• Thank the client for choosing to come to treatment to seek your help.
  
  The client may very well look at you cross-eyed and say: "I'm here because I have to. They made me come. I didn't choose to come here."
  
  Genuinely and politely you can answer: "I didn't see anyone force you in the door to sit down and talk to me as you are doing and which I appreciate your doing. You must have come here because you want my help to get something you want very much; or to figure something out that is very important to you."
  
  "No, they made me come" he or she may say.
  
  "Then what would happen if you had said - I'm not going? What would have happened to you?"
  
  "Well they would put me in jail or keep me longer", or "I'd lose my job or my children".
  
  "Would that be bad for you? So is that what you want me to help you with? Stay out of jail, keep your job, or get your children back?"
  
  Now we have a customer who wants something from treatment and wants your help to get them something important to them.
  
  
  
• Resist the impulse to immediately set out the rules and regulations with which they must comply.
  
  Remember we are engaging them to do treatment, not do time. We are hoping they will adhere and stick with treatment; not jump through the hoops of our wishes and comply with our rules and regulations.
  
  Unfortunately clinicians don't usually get a lot of help from mandated referral sources to develop an assessment-based, individualized service plan that engages people into accountable plans geared to match the client's stage of change. The pressure is on for compliance, not independent assessment and thinking. Instead of engaging people into participatory treatment that holds the promise for lasting change, there exists a lot of push for quick program compliance.
  
  While you may not be able to change the system overnight, you can work on joining with referral sources to emphasize these:
  
  >>Common purpose and mission-
  That as clinicians we join the referral agencies in our commitment to public safety, security and safety for children, etc. We all share similar outcome goals.
  
  >> Common language of assessment of Stages ofChange
  Can we both work on lasting change for our clients by understanding and using Stages of Change assessment and treatment?
  
  >>Consensus philosophy of addressing readiness to change
  Meeting clients where they are at, and using solution-focused, motivational enhancement strategies is not some softer, wimpy way. Rather it upholds accountability and treatment adherence as the path to lasting change and reduced recidivism and relapse.
  
  >> Communication and conflict resolution
  As we chart a different path together, can we keep discussion and innovation alive? Can we be committed to common goals, keeping our collective eyes on the prize?

SOUL.........
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Between now and Election Day on November 2, 2004, it will be hard to not be consumed with the clash of contentious opinions from candidates jostling for supremacy. I know I would make a lousy politician. I am not well suited to the world of either-or; all right and all wrong; you against me and me against you. I remember a mini- sermon in my high school chapel days when the chaplain tweaked our minds about the paradoxes of proverbs and what is the truth.

• Is it: Fools rush in where angels fear to tread? Or, He who hesitates is lost?
• Is it: Too many cooks spoil the broth? Or, Many hands make light work?
• Is it: Opportunity knocks but once and carpe diem - seize the day? Or, Patience is a virtue, possess it if you can?

His message was that it is not "either-or", but "both-and."

A few years ago I chaired a small workgroup composed of an African-American woman, a Caucasian man, a Caucasian woman and myself, an Australian-born, Chinese man. We were supposed to be working together for the good of people with co-occurring disorders. What a rich opportunity we had to draw on such diverse experience for a common, noble goal. It was a sad and troubling experience for me. I struggled to understand the anger and mistrust that whirled around issues of male dominance in society; race relations; empathy for sexual and physical abuse and trauma; and cultural competency and more. I think I did poorly in harnessing the rich experience and jelling that into superior work for the purpose we had gathered. And this was with people of goodwill gathered for a purpose we all believed in.

I know it is probably naively idealistic to think we could ever be a "both-and" society instead of an "either-or" one. It is tempting to only see my resolve and his stubbornness; my determination and her block-headedness; my compassion and her wimpiness; my assertiveness and leadership and his aggressiveness and control problem. But in this season of adversarial politics, might it just be possible that you and I at least, might try to resist the "us against them" mentality?

STUMP the SHRINK...
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Question:

"Insurance companies are abusing the ASAM Criteria. Without seeing the patient or knowing anything about the case, gatekeepers employed by some managed care companies are saying: "Patient does not meet ASAM Criteria." How do we overcome that? The abuse has become the Criteria.

Allen McQuarrie
PRO-ACT Chair
Pennsylvania Recovery Organization
Achieving Community Together

Response:

It is frustrating when managed care companies simply declare, "Patient does not meet ASAM Criteria". I suggest you ask them in which of the ASAM Criteria assessment dimensions do they disagree with your assessed severity? Also, what services for the problems in the most severe ASAM assessment dimensions do they specifically disagree with?

Presumably you have told them which of the assessed ASAM Criteria dimensions have problems that need treatment services, the intensity of which can only safely be delivered in the level of care for which you sought authorization. Ask them to tell you what they would do differently for the problems in the dimensions that need treatment. If they cannot explain where they disagree with the assessed severity in your evaluation, then you should appeal their ruling so that you indicate where there is disagreement, possibly overturning the original denial of authorization.

Hope this helps, but let me know if not.
David

SUCCESS STORIES..........
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At a recent workshop, I suggested that we relieve some of the burden of our paperwork by involving clients more in their own treatment plan and documentation - that we get them to do more of the paperwork since it is, after all, their treatment plan and their life. Some participants went right to work on this. Here is what one clinician reports about getting her clients to write a weekly progress note, and then to share it with the group for feedback and suggestions.

Success Story

Dr. Mee-Lee:
The progress notes have helped improve the group in many ways. The clients I work with are dual diagnosed individuals whose ages range from late twenties through late thirties. They are court ordered by the criminal justice system and have experienced several years of substance abuse and criminal behavior. The average IQ is above average but their social skills are at teen-age level. The clients are capable of success, but have been turned down at every turn because of their lack of social skills, low self-esteem, as well as mental illness and ill-mannered behavior.

After hearing about your progress note exercise, I started to do it every Monday. I would have the clients write down their past week's perceived progress, read it out loud and the other clients add to the improvements or discount the actual progress. We added if there were any indications of danger symptoms of indicated relapse or negative resurfacing behaviors. The benefits I have seen from this weekly event is that the clients have become more aware of the positive improvements they are showing, reinforcing these improvements, and showing them how these small improvements keep adding up to acceptable social behaviors as well as improved life skills. Examples of improvements and progress are incidents that show their abilities to drop their pride and ask for help, keeping appointments, clearing up past warrants and financial issues, setting boundaries with significant others and families, medication compliance, improved social behaviors in group, and taking responsibility for their actions.

The results have been increased trust in group, and a willingness to ask for help as well as seek help. The group has bonded very closely, and they are also using each other as a sober support system outside of the group. They are acting to help the clients that need extra help due to their lack of emotional stability because their medication has not yet become fully effective or have a hard time advocating for themselves. They also watch each other more closely so that they can offer something positive to each other each week as well as accountability for themselves.

This is a real bonus because the clients are actually improving their actions because they know that the other group members hold them and each other accountable for continuing their improvements and to follow through with the feedback that they all offer each other when resolving issues or problems. They are starting to learn how to advocate for themselves and understand that by discussing their positive progress to their probation officers and judges, that they are getting back more respect and a different attitude, which is significantly improving their communication skills.

The group members have bonded more by relaying positive compliments to each other and reinforcing the person's positive behavior every week. It also makes the group more comfortable about confrontation and more willing to accept feedback that will help change their behaviors. The increased self-esteem gives them more confidence to share more and work on the real issues they need to look at in a more positive atmosphere. The group has bonded so well that the quieter individuals will open up more and the group members also are more inclined to follow through with feedback because they know they will be accountable to the group the following week.

Thank you for this suggestion. It is a wonderful tool for group process.

Deborah Harkness
Dual Diagnosis Substance Abuse Counselor
Fresno New Connections
Fresno, CA

Until next time........
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I hope 2004 is a successful year for you. I look forward to your interesting 'Stump the Shrink' questions and 'Success Stories.'
David.

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