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

WELCOME!

This April edition of TIPS and TOPICS marks the beginning of the second year of these monthly bits and pieces from me to you. If you have been getting these from the very first edition, I hope they have been useful in your work and life. If you are new to TIPS and TOPICS, welcome to an unscripted array of issues that arise from reflections about my training and consulting practice (often as I sit on airplanes).

SAVVY........
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Recently, I was asked to consult on two 16-year-old boys- Ricky and Mark. I will not use their real names.

Ricky is facing sentencing in a couple of months for two charges of a minor in possession of marijuana. He has been seeing an outpatient counselor for over a year. Before that he was in a partial hospital addiction program. Ricky is now in a residential addiction facility because he continues to have positive cannabis drug screens.

Mark has agreed to an intensive outpatient addiction program. He anticipated court- ordered treatment anyway when he was to appear for a recent underage drinking arrest. I received this consultation request because Mark is extremely negative about treatment, is disrespectful to his counselor, and has tested positive for marijuana while in treatment. As we so often do, there is much to learn from the clients and families we serve.

Tips:

• Continued substance use in outpatient treatment does not necessarily indicate the need for treatment in a more intensive level of care.
  
  Both Ricky and Mark have had positive drug screens, but also both want to continue to use marijuana except for the pressure to be abstinent due to pending court appearances. Ricky is clear that he would still be using except he fears being incarcerated if he uses. Mark is waiting impatiently to turn 18, so he can leave home and do what he wants - one of which is to grow marijuana using hydroponic methods.
  
  I understand the pressure to admit such clients to more intensive levels of care. Both families and therapists get frustrated, and look to the residential or intensive program to somehow stop the substance use. Their argument for more intensive treatment seems obvious: the client cannot maintain abstinence in outpatient care; he needs more structure and protection away from his current environment if he is to succeed.
  
  But consider this.
  
  In both cases, neither young man is the least bit interested in education about addiction and recovery, or learning relapse prevention or peer refusal skills. Both have 'voted' clearly with their behavior - they are "resistant" to addiction recovery work, disruptive in groups, and negative in the program. What is not needed is more intensive addiction recovery work. What is needed is more frequent and deliberate family and "discovery" work. The current outpatient therapist has already established a working relationship with the family. She would be the best one to provide that "discovery" work. To ship the client off to a brand new staff and program (often in another state or region where working with the family is even more compromised due to distance) is too frequently wishful thinking -trying a generally non-effective geographic cure.
  
  Of course this is not to say that transfer to a distant residential or more intensive program is never indicated. More often than not though, it is not the best disposition for the Ricky and Marks of the world. Their situation calls for the current outpatient therapist to provide support, information and treatment to the frustrated parents who have struggled with how to set consistent limits, and how to hold each of their sons accountable for his behavior. Have them attend supports groups like Al- Anon or Tough Love.
  
  As for the 2 boys, the therapist's focus should be on using specific motivational enhancement strategies: for example- a pros and cons exercise on the benefits of continued drug use and the costs of continued drug use.
  
  
  
  
  
• More intensive levels of outpatient and residential care are only indicated for stabilization and safety from imminent danger.
  
  If Ricky and Mark have been striving to be sober or cut back---
  If they have been working hard with their counselor to resist cravings or learn peer refusal skills---
  If they have been attending self/mutual help meetings, and yet are still having difficulty---
  then the increased structure could be put to good use.
  
  However to this point, not only are the teens very ambivalent about stopping or cutting back their substance use, but their families have received no instruction or support in their struggle to set limits consistently. It is no surprise that the adolescents show up with repeated positive drug results.
  
  Professionals and parents alike worry about "imminent danger." Are these teens in some danger?
  
  Quote taken from ASAM PPC-2R p.12, p.187
  
  "The concept of "imminent danger" often is used to describe problems that can lead to grave consequences to the individual patient (and possibly others), some of which may be the basis for the legal commitment of an individual to treatment. The authors of the criteria believe that the application of "imminent danger" should be broader. In fact, it is the three components in combination that constitute imminent danger:
  (a) a strong probability that certain behaviors (such as continued alcohol or drug use or relapse) will occur;
  (b) the likelihood that such behaviors will present a significant risk of serious adverse consequences to the individual and/or others (as in a consistent pattern of driving while intoxicated); and
  (c) the likelihood that such adverse events will occur in the very near future.
  
  On the one hand, the concept of imminent danger does not encompass the universe of possible adverse events in any client case. An evaluation of imminent danger should be restricted to the three factors listed above. On the other hand, the interpretation of imminent danger should not be restricted to acute suicidality, homicidality, or medical or psychiatric problems that create an immediate, catastrophic risk."
  
  A residential level of care might be indicated even with Ricky and Mark's significant ambivalence about recovery. If they exhibit behavior like dangerous intoxication, unstable physical or emotional problems due to, or concurrent with, substance use, or impulsive psychosocial problems of violence (fire setting or drunk driving), this combination of factors may call for stabilization in a residential setting.
  
  The boys' continued use of marijuana while being seen in an outpatient setting alone is not alarming enough to require moving them to a residential setting. There is more groundwork/preparation to be done first. One, reassess the boys' interest and efforts in not using. Two, employ more deliberate motivational enhancement strategies if they're not interested in abstinence; or apply relapse prevention strategies if they are interested in stopping, but struggle with cravings or impulses to use. Three, work with the family to "raise the bottom" with their adolescent sons.
  
  

SKILLS........
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Here are some clinical tips that Ricky and Mark's situations suggest.

Tips:

• The more ambivalent or resistant to recovery the identified client is, the more you focus more on who has the power in the client's system.
  
  Who provides the client emotional support? e.g., a girlfriend or boyfriend; a parent or guardian; a therapist or counselor or doctor; a significant friend or relative. Who pays for food, shelter and clothing? Is there a boss, school, work or legal person who holds the power over a negative consequence? If the client is at the appointment with you, he/she will often tell you who those people are if you ask them. Ask: "What will happen, or who would be upset, if you did not come here today and follow through with treatment?" If the client's answer is the judge, my probation officer, my mother, the school etc., you will probably have your answer on who holds the power. If you are talking to someone other than the identified client, you may actually be talking to the "power person". If a different person is calling and urging the client to make an appointment and get into treatment, that may be the individual who has the ability to create incentives for change.
  
  
  
• The more ambivalent or resistant to recovery the identified client is, the more you work with family, significant others first.
  
  Rather than cajole, confront or coerce the client into doing time in treatment, work first with the system to create incentives for change.
  For example-
  What behaviors need to change to avoid going to jail or juvenile hall?
  What would need to change to retain his job or car privileges?
  What might make it difficult to actually follow through with setting limits and adhering to them?
  When has it worked well before, in following through with consequences? And what supports would strengthen that?
  
  To this point, it may not even be the best thing to have the identified person in treatment. If our Ricky or Mark truly believes there is no problem and there are no inevitable consequences, job 1 is to create the incentives in the client via those who hold the power.
  
  
  
• Increase the flexibility of your outpatient or residential program.
  
  If you find yourself saying something like: "I don't have time to squeeze in an individual family appointment to do this kind of work. We have all the families come to family group Thursday evenings for three hours"; or "We have family week the third week of the residential program and can't have families coming sooner", take a look at changing the flexibility and model of your program. Ask yourself if you only think of family work as part of discharge planning to do later after the 'real' recovery work with the client is done, or as part of a particular program slot. Involving the family and significant others is not an add-on to be squeezed in to an already busy schedule. For some like Ricky or Mark, it is an essential priority, equally as important as the rest of the groups.

SOUL.........
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This week, my 18 year-old, senior high school daughter wants to get extra credit for her Popular American Fiction class. They have been reading a novel in which one of the important characters is a psychiatrist. Her teacher is eager to introduce students to real 'live' people like the characters. She can get extra credit if I present to the class on what I do as a psychiatrist. This makes me think about who I am and what I do.

It occurred to me that many of you reading TIPS and TOPICS may have subscribed because you attended a training of mine in the past. But many may not even know what is my background and experience. I will not bore you with minute details of my biography, nor deep insights about the nature of life- who am I am? where have I been? and where am I going? But it might be helpful to share a little of how I am doing what I am doing, and where I think that came about. (The reason I created a "Soul" section is that it is not what we do that is so important, but who we are.)

As a Chinese person growing up in a predominantly white (and, back then, aggressively so) Australian society, I coped by excelling, leading and people-pleasing. Add to that a relatively strict religious upbringing in a fundamental Christian church at a time when it was not acceptable to believe in vegetarianism, abstinence from tobacco and alcohol and a host of other limitations that defined the church's abstemious lifestyle. When you are not solidly in the mainstream, the conditions are ripe for a focus on bridge-building. Translation: it is therefore not surprising that much of my career has focused on bringing together people and systems - addiction and mental health; therapists getting closer to clients as customers; helping teams resolve conflicts and build cohesion.

Here is the mission statement I wrote when I started my training and consulting practice:

I am actively creating a unique forum using my talents of bridging the gap for people between disparate fields and concepts, in a very persuasive, challenging and inspiring manner; simultaneously influencing systems in a global way for the greater good, with rich personal satisfaction and financial reward.

So what is your history and who are you? Are you doing what you want to do? It is an illuminating exercise to examine your roots and write your own mission statement. Mindful living and conscious choices makes for proactive peace of mind.

STUMP THE SHRINK....
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The following question relates to the assessment dimensions of the Patient Placement Criteria for the Treatment of Substance-Related Disorders of the American Society of Addiction Medicine (ASAM PPC).

Since not all readers may be readily familiar with ASAM PPC, here are the assessment dimensions:
1. Acute intoxication and/or withdrawal potential
2. Biomedical conditions and complications
3. Emotional/behavioral/cognitive conditions and complications
4. Readiness to Change
5. Relapse/Continued Use/Continued Problem potential
6. Recovery environment

Question:

"I have a couple of questions about the ASAM Patient Placement Criteria that I need clarified:

A. To meet criteria in Dimension 3, my understanding is that the issues need to relate to a co-occurring mental health disorder. i.e., domestic violence probably isn't an issue for that dimension unless it is related to depression. Otherwise, the domestic violence could be addressed in Dimension 4 as a barrier to seeking treatment; in Dimension 5 as a relapse trigger; or in Dimension 6 as a living/recovery environment issue.

Or, could it be addressed in Dimension 3 related to abuse/trauma history? Is this as true in the adolescent criteria as in the adult criteria?

B. In level II.1 (Intensive OP), Dimension 5, it states that a person needs to have been active in a lower level of care; had their treatment plan amended; and had problems intensify to meet.
Please clarify."

ML Ruef,
Boise Idaho

Answer:

One way to think of what issues belong in which dimension, is to think of what kind of services are needed to address the problem or issue. There is often overlap for how a problem affects the assessment dimensions. But in deciding which dimension to choose, think of what services would be needed to address the clinical issue.
For example -
If the person is a victim of domestic violence, and is therefore depressed and anxious and emotionally distressed by that victimization, then that would be Dimension 3 as some mental health services would be needed and appropriate.
If the person was the perpetrator of domestic violence, then it would also be Dimension 3 as the client would need help to deal with his/her behavior.
If the issue with the domestic violence was that the client needs a safe place to live; or needs help to find shelters, then that would be Dimension 6.
If the client felt that because she was a victim of domestic violence, she used drugs to cope with the stress and that she doesn't have a drug problem (when your assessment indicates that she indeed does meet criteria for a Substance Use Disorder), then that would be a Dimension 4 issue needing motivational enhancement strategies.
If the client uses drugs as a way to cope with the violence and needs help with coping skills to deal with negative affects and the stress of the domestic violence and cravings that arise, then that would be Dimension 5 relapse prevention strategies.

It is the same for adolescents and adults in this way of thinking about what services are needed and which assessment dimension is involved.

As regards question #B, "active" means that meaningful treatment has been unsuccessful in Level I and the deterioration requires services that can only safely be delivered at a more intense level of care. Some people go to Level I, sit and do time not do treatment, then use. That does not necessarily indicate a failure of a trial of OP treatment. It may be that the client was never engaged in a participatory, active plan, just sat in a mandated program, and therefore used again. That person may now be ready to be engaged in Level I and need not go to Level II.1 (Intensive outpatient)

On the other hand, if you have a person who is actively working on cravings, going to AA, trying to stop, but these recovery strategies are not working in Level I, then the increased structure may be needed in Level II.1 or II.5 (Partial hospitalization). There may be people who are having such severity of Dimension 5 problems that you want them to go directly to Level II.1 before even trying Level I.

Hope this helps.

SUCCESS STORIES......
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In the February edition, I asked for any suggestions for the frustration of this writer:

"I am a dually licensed (MH/SA) therapist who works for a rural community mental health center. I just came back from a family services team meeting for a juvenile who suffers from chemical dependency and I'm so frustrated I want to scream, cry, etc. She is a decent kid, no history of conduct disorder or other behavior problems prior to the onset of substance abuse. I was the lone voice recommending treatment. I love working with individuals with CD disorders because treated appropriately there is so much hope and improvement. However, the criminalization of addiction, the lack of compassion, understanding and punitive approaches is getting to me. Thank you for your humanistic understanding of the disorder and the men women and kids who suffer from it. Any suggestions on increasing my coping skills with my frustration?

LSCW

Here is the response of a fellow TIPS and TOPICS reader:

"One way I keep my ability to be the "lone voice" fired up is to frequently connect with others (either inside or outside my organization) who share my views and who even push me to go farther to advocate for my clients. I get weekly newsletters emailed to me from the Drug Policy Alliance that inspire me to act with passion to reform our ridiculous drug laws. I am part of a dual diagnosis listserv run by www.treatment.org where these issue are constantly discussed. Additionally (of course) I call supportive colleagues at those times when I feel like no one I work with cares about treating clients with compassion."

Jennifer, LCSW

Until next time......
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Thanks for reading TIPS and TOPICS. Here we go for year 2.

Talk to you in May.
David

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