June-July 2004
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In this issue
-- SAVVY........
-- SKILLS........
-- SOUL.........
-- STUMP THE SHRINK....
-- Until next time......

WELCOME!

Welcome to the June/July edition of TIPS and TOPICS. This monthly publication just suddenly turned into a two-editions-in-the-summer, "monthly" newsletter! You will receive a July/August edition around mid to late August. You can also see this and previous editions on my website.

SAVVY........
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As I was preparing this edition, I was reflecting on two main themes that have emerged from my June work and travels: (1) the interface between addiction and mental health systems; and (2) the vast contrasts between cultures. In June, I was in Vancouver, Canada where they recently opened the first injecting clinic in North America. Later that same week I was in Singapore, where a person gets the death penalty if they deal drugs. Cultural clashes between the addiction treatment and mental health systems may not be as obvious as those of Vancouver and Singapore, but they nevertheless still divide us - to the detriment of the people we serve.

Tips:

Consider a couple of cultural clashes that inhibit integrated co-occurring disorders treatment:

• Care versus Confrontation
  
  >> Mental health has had a tradition of taking a long view of treatment - providing support, case management and a chronic disease approach - especially with severe and persistently mentally ill people.
  
  >> The addiction treatment field has been good at expecting accountability and behavior change in a relatively short time frame.
  Do you recognize these statements?
  For example:
  'Stop using all mood-altering substances';
  'If you used before coming to group, leave and come back when you are sober';
  'Change your friends';
  ' 90 meetings in 90 days';
  'Change your leisure activities' etc.
  
  Mental health rarely plans for a quick discharge of clients from the mental health system, while addiction treatment speaks often of "completing the program" and "graduation". The downside of mental health's culture of ongoing care is the danger of breeding passivity in clients - "Is everything OK? Here's your prescription; see you in three months." The downside of addiction treatment's culture of confrontation is the danger of setting clients up to just comply with the program, not having the opportunity to work through their ambivalences, coping and impulse problems.
  
  There is something to be learned from each of the cultures. Mental health needs help to sharpen accountability and expectations for change and recovery. Addiction treatment needs to work towards progress, and not expect perfect abstinence and perfect impulse control immediately.
  
  
  
  
• Abstinence- oriented versus Abstinence-mandated
  
  >> If alcohol and other drugs are interfering with a person's functioning, the sooner we can attract a person into recovery involving total abstinence, the better their chances of full health and well- being. However, if the person cannot yet see the full value of embracing recovery and sobriety, we want to attract and engage them to develop buy-in at their pace and progress.
  
  >> Mental health understands this for other behavioral health problems like psychosis and thought disorder, depression and cutting behaviors, panic and compulsive rituals and mood swings and manic episodes. I have never heard mental health clients turned away from sessions because they arrived depressed or psychotic, panicky with fresh cuts on their wrists, or thought- disordered due to poor adherence to their medication regimen.
  
  
  Yet, in addiction treatment, we still often refuse treatment to someone who just slipped and used a drug. We discharge a person from treatment because they were not in perfect control of cravings to use. I know (and used to say) that we are concerned that clients not get the message it is OK to use. We believe there must be consequences for use. I also recognize some other clients in group may get triggered by witnessing a fellow group member who has been using or getting high.
  
  
  But compare the approaches.
  
  I have never heard mental health professionals be concerned about permitting a depressed, self-cutting individual in group because her presence might transmit a message that it's OK to cut oneself. Nor have I heard it said that there needs to be consequences for cutting; nor to discharge a person for being psychotic and not taking his medication. I haven't heard of excluding a person from group therapy for crying about past trauma, fearful this might trigger another client with a similar painful history of abuse.
  
  Before you brand me as soft on drug use and an "enabler" with codependency issues, consider a few tips and skills around these clashes. It is possible to balance care and confrontation. We can expect accountability and responsibility, yet still meet people where they are at, rather than expect them to be perfectly where we want them to be immediately.

SKILLS........
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Below are some commonly heard client statements, some counterproductive thoughts or words from both fields, and a tip in the direction of an integrated approach.

• "I came here for depression. I'm not going to stop smoking weed. It relaxes me and it's a natural herb anyway."
  

Mental health's caring support gone wrong:
"If you don't want to work on your marijuana use, that's OK and I will keep seeing you and building trust and forming a relationship for the next year. Every third session I will nag you about your drug use and hope you come round eventually."

Mental health's attempt at confrontation gone wrong:
"Come back when you are 30 days sober and I'll see you for your depression then."

Addiction treatment's attempt at caring support gone wrong:
"OK, since you don't want abstinence, we'll put you in our pre-treatment, education group and hope we'll plant some seeds."

Addiction treatment's confrontation gone wrong:
"That's stinking thinking. You're in denial and need to be abstinent now. Get your priorities straight and focus on first things first."

Tip #1
A Person-centered, integrated co-occurring disorders treatment approach could sound like this:

"Let's work on this depression that concerns you so much. But I am worried that your heavy marijuana use may worsen your depression. If you really are not interested in stopping, I won't and can't force you to stop. So let's monitor our work together on the depression. If it keeps improving, then great - you must be doing something well. If it doesn't improve, we might have to look again at your drug use, which I recommend you stop. But I don't know and I could be wrong.
So let's see if your depression improves or not over the next three sessions and re-evaluate the marijuana use then. How does that sound to you?"

• "I had a couple of drinks on the way to group today."
  

Mental health's attitude towards abstinence gone wrong:
"A couple of drinks is not so bad. After all he was honest about it. It is probably a self- esteem problem or attention-seeking. I'll ignore this and not reinforce his attention-seeking by asking too much about the drinking."

Addiction treatment's attitude towards abstinence gone wrong:
"I'm sorry, but it's our policy that you need to leave group and come back tomorrow when you are sober. We have to keep group safe for others. You need to have consequences for use. You need to know there are never any excuses or reasons to use."


Tip #2
A Person-centered, integrated co-occurring disorders treatment approach could sound like this:

"That must have been hard to admit the mistake of using. Thanks for being honest. But it will be important for you to open up in group, tell them what happened, and that you used. Ask them for help on what you can do differently next time to deal with cravings or whatever happened. Others will notice that you used anyway, and may even be triggered by your smelling of alcohol. But we will hang in if you want help.
Let's reassess what happened and how to change your treatment plan."

• "I'm being triggered and am uncomfortable smelling alcohol on him. Can't you kick him out?

Caring support gone wrong:
"Yes, I agree that we need to keep the group environment safe, so I will tell him to leave."

Confrontation gone wrong:
"Don't you worry about him. Focus on yourself. I'll be the one to decide who should be in the group or not."


Tip #3
A Person-centered, integrated co-occurring disorders treatment approach could sound like this:

"Yes, I know it is scary when you are face to face with active drinking or drugging again; and here in a treatment group too. But I am relieved that you are being triggered here where we can both help you deal with what is being triggered; and can also help Joe who needs to deal with his relapse. His crisis could be a learning opportunity for him and for you.
Would you be willing for us to help you deal with what Joe's drinking brings up for you? And would be willing to help him learn from your experience and recovery? "

SOUL.........
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About fifteen years ago, I remember Mark E. King, Ph.D. demonstrating something in a keynote presentation which had a lasting impression on me. He took a jug of water. Instead of filling up an empty glass, he poured water (or tried to) into a full glass of water. As you can imagine, water spilled all over the floor as no new water could be added.

He then quoted Nietzsche. It went something like this: "Convictions are greater enemies of the truth than lies". When we are so full of our convictions about what is truth, we are not open to new knowledge that flows over us. Lies can be exposed with new knowledge. Convictions, if so tightly held, are not open to modification from new knowledge.

Whenever I feel myself rising up in righteous indignation, I check whether I am holding too tightly to my convictions. I was reminded of the Nietzsche quote as I pondered the various cultural clashes I observed this month. If you live in Vancouver (and even the USA), it is hard to imagine the death penalty for drug dealing as in Singapore. But there, they could not imagine that some in Canada and Australia would actually provide an injecting clinic as a legal place for folks to do IV drugs.

Even in this country, some in my state are working to have cigarette smoking banned on the beaches of California; while in Louisiana, I understand they only just recently passed a non-open container drinking ban in cars. (I was told that to comply with that law, you can still get your beer in a cup with the lid, but the hole for the straw now has some tape lightly covering it.) The cultural differences in attitudes towards substance use within the US states are amazing and amusing.

So what about us in the addiction and mental health system?

Last month's Stump the Shrink question on methadone maintenance and recovery stirred up strong feelings with convictions pro and con. I witnessed a recent extended exchange about the use of psychotropic medication on the Co-Occurring Disorders Electronic Discussion Listserv (dualdx@treatment.org). It stirred up equally strong convictions pro and con. The cultural clashes even in our behavioral health field are alive and well.

Is your glass full of water with no room for what might flow from the jug of new water?

STUMP THE SHRINK....
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Question:

"I work for Mental Health and we have a dual diagnosis crisis stabilization residential treatment facility - a Crisis Resolution Center. So you can see why I love the new ASAM PPC2R and how it is so valuable to the population that we serve. Based on the "no wrong door policy", if a client is willing to come into treatment and accomplishes withdrawal safely, stabilization back on medications, health (eating and sleeping as needed), removal from unsafe environment, and some pretreatment (Motivational Enhancement), when does it cross over from assisting and welcoming to enabling? Or does it? Question simplified.... how many attempts does it take for a person to establish recovery? Five, twelve? I would value your clinical opinion.

Thank you,
Carol from Southern Oregon

Answer:

Carol:
This is an important question especially for all who work with severe and persistently mentally ill populations. One way to answer it is that we usually don't ask how many times we should stabilize a person with diabetes or hypertension. Nor do we ask when to decide if we should welcome the patient back or consider it enabling. To continue the analogy, if a patient repeatedly refused to stick to their diabetic diet and/or adhere to their insulin regimen, we might have to ask the patient if they want help with their diabetes and whether we are the right fit for them to help.

If they repeatedly don't like our treatment recommendations and don't adhere to them, then perhaps they are saying they don't want treatment from you. This is especially true if you can't think how else to treat their diabetes other than what you have already recommended. Similarly, if a behavioral health client gets unstable, we keep working with them:
1. As long as they feel it is helping
2. That they want help from us
3. That the fit with you and the agency is right for them
4. That they are progressing in the right direction.

If they repeatedly are unstable, then we would want to assess with them whether they understand the treatment regimen, have truly agreed with it, want to do it and are adhering to the plan. We should change the plan if it doesn't make sense to them up to the point that you clinically can't think how else to change it in a participatory way.

In summary, if you have a client who wants to work with you and is willing to try something different in a positive direction, then it is not enabling to stabilize and adjust the treatment plan and keep going. If, after checking with the person, they don't agree with the plan that you have worked to modify as far as you can to fit what they want, then they are choosing no further treatment from you and you thus end the relationship.

I realize you work in the Crisis Resolution stabilization phase. So your focus is on stabilization and in helping the ongoing treatment team to explore carefully with the client whether the person is engaged and participating in a collaborative way in treatment and service planning. If the treatment team takes a pathology-oriented approach to the client and prescribes treatment with little meaningful input or negotiation with the client, you can expect to see the person return many times. The client and family may have no buy-in to the plan and therefore no treatment adherence and multiple unstable return episodes.

Let me know if this helps or come back at me if not.

Thanks for this important question.

David

The Response:

Dr. Mee- Lee:
The information you gave me was very helpful. Shared it with many, in several different departments. (Different departments within the same organization sometimes has very different schools of thought) The way you were able to describe the process in such a succinct, yet basic way was fabulous. My peers and I were on the right track, but at the same time unsure and questioning. If this would benefit others in your Tips and Topics please feel free to use it.

Sincerely,
Carol from Southern Oregon

Until next time......
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Thanks for reading TIPS and TOPICS and thanks for the feedback, comments and questions you send. Until the July/August edition, enjoy the summer, but remember the sunscreen!

David