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"TIPS
and TOPICS" from David Mee-Lee, M.D.
Vol 2, No.4
August
2004
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In this issue
-- SAVVY........
-- SKILLS........
-- SOUL.........
-- SUCCESS STORIES......
-- Until next time......
WELCOME!
A
new reader of last month's June/July issue
of TIPS and TOPICS asked me if I had considered
making the newsletter a monthly publication.
I quickly reassured her that it is indeed
a monthly publication- except for the summer-when
I combine a couple of the months to give myself
a little bit of "laid back" relaxation.
So
welcome to the August edition. We are now
back on track monthly.
SAVVY........
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Just
this past week, I had the opportunity to sit
in on a treatment-planning meeting with the
parents present along with the client and
the treatment team. There was an additional
meeting with the mother and an interpreter,
together with the team. We reviewed the treatment
progress, discussed client and family preferences,
plus revisions to the plan. As I sat, I wondered
to myself how often (or not) this kind of
participatory treatment planning occurs in
programs around the country. I suspect it
is far less often than our politically-correct
'Mission and Vision' statements suggest. And
definitely less than what the clinical and
service needs of clients and families deserve.
Tips:
- Consider
Arizona's Strengths-Based Behavioral Health
Assessment and Service Planning
After many years of State and provider collaboration,
the Arizona Division of Behavioral Health
Services last year introduced a common approach
to assessment and service planning for all
behavioral health providers - adolescent,
adult, mental health and addiction treatment
providers.
You can access information on the Arizona
ADHS/DBHS Revised Assessment Process at:
http://www.hs.state.az.us/bhs/assess_ process.htm#assessment
Here are a few excerpts from the training
worth considering.
1. A Strength-based, family friendly,
culturally sensitive and clinically sound
model is based on three equally important
components:
> " Input from the person and family/significant
others regarding special needs, strengths
and preferences"
> " Input from other individuals who
have integral relationships with the person
"
> "Clinical expertise "
2. Six Principles of Assessments and
Service Plans
> 2a. They are developed with unconditional
commitment to enrolled persons and families.
> 2b. They begin with empathic relationships
that foster ongoing partnerships, respect
and equality.
> 2c. They are developed collaboratively
with families to engage and empower unique
strengths.
> 2d. They include other individuals
important to the person.
> 2e. They are individualized, strength-based,
culturally appropriate, clinically sound.
> 2f. They are developed with the expectation
that the person is capable of positive change,
growth and leading a life of value.
-
Assessing Family and Significant Others'
Issues is not Discharge Planning. It is
here and now Treatment and Service Planning.
ASAM Assessment Dimension 6, Recovery
Environment, is equally important as
traditional medical necessity dimensions!
Whether a person is in severe withdrawal
or not (Dimension 1, Acute Intoxication
and/or Withdrawal Potential)---
or suffering from unstable diabetes
or ailing with cancer (Dimension 2, Biomedical
Conditions or Complications)---
or is suicidal, psychotic or anxious
(Dimension 3, Emotional, Behavioral
or Cognitive Conditions and Complications)--
these symptoms are important to assess.
But if a client lives with a family
distressed and overwhelmed with the identified
client's addiction behavior, or their severe
and persistent mental health symptoms, that
is as important and urgent a service need
as detoxification services.
Consider these clinical vignettes drawn
from past clinical work and case consultations.
Case #1
A 24-year-old single, unemployed son
had many previous addiction treatment episodes
and even long periods of recovery. His parents
had set a limit. If he took the family car
and went on yet another cocaine binge, snuk
back in to take and sell the family silverware
for drug money, then he could no longer
stay at home. He would not be supported
by his family without resuming recovery
immediately. They were having difficulty
following through with that limit.
On the next acute detoxification and stabilization
episode, the managed care company approved
a residential stay. This was for the express
purpose of helping the family decide if,and
how, to follow through with their limit;
and to help the son develop new living plans
depending on what the parents decided. The
28 day residential treatment program insisted
that it would not be appropriate to have
a family meeting between parents and the
son in the first week, as the 'family week'
is week 3 of a 28 day stay.
My appeals to the residential counselor
to advance the family-focussed treatment
goals commenced in outpatient care were
to no avail. The family work was not seen
as a central treatment issue, equally important
as important as the detoxification stabilization.
It was viewed as some programmatic module
which was divorced from the particular assessed
needs of this son and his parents.
Case #2
A 17 year old, high school student was about
to be discharged from the adolescent residential
program. His mother was a single parent
whose day job meant that there was no one
to supervise him upon return to his community.
Mother was urging the managed care company
to place her son in a day-long partial hospital
program. The funder believed this partial
program to be more intense than was needed
for now well-stabilized substance and mental
health issues. It became clear that mother
understandably wanted the day program as
a "baby-sitter", and as a relapse prevention
strategy, rather than for any concern over
specific addiction or mental health symptoms.
The adolescent residential program had only
just begun to identify possible outpatient
therapists and referrals a few days prior
to the anticipated discharge date. There
had been no meeting with mother in person,
or on the phone, to hear her concerns about
an adequate transition and community reintegration
plan for her son.
The family work was viewed more as an afterthought
to deal with the "squeaky wheel" mother,
rather than a primary service need to be
addressed much earlier in treatment.
These are isolated situations you say. They're
aberrations from the usually high-quality
family work in addiction and mental health
programs, aren't they? I suspect not!
Take a look at your program- or those that
serve your clients and families- and you
be the judge. Isolated incidents? Or insufficient
investment in the value and power of early
family and significant other services.
SKILLS........
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So
if family work is to assume a greater role
in our assessment and service planning, here
are a few tips to think about.
Tips:
-
If you describe your agency as having a
"family program", perhaps you should have
"family services" not
a family program.
It may sound like this is just semantics.
But if family work is viewed as plugging
families into the weekly multiple family
group or the weekend or weeklong program,
then family needs assessment is shortchanged.
On the other hand, if an agency provides
family services, then assessment of family
needs is considered as relevant as vital
signs are for detoxification services,
and as central as blood pressure monitoring
for unstable hypertension.
One family may need a specific family therapy
session to help the parents set the limit
with their son; and then to assist them
in staying clear when he tries to persuade
them to change their minds through intimidation
or guilt inducement. Another family may
benefit from a multiple family group so
they can hear they are not the only ones
to feel frustrated, angry and overwhelmed
in dealing with their loved one's mental
illness. Yet another set of parents may
need skillful motivational enhancement therapies
to artfully engage them in treatment. They
may best be engaged to prove to child protective
services what good parents they really are,
and how they deserve their children back.
Such a variety of family services is essential.
A family "program" of set psychoeducational
modules and general family groups does has
value. But family needs can be as unique
and diverse as any other assessment dimension.
They deserve the same attention and skills.
-
If the assessment data indicates family,
living or recovery environment problems,
check to see if the treatment or service
plan addresses these.
Atriage counselor noted that the mother
entered treatment at the insistence of her
partner and father of their two-year old
daughter. Unless she received addiction
treatment, not only might the relationship
be in jeopardy, but also custody battles
could ensue.
The chart noted that a letter of invitation
was sent to the partner/father to attend
family group on Thursday night. But nowhere
in the treatment plan was there a problem
identified such as: "Partner and father
threatening the relationship and possibly
wanting custody" with an accompanying treatment
goal: "To clarify whether the partner is
seriously setting this limit, or is threatening
this out of frustration." A specific, focussed
treatment treatment strategy would
be to: "Call the partner and discuss his
concerns. Set up a family meeting to clarify
his concerns and limits with his partner".
Assessment of this family issue is central
to the approach with this mother. She may
need empathy and reassurance that with meaningful
recovery work, her family can remain intact.
Or she may need preparation for the reality
that the relationship is over, that she
is likely to lose custody of her child.
Or she may need assistance to examine her
options, in light of the fact that her partner
is ambivalent and unsure of his feelings,
options and intentions.
What is clear is this: the family work is
more than a letter of invitation to family
group.The treatment plan must articulate
it in black and white.
- If
a client is about to be transferred to a
less intensive level of care, check to see
if any preparation has been done with the
family.
A family-friendly focus requires specific
assessment and service planning around family
issues, not just if there are glaring family
problems. But even if a family is well supported,
and only needs self/mutual help groups like
Al-Anon, general multiple family groups
or psychoeducation, community reintegration
remains an important focus - and not just
in the day or two before discharge.
Q: Does the family know how to balance over-
protectiveness and reasonable concern for
any deterioration they notice?
Q: What should they say, and how should
they say it, if they notice their family
member is not taking their medication or
keeping up with AA meetings?
Q: Should they encourage the client to talk
to the counselor or therapist; or should
they call and report clinical changes they
observe?
Even for clients in outpatient settings,(those
not transitioning back to the community)
these are ongoing questions to ask in order
to assist families. And if the family system
is so chaotic and unsupportive of recovery,
all the more reason to carefully assess
the environment to see if the client can
cope with the toxic effects of this system.
Does the client need help to separate him/herself
from the family influences?
SOUL.........
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This
month my youngest left for college leaving
an empty nest. It is however, not an empty
budget - that will remain robust for several
years to come! I think we will handle this
family stage well without the need for any
specific family therapy. But as I have said
to her two older siblings, I reiterated my
parting and ongoing advice to her as she moves
away from the watchful eyes of loving parents:
"Remember the five S's." These are the areas
of life critical to have thought through ahead
of time - to examine one's values, practices
and their consequences. It is too late to
consider what to do in the immediacy of the
moment - the results can be irreversible and
profoundly life-changing.
For
all of you who have family, friends or clients
who might benefit from the five S's, here
they are:
1.
Substances - Besides addiction that is
treatable, there are consequences that can
be irreversible: acute intoxication that causes
a fatal accident or overdose, or a head injury
with permanent cognitive impairment.
2.
Sex - In the midst of making out, it is
not the time to begin an examination of your
values and practices about abstinence, safer
sex, pregnancy and abortion.
3.
Speed - I don't mean stimulants, I mean
cars and driving speed. When the tire blows
out and the car rolls, or the car upfront
suddenly stops, or the road is wet and the
brakes don't work well - that is too late
to think about speeding.
4.
Seat belts - When the car is rolling or
you are heading for the windshield, it is
too late to buckle up.
5.
Sleepiness - I read somewhere that a sleepy
driver is as dangerous to self and others
as a drunk driver. When my son sideswiped
the median barrier dozing off for a split
second after a late date, sleepiness was added
to the list.
It
is a family joke to mention the five S's.
But hopefully it will prevent some pain, save
lives and that's no joke.
SUCCESS
STORIES......
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"First
of all I want to tell you how much I've enjoyed
reading your Tips and Topics e- zine, and
the way you weave your knowledge into practical
discussion is sheer genius. I guess you can
assess I am a fan. Obviously you are a busy
person, and may get plenty enough feedback.
I still feel compelled to reply with a few
comments regarding the issue of relapse and
sustained support. My heart leapt when I first
heard it said that a relapsing customer should
be dealt with in a positive manner instead
of being chided and turned out. As a past
chronic relapser, I can tell you that it can
make all the difference in the world being
treated with the respect of hope rather than
like a leper. I had been in and out of treatment
facilities; always kicked out for using.
The
last one I went through (8 years ago) was
different as I did not feel like a hopeless
case, but instead treated as an individual
who could work through the hardest part, with
help of course. I always wondered why my failure
to stay abstinent would be met with that ol'
righteous indignation, almost as if it was
taken personally! There was a lack of understanding
of "seeds being planted". Looking back, I
realize that last facility was unusual in
their approach and years ahead of their time...Thank
God. Their cup was not already full, and they
were willing to try a different approach.
Also, a quick note on needle exchange programs.
I had been a loyal customer for many years,
and am certain this service kept me from dying
of AIDS as what happened to many of my not-as-careful
friends. A couple of times when "re-ordering",
I was met by protesters just filled with that
righteous indignation that these programs
would be allowed "to enable drug addicts".
I cannot forget the scorn and the ugly words
spewed as I exchanged my stash of needles.
Honestly, their display did nothing for me,
only made me hurry to use!
I feel very fortunate to work in a facility
that values a balance of care and gentle confrontation.
I believe we truly help/have helped/will help
many individuals because of this approach
and what a great feeling that is! I believe
your influence, as a trainer is directly to
do with this, and I thank you."
Respectfully,
A counselor in recovery
Until next time......
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I
hope this edition of TIPS and TOPICS has been
helpful. Thanks to all who send feedback,
comments and questions. I really appreciate
your insights even if I can't get to respond
to them all.
Talk
to you in September.
David
Contact Information
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email: info@dmlmd.com
voice: 530-753-4300
web: http://www.dmlmd.com
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