August 2004
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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........
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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........
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

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.........
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

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......
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

"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......
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

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