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TIPS & TOPICS from David Mee-Lee, M.D.

Volume 3, No.7
December 2005
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In this issue
-- SAVVY
-- SKILLS
-- SOUL
-- STUMP THE SHRINK.......
-- Until Next Time

• Each of the six assessment dimensions highlights a particular area of function and services which may need attention.

With the publication of the Second Edition Revised (2001), the MDA is also applicable to those with mental health issues as well as substance use problems.

Assessment Dimensions	Assessment and Treatment Planning Focus
1. Acute Intoxication and/or Withdrawal Potential	Assessment for intoxication and/or withdrawal management. Detoxification in a variety of levels of care and preparation for continued addiction services
2. Biomedical Conditions and Complications	Assess and treat co-occurring physical health conditions or complications. Treatment provided within the level of care or through coordination of physical health services
3. Emotional, Behavioral or Cognitive Conditions and Complications	Assess and treat co-occurring diagnostic or sub-diagnostic mental health conditions or complications. Treatment provided within the level of care or through coordination of mental health services
4. Readiness to Change	Assess stage of readiness to change. If not ready to commit to full recovery, engage into treatment using motivational enhancement strategies. If ready for recovery, consolidate and expand action for change
5. Relapse, Continued Use or Continued Problem Potential	Assess readiness for relapse prevention services and teach where appropriate. If still at early stages of change, focus on raising consciousness of consequences of continued use or continued problems as part of motivational enhancement strategies.
6. Recovery Environment	Assess need for specific individualized family or significant other, housing, financial, vocational, educational, legal, transportation, childcare services

Reference:
Mee-Lee D, Shulman GD, Fishman M, Gastfriend DR, and Griffith JH, eds. (2001). ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition-Revised (ASAM PPC-2R). Chevy Chase, MD: American Society of Addiction Medicine, Inc.
American Society of Addiction Medicine - 4601 Nth. Park Ave., Arcade Suite 101, Chevy Chase, MD 20815. (301) 656-3920; Fax: (301) 656-3815; www.asam.org; To order ASAM PPC-2R: (800) 844- 8948.

For more tidbits on the ASAM Criteria, refer to previous editions:

April 2003: in Savvy & Skills
June 2003: in Savvy & Skills
Sept 2003: in Stump the Shrink
Nov 2003: in Skills
Jan 2004: in Stump the Shrink
Mar 2004: in Savvy & Skills
Oct 2004: in Savvy

• Use the multidimensional assessment to structure case presentations and clinical formulations, diagnostic, interpretive or clinical summaries.
  

Clinicians collect a lot of biopsychosocial assessment data. But often this is an onerous paperwork exercise more than it is an aid to focused clinical care. It is not that we need more assessment data. It is that we need to focus the data to actually assist us in serving clients, consumers and their families better. Whether a verbal format or written format, here is a suggestion of how to present clinical data which leads to individualized service planning.

Case Presentation and Clinical Formulation Format

I. Identifying Client Background Data

.. Name
.. Age
.. Ethnicity and Gender
.. Marital Status
.. Employment Status
.. Referral Source
.. Date Entered Treatment or Date Assessed
.. Level of Service Client Entered Treatment or Where Assessed (Case management, Outpatient, Inpatient, Emergency Room etc.)
.. Current Level of Service if already in treatment
.. Stated or Identified Motivation for Treatment (What does the client most want your help with?)

II. Current Dimension Rating of Severity or Function

(High, medium or low severity and why?)
Has It Changed? (If case is being re-presented)

1. Acute Intoxication and/or Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral or Cognitive Conditions and Complications
4. Readiness to Change
5. Relapse, Continued Use or Continued Problem Potential
6. Recovery Environment
(Give a brief explanation for each rating of High, Medium or Low severity. Note whether it has changed since the client entered treatment and why or why not)

III. What dimension(s) with High and Medium severity rating are of greatest concern at this time?

.. Specificity of the priority in each of those dimensions
.. Specificity of the strategies/interventions to address those priorities
.. Efficiency of the intervention (Least intensive, but safe, level of service that can provide those strategies)

When I was in medical school, if I were to present my evaluation and physical examination of a patient as a rambling discourse of disjointed historical facts, stories and anecdotes, I would have failed. That is why they teach you the structure of review of systems-cardiovascular, respiratory, gastrointestinal, neurological etc., and the presentation of findings (both positive and negative) gained from the patient’s physical examination. This helps you communicate your case in an efficient, transparent and focused manner.

A Case Presentation Format or Formulation is the behavioral health practitioner’s version of review of systems and physical examination findings. It will help those who listen to you understand your data and clinical process without getting lost in a sea of historical information.

SKILLS
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ASAM multidimensional assessment is far more than a method to place a person in a level of care or a program. It can provide the focus needed to build an alliance with a client and engage them in services that are truly client-directed.

Tips:

• Use multidimensional assessment (MDA) to identify both strengths and liabilities; resources and barriers to reaching the client’s goals.

If you view the MDA from a pathology-oriented perspective, you identify only problems in the assessment dimensions. If you expand your view of the MDA, you view the dimensions as an opportunity to identify a client’s strengths and resources as well. For example, in Dimension 1, Acute Intoxication/Withdrawal Potential, you can focus on who is in need of detoxification services right now (pathology). But if you remain equally aware of the client’s capacity to cope well with the discomfort of withdrawal, and handle even severe symptoms (strengths), you could utilize a less intensive and less restrictive withdrawal management service.

Or in Dimension 6, Recovery Environment, it’s easy just to pay more attention to your client’s many friends who are active drug users (liabilities), and forget to harness the positive influence of the one supportive friend who is in recovery (resource). The family may certainly need help to look at their nagging or rescuing behavior (barrier). But you can give equal attention to the fact that they are involved, concerned and present. These are resources which can be a support for someone just getting back on his feet. (strength)

Here is an example:

Consider a mother who comes to you wanting to get her children back. She wants to convince Child Protection Services that she is indeed a good parent and fit to regain custody. The MDA is used in the service of this client and what she wants help with:

1. Acute Intoxication and/or Withdrawal Potential – History of only mild withdrawal in the past with no need for intensive detoxification services before; and no recent use of substances reassures the clinician and client that she is not intoxicated or in need of withdrawal management and is safe for outpatient treatment. If we can help her continue to avoid intoxication, this will help us make a strong case for regaining custody of her children.

2. Biomedical Conditions and Complications – A history of mild hypertension is well stabilized with the client’s efforts to lose weight and to exercise regularly. A focus on maintaining her weight and exercise program will strengthen her case that she is a good parent who demonstrates a healthy lifestyle worthy of reuniting with her children.

3. Emotional, Behavioral or Cognitive Conditions and Complications – A history of angry outbursts at her children is balanced by her current stability since not using alcohol or other drugs. She is still ambivalent about whether her anger is as bad as her child protection worker says. However she is open to attending parenting classes to check on how effective her parenting techniques are or not.

4. Readiness to Change – She is highly motivated to maintain custody this time, having had a history of half-hearted attempts in the past when more consumed with her substance use. She is clear that addiction has affected her parenting ability, though she is not convinced that staying drug-free will require as much lifestyle change as what she is being told in her addiction treatment. Rather than insisting she commit to lifelong abstinence and recovery, it will be more effective to engage her around wanting to keep her children.

5. Relapse, Continued Use or Continued Problem Potential – While she has had a history of only brief periods of abstinence in the past five years with little self help/mutual help group participation, she has maintained abstinence for three weeks already. Building on whatever has been working for her in the past month will help her establish the necessary track record of stability that will strengthen her case for regaining custody of her children. Identifying, reinforcing and adding to what attitudes and strategies have so far been effective to prevent continued use will be the focus of Dimension 5 work.

6. Recovery Environment – Her history of inconsistent employment and volatile relationships with significant others is a challenge in building a case for reunification. However her mother is very supportive though frustrated and uncertain how best to be help her daughter. The client also does have an increasing interest in computers and may be a candidate for job training. A joint effort with mother may be the client’s only chance at this point to stabilize her living and job training situation. This will be especially important to demonstrate that she is willing and able to provide a safe environment for children.

• Practice presenting a case in five minutes or less.
  

There is an occupational hazard of people in behavioral health: we can discuss a case for hours, sharing every anecdote and voyeuristic detail in a person’s life. Then we run out of time before really reviewing the person’s progress and actually adjusting the service plan. Instead of rambling on about every historical fact or pontificating on your pet psychodynamic or insightful theory about the person’s life, try focusing the case presentation only on pertinent historical and here-and-now data and functioning.

Some helpful guidelines to focus your presentation of the MDA is to use the three H’s: History; Here and Now; and How Worried Now. You can read more about this in the Skills section of the April 2003 issue (http://www.dmlmd.com/2003.04.ezine.html),but I will again refer to a part of that information here.

With each dimension don’t recite every minute, chronological detail of the person's history and treatment episodes. Stay focused on a brief explanation of your dimensional assessment rating and use the framework of the 3H's to structure your information. For example, you might state:

“Dimension 5 is high severity. Even though the client wants to stop using all substances (Dimension 4), he has never had a History of being able to stay abstinent for longer than two weeks. He has never had treatment or experience with recovery groups. Here and Now he has intense cravings with few peer refusal and coping skills. As I look at him, he is anxious, craving and I am Worried Now that he has no internal knowledge, coping skills or ability to prevent continued alcohol use. This will be a priority area to collaborate with Joe about if we are going to help him avoid going back to jail, which he really wants help with.”

Notice in the example under Skills Tip #1 above: I incorporated History and Here and Now information under each dimension.

SOUL
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What is a brand? Jeff Bezos, the founder and CEO of Amazon.com, defined it this way: “What people say about you when you are not in the room.” On some things, I have strong brand-loyalty. I own a Sony TV, video camera, DVD player and recorder and laptop computer. I have had eight VW cars (Beetles, Rabbits and Golfs). On other things, I don’t much care – paper towels, gasoline, motor oil. I usually don’t think of brands applying to people, but the New Year can be a time when we revisit our life and career direction and, if you like, your brand.

Marketing folks talk about one’s Elevator Speech:– Can you state what your product or service is - succinctly and persuasively- in the time it takes to ride from the 1st to maybe the 5th floor? In an Elevator Speech, how would you define who you are and what you do? It is much harder to distill and state your essence in 3 sentences or 2 minutes, than to ramble on for hours!

What is your brand for 2006? – Angry activist or charismatic change agent; boring or brave bureaucrat; cranky complainer or caring conciliator; dangerous daredevil or entrepreneurial innovator; progressive leader or passive participant? For myself, I am playing with: bold bridge-builder; or relaxed rose- smeller; or a non-alliterating literate!

Have some fun with it. You might learn something about yourself next time you are in an elevator.

STUMP THE SHRINK.......
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Here are a few questions about the ASAM Criteria:

Question #1:
Could you tell me if there is anything like an "official" cross-walk between Patient Placement Criteria (PPC) and DSM-IV? Thanks in advance.

William J. Sarasin
Treatment Consultant
Michigan Department of Community Health
Office of Drug Control Policy

Answer:

William:
In the ASAM PPC, there are diagnostic admisssion criteria for each level of care and also the six dimensional assessment criteria for each level of care. Diagnostic criteria are included to ensure that the client does indeed need definitive addiction treatment versus education and risk advice for problem drinking or use as in Level 0.5, Early Intervention.

The diagnostic criteria for each level of care refer to the DSM diagnostic criteria, but the PPC does not require people to do an official five axes DSM diagnosis. There is no crosswalk between PPC and DSM as each is serving different purposes - the diagnosis to determine the kind of treatment i.e. addiction treatment versus mental health or biomedical services or co-occurring disorders treatment. The PPC is looking at the multidimensional needs in the treatment plan.

It is true that DSM has multiple axes and there is some correlation with the ASAM PPC assessment dimensions. For example, DSM Axis IV does correlate to ASAM Dimension 6; and DSM Axes I and II relate to ASAM Dimension 3; and DSM Axis III relates to ASAM Dimension 2.

From my point of view, addiction clinicians can gather most of the information to allow a DSM five axes diagnosis to be made, though any formal Axis I, II or III diagnosis should probably be made by the appropriate doctoral level person i.e. a psychiatrist or psychologist as regards DSM Axis I and II; a physician for DSM Axis III. A counselor, with some training could do relatively easily DSM Axes IV and V.

If a counselor identifies a DSM Axis I and/or II diagnosis and pays attention to ASAM Dimensions 1 - 6, then he/she will be taking care of DSM Axes III through V anyway. Whether they need to do a formal DSM five axes diagnosis is up to the agency - but is not an ASAM PPC requirement.

Question #2:
I've been asked by a co-worker how to apply the ASAM criteria to a client who is seeking services with us as a significant other. I work at an addictions outpatient counseling facility. The client is seeking help for co-dependency. She is not abusing or dependent on alcohol/drugs herself, so would it even be appropriate to use ASAM criteria in determining level of care?

Shari Simon
Alcoholism/Substance Abuse Counselor
Fulton County Addiction Services

Answer:

Shari:
As regards your question, the ASAM Criteria are for the Treatment of Substance-Related Disorders. So strictly speaking, a person who does not meet criteria for a Substance-Related Disorder would not be eligible for application of the ASAM Criteria. If the significant other was a family member of a person who was in addiction treatment, then the family could be seen as a Dimension 6 Recovery Environment treatment strategy. But if the client is presenting as an independent person not part of the family of someone in addiction treatment, then the ASAM Criteria would not apply.

Question #3:
I have a question on legal issues such as arrest. Does it go under Dimension 3 or Dimension 6? I would appreciate an answer to make the right assessment. Thank you for your time.

Rene Rehmel, CADC Intern

Answer:
Rene:
The dimensions guide whether there are any issues to be dealt with to help the client reach the goals that brought them to us in the first place. Which dimension an issue belongs in depends on what kind of services they will need. This ensures that we not overlook any issues that may need addressing as regards detoxification services (Dimension 1); physical health services (Dimension 2); mental health services (Dimension 3); motivational enhancement services (Dimension 4); Relapse prevention services (Dimension 5); and family, significant others, legal, vocational, educational, housing, finances etc. (Dimension 6).

So if the client has legal issues, and needs help collaborating and case managing with the probation officer and the courts, that would be legal help (Dimension 6). If there were some mental health issues and counseling or treatment needed for criminal thinking; or anger management and impulse control, then those issues would be Dimension 3 issues as they need counseling and mental health interventions. But if it is purely interfacing with the courts and the judge or the probation officer., then that would be legal and case management issues for Dimension 6.

Until Next Time
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Thanks for reading and thanks to all of you who send me comments, questions and success stories. See you in the next edition of TIPS and TOPICS.
David

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