~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
TIPS & TOPICS from David Mee-Lee,
M.D.
Volume 4, No.3
June 2006
Copyright
2006 DML Training & Consulting | 4228 Boxelder
Place | Davis | CA | 95616
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
In this issue
-- SAVVY
-- SKILLS
-- SOUL
-- STUMP THE SHRINK
-- Until Next Time
Welcome
to the June edition of TIPS and TOPICS (TNT). We
won’t call it the June/July issue even though
you are receiving it in the first few days of July.
You will however receive a combined July/August
edition sometime in August - as is our custom in
the summer.
SAVVY
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
The website for the Substance Abuse
and Mental Health Services Administration's Co-Occurring
Center for Excellence (SAMHSA COCE) was launched
on February 14, 2005 as a rich resource on co-occurring
disorders. As a Senior Fellow for the COCE, I was
notified that the COCE website was recently updated
on June 8.
Tips:
Central
to the COCE approach is a series of overview papers
addressing key COD topic areas. The overview papers
summarize the science base for each topic addressed,
and make recommendations for practice, systems,
and State and local laws and regulations which support
treatment and prevention systems as appropriate.
Three overview papers are now available in print
and PDF format. Two additional overview papers are
available in PDF format (clearance for printing
is pending) from the COCE website. http://www.coce.samhsa.gov/cod_resources
/index_right_2.aspx?obj=77)
No.
1 - Definitions and Terms Relating to Co- Occurring
Disorders - Available now in PDF and printed copies
It is essential to use a common language to develop
consensus on how to address the needs of persons
with co-occurring disorders. This paper provides
definitions of terms associated with substance-
related disorders, mental disorders, co-occurring
disorders, and programs.
No.
2 - Screening, Assessment, and Treatment Planning
for Persons with Co-Occurring Disorders - Available
now in PDF and printed copies
Clients with co-occurring disorders are best served
through an integrated screening, assessment, and
treatment planning process that addresses both substance
use and mental disorders, each in the context of
the other. This paper discusses the purpose, appropriate
staffing, protocols, methods, advantages and disadvantages,
and processes for integrated screening, assessment,
and treatment planning for persons with COD as well
as systems issues and financing.
No.
3 - Overarching Principles To Address the Needs
of Persons With Co-Occurring Disorders - Available
now in PDF and printed copies
Principles, by their nature, are consistent with
a concern for the well-being of the client and his
or her loved ones. This overview paper outlines
12 overarching principles for working with persons
with co-occurring disorders. These principles are
intended to help guide, but not define, systemic
and clinical responses.
No.
5 - Addressing Co-Occurring Disorders in Non- Traditional
Service Settings - Available now in PDF only
Settings outside the substance abuse and mental
health system, or settings where service missions
do not include a primary focus on COD but where
persons with COD are likely to be seen, are the
focus of this overview paper. These include primary
health, public safety and criminal justice, and
social service settings. These settings should be
prepared to identify and effectively respond to
persons with COD.
No.
6 - Understanding Evidence-Based Practices for Co-Occurring
Disorders - Available now in PDF only
The advantages of employing evidence-based practices
are now widely acknowledged across the medical,
substance abuse, and mental health fields. This
paper discusses evidence-based practices and their
use in treating persons with co-occurring disorders,
discusses how evidence is used to determine if a
given practice should be labeled as evidence based,
and gives some brief examples.
Other
COD Resources on the COCE website:
>>COCE
Products - Presentations - A new expert presentation
is now available
http://www.coce.samhsa.gov/cod_resources
http://www.coce.samhsa.gov/cod_resources
/index_right_3.aspx?obj=82
>>ATTC
Resources and Publications - A new link has
been updated to provide access to a new edition
of Psychotherapeutic Medications 2006: What Every
Counselor Should Know - The language has been modified
to increase readability for a larger audience, and
in keeping with the goal of updating the brochure
annually, several new medications are included.
http://www.coce.samhsa.gov/cod_resources
/index.aspx?obj=23
>>
Policy Academy States Products - Five new action
plans have been added for the States of Arkansas,
Delaware, Pennsylvania, Montana and New Mexico
http://www.coce.samhsa.gov/cod_resources
/index.aspx?obj=26)
>>
COD Federal
http://www.coce.samhsa.gov/cod_resources /index_right3.aspx?obj=31):
**New HRSA Cultural Competence Web Page
**NIMH Study to Help Depressed Patients Become Symptom-Free
For more information, e-mail coce@samhsa.hhs.gov
or call (301) 951-3369.
-
TIP
2: The American Society of Addiction Medicine
Patient Placement Criteria, Second Edition, Revised
(ASAM PPC-2R) describes three types of programs
for people with COD. These program types can be
established at any level of care.
The first COCE overview paper on definitions and
terms included terms associated with programs.
While the original ASAM PPC-2R descriptions were
of programs within the addiction treatment continuum
of care, the COCE expanded the program descriptions.
The paper referenced definitions that should be
used with mental health as well as addiction programs.
While the ASAM Criteria describes Addiction-Only
Services (AOS) programs, there are no criteria
for who belongs in an AOS program. Dual Diagnosis
Capable (DDC) is considered the base level that
should exist to at least evaluate a client for
COD and case manage a person if a COD is present.
Here is more detail on the three types of programs:
A.
Programs that offer Addiction-Only Services (AOS)
or Mental Health-Only Services (MHO)
Cannot accommodate people with COD who require ongoing
treatment, however stable the co-occurring illness
and however well functioning the individual. The
policies and procedures typically do not accommodate
COD: For example, individuals on psychotropic medications
generally are not accepted in addiction programs;
or in mental health programs, people still using
substances are told to return when thirty days sober.
Coordination or collaboration between mental health
and addiction services are not routinely present.
B.
Dual Diagnosis Capable (DDC) Programs
* Dual Diagnosis Capable (DDC) programs routinely
accept individuals who have co occurring mental
and substance related disorders.
* DDC programs can meet such clients’ needs
so long as the co-occurring disorder is sufficiently
stabilized and the individuals are capable of independent
functioning to such a degree that the co-occurring
disorder does not interfere with participation in
treatment.
* DDC programs address COD in their policies and
procedures, assessment, treatment planning, program
content, and discharge planning.
* They have arrangements in place for coordination
and collaboration between addiction and mental health
services.
* They also can provide addiction treatment consultation;
or psychopharmacologic monitoring and psychological
assessment and consultation on site; or by well-coordinated
consultation off-site.
C.
Dual Diagnosis Enhanced (DDE) Programs
* DDE programs can accommodate persons with COD
where both disorders are unstable to the extent
that integrated addiction and mental health services
are needed.
* DDE programs are staffed by psychiatric and mental
health clinicians as well as addiction treatment
professionals. Cross training is provided to all
staff. Such programs tend to have relatively high
ratios of staff to clients and provide close monitoring
of clients who demonstrate both addiction and mental
health instability and disability.
* DDE programs have policies, procedures, assessment,
treatment planning and discharge planning that accommodate
more acute clinical presentations and crises in
people with COD.
* Dual diagnosis-specific and mental health symptom
management groups are incorporated into addiction
treatment. Motivational enhancement therapies are
more likely to be available (particularly in outpatient
settings.)
References
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.
See
Pages 7-11 for more detail on Co-Occurring Disorders.
SKILLS
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What kind of program and service do you provide?
Is your agency AOS or MHO, DDC, or DDE? Here are
a couple of tips to help you evaluate that more.
Tips:
What
do addiction programs often do?
They
do one of two things: send the person away and refuse
admission; or begin immediate detoxification whether
the person wants to do that or not. If a client
presents to you on medication, which you believe
to be detrimental to the client (e.g., benzodiazepines
in a person with addiction illness) you are right
to be concerned.
What
would be a more effective approach?
Admit
them to the program. Good assessment and treatment
cannot really be done before a person is actually
admitted to a program. This is a person who needs
assessment and treatment, not a plan based on a
policy and procedure.
The
purpose of admission is:
(1) taking a careful history from the person and/or
the family;
(2) assessing over time whether the person has a
co- occurring disorder or not;
(3) engaging the client in a plan to collaborate
with the prescribing physician;
(4) working with the client’s stage of readiness
to detox off the medication and try other medication
or non-medication methods.
This is not an all-inclusive list.
These
are all challenging issues. This is what treatment
in a DDC or DDE program encompasses. It does not
exclude the client from the very assessment and
treatment planning they need.
Similarly,
mental health programs often ignore the substance
use problems and focus just on the mental health
problem.
For example- The clinician stabilizes an intoxicated,
suicidal, impulsive, depressed client; sends them
out with a Major Depressive Disorder diagnosis;
and next sends them to a psychiatrist who prescribes
an antidepressant.
What’s
missing in this approach?
>
An assessment of the substance-induced depression.
> Engaging the person into exploring substance
use problems.
Oklahoma,
like many states and counties, is examining and
improving their infrastructure to better address
the needs of people with COD. I was interested to
hear them raise the following point: In moving towards
“every door being the right door” or
“no wrong door”, we have to change how
we respond when a person walks into a treatment
program which may lack all the services needed for
that person or population.
What
is often our first impulse? Either to give the person
a different number to call, or to make an appointment
with someone else a few days or weeks away. We hope
they make it, but at least we did the right thing
and gave them a referral. So thus we soothe ourselves
that we have done all we can.
A
few years ago I called AT&T to enquire about
a service; I thought I had the correct number. As
soon as the service representative realized I had
called the wrong service number, she did not merely
tell me to hang up and call the correct number.
While I was still on the phone and could hear what
she was doing, she called the correct number, explained
to the different service representative what I was
wanting, then introduced me, and passed me over
to get my question correctly answered. I know we
are not offering voice mail, call-waiting or conference
calling services. But I got better linking
service than the people who reach out to us- those
often psychotic and/or intoxicated. And I wasn’t
even psychotic (I don’t think).
If
you or your agency is still thinking in terms of
referral, you may still be an AOS or MHO program.
Start talking about ways you can at least become
a DDC service, one that at a minimum can link people
to get their needs met, even if you cannot provide
integrated services- yet!
SOUL
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I just returned from an invitation-only conference,
which examined current research and clinical applications
to facilitate the client process of change in substance
abuse treatment. Carlo DiClemente, Ph.D., one of
the originators of the Transtheoretical Model (TTM)
of Stages of Change, invited us to make a presentation
in twenty minutes or less. When you are challenged
to distill the recommendations you would give for
incorporating stages of change in clinical work,
there is no room for fluff or waffling. It is not
a bad way to discover what you really believe about
any subject, not just stages of change.
It is cliché to say the more you know, the
more you realize you don’t know. But again
that was my experience there as I sat around the
table with American and international researchers
and clinicians. I think I made a good contribution,
and I know I certainly learnt a lot from them. You
often don’t know what you don’t know.
Putting aside all the research validity questions
(about whether you can really categorize people
into neat stages of Precontemplation, Contemplation,
Preparation and Action) there is something really
useful about thinking of stages of change in your
personal and professional life. In this month’s
Stump the Shrink you will see how different counselors
can view stages of change differently depending
on one’s view of the world. That’s in
the clinical and professional world.
But
in my personal life, I find it useful too. Before
beating on yourself for not sticking to the diet
or exercise plan you vowed to do, you might just
own the fact that you are more in Contemplation
(ambivalent) than you thought. Re-look at your commitment
and reasons to change (or not) and renew your choice.
Perhaps you may decide you really don’t want
to get started yet.
This
can apply to significant others and family too.
Instead of feeling frustrated at others who don’t
do what you think is important, remember they might
be in Precontemplation (don’t think there
is a problem – that what you think is important
is not necessarily on their radar screen). You could
yell at their resistance and unthoughfulness, but
you may need to raise their awareness of what is
going on for you, then make a request of them.
When
my college-student daughter was living at home in
her teen years, I was continually frustrated with
her wasting electricity by leaving lights and air-
conditioning on when she would go out. Nagging didn’t
work. It just didn’t seem to propel her to
Action in turning lights off. So I started putting
Post- It notes on her mirror (one place I was sure
she would look at). The notes weren’t reminder
notes. They were “User Fee” notes, stating
the amount to be deducted from her allowance for
whatever length of time the air-conditioning was
left on. “12 hours of air conditioning - $2.00.”
(I don’t know what it actually costs to leave
the AC on for 12 hours).
Even
if it didn’t raise her consciousness all the
way to Action, I felt better. If she left the electricity
on, then she was choosing to spend part of her allowance
on my electricity budget. She was far more at Action
for keeping her money than in submitting herself
to my fruitless nagging. And you thought stages
of change was just for clients!
STUMP
THE SHRINK
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
The
email below was not intended as a Stump the Shrink
question, but raises good points anyway. (The reader
is referring to the April 2006 edition of TNT.)
http://www.dmlmd.com/2006.04.ezine.html
Reader Comment:
Hi
Dr. Mee-Lee:
As
always I appreciated your recent Tips and Topics.
I wanted to comment on the table with the stages
of change and the levels of care. In that context
I think it's important to frame the "level
of service" as a key component of the treatment
plan. How do we strategically match the patient
to a level of service that will enhance and reinforce
the stage- based treatment plan objective and activities.
The way the table is designed makes me concerned
providers will make concrete level of service decisions
based solely on stage of change. Realizing stage
of change addresses multiple issues, as you defined
later in your article, shows it's not as concrete
as the table defines. It also reflects that stage
of change on an issue that may be perceived as unrelated
to recovery could be a key component in engaging
the client in service.
The
other continuous challenge regarding stage of change
for providers continues to be their own personal
bias on "recovery" and making the stage
assessment from that. For example; two therapists
look at a client. One therapist has strong roots
in a 12 step model, the other more "eclectic".
The patient hasn't used in 2 months, is attending
group, complying with the treatment plan. The eclectic
counselor views him in "action".
Same
client, but the "12 step model" counselor
says he's in pre-contemplation. Why? He refuses
to attend meetings and says he now has control over
his use, "if I wasn't in control I wouldn't
have been able to quit". Seems like stage of
change should be based on the client’s perception
of recovery. Of course a counselor can't do that
if they don't see that the client’s view of
recovery is as relevant. So what is the baseline
definition specific to substance use/dependency
we should use when assessing stage of change? Abstinence,
"recovery", desire for help??
This
wasn't intended to be a "stump the shrink"
Scott
Boyles
Program Administrative Officer
Montana Addictive and Mental Disorders Division
Chemical Dependency Bureau
406-444-9408
Response:
Hi
Scott:
Thanks
for your comments with points well taken.
I
understand your concerns about the table, especially
if taken out of context with the clinical caveats
I mentioned. It is the danger of trying to get one
point across that can be misunderstood if not seen
in its entirety. The main point I was trying to
make was that when people are in early stages of
change, the motivational enhancement strategies
should be done in less intensive levels of care,
and not more intensive levels- as is often the practice
in the field. For example, it is difficult to test
out and have the client do their own research on
the “just cutting back” treatment plan
when they are in a residential program. Or it is
hard to have them try the “I have strong willpower,
no AA” treatment plan if in a program where
everyone is expected to attend and appreciate AA.
Your
next point about assessing stage of change is important
too. What I usually say is that if the client is
there talking to you in treatment, then they are
in the Action stage for something e.g., staying
out of jail; getting their kids back; keeping their
job. They may be in Contemplation or Precontemplation
as regards to what WE think they should work on
e.g., abstinence, recovery etc. But of course we
should start with where THEY are at, not where WE
think they should be at.
Thanks
for your feedback.
David
Until
Next Time
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
See you next month for a combined July/August edition
of TNT.
David
Contact Information
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
email: info@dmlmd.com
phone: 530-753-4300
web: http://www.dmlmd.com
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Copyright
2006 DML Training & Consulting | 4228 Boxelder
Place | Davis | CA | 95616
| 
