~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
TIPS & TOPICS from David Mee-Lee, M.D.
Volume 4, No.4
July/August 2006
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
In this issue
-- SAVVY
-- SKILLS
-- SOUL
-- STUMP THE SHRINK
-- Until Next Time
Welcome to the summer edition of TIPS and TOPICS.
(For the Southern Hemisphere readers, it’s
the winter edition). August has been a month of
stimulating international travel. The rich cultural
experience and still vivid images makes writing
about clinical behavioral health issues an anticlimax.
So this edition of TNT is going to be a version
of “What I did on my summer holidays.”
SAVVY
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
A twelve day trip to India is far too short. But
here are some views of this vast and fascinating
country and culture with perspectives provoked by
our travels.
Tips:
*
Be open to new ideas and find ways to get exposure
to alternate perspectives.
At
a conference many years ago I was startled when
the plenary speaker picked up a full glass of
water and started pouring into it from another
full jug of water. Of course it was only moments
before the overflow was splashing noisily and
messily on the stage floor. His point being :(which
I will always remember, was easy to grasp, but
would never have occurred to me to illustrate
it in quite that way)-- If you think you know
everything, are so satisfied and full of your
own knowledge, you will never benefit from new
knowledge that will wash over you. It will fall
on deaf ears and go to waste.
Nietzsche
said it another way in words to this effect: “Convictions
are greater enemies of the truth than lies.”
Being full of our certainty on how the world turns;
what treatment approaches are best; and what I know
is the right way to do recovery etc. are all convictions
which block openness to new findings. Lies can be
exposed for their invalidity. However convictions
and ideology are much more embedded in us. People
fight, kill and die for their convictions, and see
attacks as even more justification to be closed
to any alternate perspectives.
Our
Indian exposure to a wide variety of socioeconomic
groups, rural and urban settings, and such ranges
of work duties and human roles - even in a brief
stay- made thinking outside of our American 'cultural
box' a necessity, not a choice. Our first stop was
in Bangalore, a southern Indian city throbbing with
7 million people. Roughly 600 new drivers’
licenses are approved every day. 900 newly-registered
vehicles hit their already- clogged roads each morning
(mostly two and three- wheeled motorcycles-come-taxis.)
Never mind the media scrutiny that Britney Spears
got for driving her car with her infant on her lap
and not in a car seat! Bangalore’s roads were
choked with every mode of transportation- jammed
with motorcycles carrying dad, mom and junior, all
without helmets. Dad talked on the mobile phone
while mother shielded the baby- squashed in between
them- from the monsoon rains.
Last
stop -*Mumbai (Bombay). We were told that 5,000
people move into this vast city daily, villagers
pouring in for housing and work. In this metropolis,
rather than the countryside, they can at least have
a chance at work. Their highway-lined shanties and
living conditions sat in stark contrast to the well-
appointed, floor-to-ceiling marble/granite designer
apartment of the friend of a friend who picked us
up at the airport. These folks have the exclusive
contract for all advertising and promotion of Bollywood
movies and music on the SKY TV satellite network
in India. Not many of us have on the payroll a fulltime
driver at our disposal. It just seemed obvious to
me that people living in those shanty conditions
must be sad, frustrated and/or angry. On the contrary,
they 'voted' with their feet by relocating; our
host explained that generally many newcomers feel
privileged and relieved that they now have some
hope for a better life.
*
From Wikipedia, the free encyclopedia / Mumbai is
the 5th most populous city on the planet/~18 million
* Looking at the world through another’s eyes
is an illuminating experience.
We
received our touring recommendations for Mumbai
from “Joanna”! She was taking our May
service call from California to Capital One Bank,
from her phone in Mumbai (Bombay). Joanna suggested
we should visit a meditation center in Pune, three
hours drive from Mumbai. So we booked one night
there. Our friend arranged for a driver to take
us; wait for us and stay overnight; then return
us to Mumbai the next day. Eventually when we arrived
late in the day, it was clear one night would not
be enough. We sheepishly informed our driver we
wanted to stay 2 days instead of 1. Would he agree
to stay longer and wait for us?
Here
was a man who moved from Kolkata (Calcutta) to Mumbai
to work as a driver so he could support his wife
and three children back home. Mahesh works seven
days a week. He sees his family once a year. He
is perpetually on call. One month’s pay for
him almost equals what three friends paid for cocktails
on Saturday night at one of Mumbai’s hot nightspots
(where the closest our driver will ever get to such
a place is waiting outside.) Back to Pune: Mahesh
gladly waited 2 days for us, especially when we
tripled the daily allowance his boss typically gives
him, so he could lodge at a better hotel and eat
more generously.
I
cannot imagine working under those conditions. And
yet he remained personable, friendly, enjoying sharing
his perspectives on family, work, marriage and children-
to the extent he understood our questions, and we
his responses. If only we could speak his language
as well as he understood and bravely ventured into
English. I could have learned so much more about
cultural differences in attitudes, values and priorities
in life.
In
the late 1970’s just after China was opening
itself up, our Chinese guide shared that he worked
in one city while his wife lived and worked in another
faraway city. At that time, the government assigned
people to their work positions; people willingly
accepted. That was amazing to me. I remember asking
how he could stand to be told where to live and
what job to do, especially separated such a distance
from his wife. He looked at me and asked how I could
stand to live in a country where I didn’t
know if I had a job for sure, nor a place to live!
SKILLS
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
The clinical applications of such rich international
travel go far beyond traditional admonitions about
cultural consciousness, competency and proficiency.
There are implications for all clinical work.
Tips:
* Enter individual counseling and family therapy
as you would enter another's country and culture.
Perhaps
it is because caseloads and the demand for services
are high; or because it is easy for any work to
become routine and predictable--but when we enter
into the world of clients and their families, it
should be with the same respect, curiosity and novelty
as a trip to India, China or any other travel destination.
How
does this client see the world? What is this client’s
view of relationships, family interaction, vocational
and living situations, and socioeconomic values?
How can I best communicate with this family? Do
I speak their same language; or am I using jargon
as if speaking a whole different dialect and vocabulary?
What is important to this client and his/her family?
Imagine
entering another’s country and confronting
people for thinking differently from what you value.
Could you conceive of seeing a vastly different
world view, living and working environment, and
being more interested in telling the citizens what
they should do to change VERSUS being genuinely
curious about how they got there, how they experience
their environment and conditions? Could we enter
the client’s world with the same openness
to new experiences, new perspectives and with the
same sense of being lost in unfamiliar territory
as when we pass through passport control and step
out into a new country and culture? There are a
multitude of rich discoveries that open up not only
ourselves, but also clients and families to see
the world from a different angle.
When
the therapist (the “foreigner”) and
the client (the “local”) relate in an
open and curious way, when there is enthusiasm for
one another’s perspective, when there is an
attitude of wide-eyed exploration of the other’s
“world”, it's easy to empathize and
engage clients.
*Leave your comfort zone and stretch
into territory that leads to new skills and knowledge.
It
doesn’t have to be international travel or
globe- trotting which stretches you beyond familiar
tried and true set of values, perspectives and belief
systems. Travel certainly is a faster way to literally
and figuratively put oneself in a whole new world,
when you sit in a plane for 20 hours and disembark
in an India or China. But find some way - if not
through travel- to take those figurative 'cataracts'
that may cloud your viewpoint and vision and replace
then with a new set of lenses or glasses.
Are
there some team members whose ideas and skills you
find hard to identify with? Could you make a renewed
effort to reach out and approach them as you would
a local citizen in a foreign land? With a new mindset,
you could seek to understand; you might compare
and contrast your experiences with them; you may
decide to be willing to value perspectives different
from yours, even those perspectives you never imagined
you would ever change.
Perhaps
you work with clients and families who, despite
your good intentions and hard work, still do not
seem to “get it”? To what degree are
you willing to start with them in a new place exploring
different, unfamiliar approaches which broaden your
toolkit of therapeutic interventions?
SOUL
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
On the last day of our Indian vacation, the front
page of the Sunday edition “Times of India”
featured three stories which underlined this country
of vast contrasts. Within the previous few days,
thousands of people had flocked to Mahim creek to
wash away their sins in the “miraculous”
water that had turned sweet overnight. Some drank
the water; others brought sick relatives to dip
in the water to cure their illness; and many brought
infants in the belief that a wash would keep them
healthy for life. Some entrepreneurs even bottled
the water and sold it.
The creek flows into one of the most polluted beaches
in Mumbai. Government agencies tested the water
and declared it “unfit” for drinking.
Others elaborated that heavy monsoon rains always
dilute the water at this time of year, and that
water samples show very low levels of salt. This
could explain why normally salty water tasted “sweet”.
On
that same page was a photo of an attractive Bollywood
actress, Amisha Patel. An Air India employee claimed
the actress and her friend got verbally abusive
and threatening while flying to the USA. The two
women allegedly were so foul- mouthed that other
passengers were provoked into summoning the security
guards. Amisha countered that she was shocked to
hear about the complaint, that in fact, she was
planning to file her own complaint against the airline
for their rude behavior. “We kept telling
the ground staff about a drunken fat man who was
misbehaving with us, but they did not pay any heed
to our complaint. Even the lady at the counter was
rude to us.”
The
third article reported that Mumbai was cruising
towards its second airport. It would be brand new
and built by a consortium of state government, Airports
Authority of India and a private investor group.
The need for a second airport reflected the tremendous
growth and opportunity in Mumbai and India in general.
It’s
not so unusual for a newspaper’s front page
to report contrasting stories which point to the
clash between issues of faith and science, the secular
world of pop culture, and the unrelenting push for
new development and construction. But I had not
witnessed quite this clash since our trip to China
in the late 1970’s. It was then that people
were beginning to talk more openly against some
of the excesses of Mao Tse Tung, their revered leader
of 27 years. We saw one of Beijing’s very
first commercial billboards advertising cosmetics,
when all other billboards to that point sported
political slogans. Of course China is a whole different
story today.
So
I ponder how we view our own families and cultures.
How do we deal with the contrasts even between siblings
and within extended “families”? I wonder
how we approach others whose culture and background
are even more removed from our understanding and
experience. What we don’t understand provides
such a rich opportunity for new knowledge so long
as we can get our “convictions” out
of the way and keep our glass half full, ready and
able to receive more.
STUMP THE SHRINK
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Here’s a question to do with placing people
in programs versus designing services to match needs
and level of function.
Question:
We have a residential treatment center with
three beds earmarked by the state for dual diagnosis
clients who are severely and persistently mentally
ill with substance use problems. In your opinion,
and the ASAM opinion, does the borderline personality
disordered client fit the criteria for this population
i.e. dual diagnosed enhanced treatment?
There
is a split decision at our facility on whether they
fit the criteria or if they should just be in a
straight alcohol and drug treatment center with
dual diagnosis capable features.
Please
give us your thoughts on this.
Truly
Counselor, Oregon
My response:
My
perspective on your question is not to focus on
the diagnosis, but more on the function and severity
that needs treatment right now. There would be times
that a person affected by Borderline Personality
Disorder issues might need a DDE (Dual Diagnosis
Enhanced) service e.g., suicidal and intoxicated;
or self mutilating and impulsive or some psychotic
symptoms or dissociation along with substance use.
There
are other times that the dual issues need to be
addressed but can be handled in a DDC (Dual Diagnosis
Capable) service e.g., some suicidal ideation, but
not impulsive. However the person is using substance
and also needs addiction focused treatment.
States
and counties often define severe and persistent
as people with major Axis I DSM diagnoses, and not
a focus on function and needed services. I can understand
the need to have funding distinctions, but it would
be better to focus on function and need, not diagnoses.
There could be times that a stable schizophrenic-disordered
substance user could be well served in a DDC program
in an addiction setting.
The
ASAM PPC-2R criteria give you guidelines on function-oriented
criteria for DDC and DDE. (Readers, if you need
information on DDC versus DDE, see the last issue
of TNT in June 2006. Thanks,
David
Follow-up Question:
I
would like to expand on the questions that I asked
you about the borderline personality disordered
clients and where they fit into the picture for
alcohol and drug treatment, or maybe it doesn't
have to do with it at all.
We
do have these 3 beds for the Severe and persistent
mental illness (SPMI) persons for residential alcohol
and drug dual diagnosis treatment. If there is a
client who has had many treatment experiences and
has not been able to stop drinking, chronic late
stage, would it be appropriate to place them in
the dual diagnosis bed? It seems to me that if mainstream
alcohol and drug treatment has not been successful
with them, we should try a different avenue (DDE).
They are not necessarily actively suicidal when
not under the influence, but obviously have difficulties
with poor impulse control. Once again I would like
your feedback on treating the clients who have been
unable to remain abstinent, have lost everything.
Thank you.
My response:
With
people who continue to use or relapse despite many
treatment experiences, it is true that you need
to try something different. Why a person keeps using
or relapsing, however, is an assessment question
that can involve a variety of factors. If you have
ASAM PPC-2R (2001) you will see in Appendix C that
there are many factors that should be assessed to
understand relapse for a particular individual.
(Readers:
See Volume 2, No. 6 October 2004 for more detail
on these relapse factors.
The
reasons for relapsing can involve any one or more
of the ASAM assessment dimensions. A person may
continue to use because of a Dimension 4, Readiness
to Change issue where s/he is not even sure that
they have a drug problem or are very ambivalent.
Or they may really know they have a problem, but
have poor refusal skills to overcome peer pressure;
or have intense cravings for which they have few
skills to resist. Or they may live in a toxic environment
with poor housing, little money and few positive
significant others to support recovery (Dimension
6, Recovery Environment). Or indeed there may be
a co-occurring mental disorder that is poorly controlled
or stable, which contributes to repeated continued
use or relapse.
If
the services needed require staff who are skilled
in mental health and addiction treatment; and both
the mental health and addiction problems are unstable
and need to be concurrently addressed, then a Dual
Diagnosis Enhanced (DDE) program is appropriate
regardless of the specific diagnoses. Again, to
me, it is a focus on level of function and current
severity needing services that determines the type
and intensity of the level of care and program needed.
Eligibility for an SPMI DDE bed should be based
on the current function and service needs that can
only safely and effectively be delivered and provided
in that kind of setting and program.
Repeated
use and relapse might just as effectively be treated
by addressing the Dimension 4, 5 and 6 issues if
it is determined in the assessment that those areas
explain most of the relapse behavior. These service
needs may not need to be done in an SPMI DDE bed.
Case management, Assertive Community Treatment team,
housing, financial and vocational help and motivational
enhancement work may be what is needed. Those services
could be delivered by an SPMI program, but also
be delivered without a special program as well.
David
