Clinical
work
In documentation, Progress Notes are often too general
- focused on attendance and compliance, rather than
on the client’s clinical progress and outcome
of the strategies in the treatment plan.
Examples
of general Progress Notes: “More willing to
follow rules and compliant with treatment activities”;
“Compliant participation in group”;
“Attended and participated in all scheduled
groups”; “Plan: Continue to monitor”
The
goal of treatment is not to get patients and clients
to jump through the hoops, to be good boys and girls
who do what they are told in the program. When counselors
and therapists focus on compliance, clients often
seem resistant and frustrating. When administrators
and accreditors focus on compliance, clinicians
often seem resistant to change.
“Continue
to monitor”-----What?
A
client might be trying to deal with cravings through
a combination of relaxation techniques, reaching
out to others, recovery group attendance and anti-
addiction medication. The Progress Note should state
whether the cravings are improving with these treatments
or not. The important point is whether the cravings
are improving, not whether the person is atttending
all treatment groups. Now the "continue to
monitor" is focused on whether the cravings
are increasing or decreasing. Then you can change
or tweak your strategies based on outcome.
Administrative
or quality audits
Too much emphasis is placed on compliance with the
administrative rule or quality standard. A better
emphasis would be on whether the program is actually
achieving what the standard is meant to safeguard.
Here
are examples of well-intended standards and audit
procedures designed to assure quality and safety:
1.
All clients will be informed of the benefits and
risks of their medication. Compliance with this
standard will be monitored by percentage of all
medical records which have signed consent forms
present and up to date.
2. All clients will have an individualized treatment
plan based on their goals, preferences and stage
of change. Compliance with this standard will be
monitored by review of ten charts at random. The
quality audit will review the degree of individualized
Problem statements, Goals and Objectives, Interventions
and Progress Notes.
However----
An
agency might achieve 100% compliance with signed
consent forms or beautifully-written individualized
treatment plans. But the real question is this:
-->Do clients really know about their medication?
-->Do they even know what their treatment plan
says and what they are working on?
These
questions suggest an alternate way to audit quality
and safety:
-->Interview ten clients at random. Measure what
percentage can describe the medication they are
taking, why, and what the benefits and risks are.
-->Interview ten clients at random. See if they
can tell you about their treatment plan, and if
it is helping them.
I
travel a lot and many of the hotels I stay in provide
a welcome letter and at the end of the stay, another
reminder. Their main focus is on the outcome of
my stay. The letters say something to the effect
that if there is anything that would prevent me
from giving them the highest rating of satisfaction,
they want to know about it at the time, so they
can fix it. They also want to know if my complaints
were satisfactorily responded to.
Probably
they have supervisors who check that the rooms are
cleaned, refurbished to certain quality standards;
they likely audit workers to ensure that they comply
with all rules and standards. But 100% compliance
is secondary; it takes second place to whether the
customer had a pleasant stay and would return and
recommend the hotel to others.
Perhaps
it’s time!
With
the degree of stress, time, energy and resources
that go into paperwork as well as administrative,
accreditation and quality audits, perhaps it’s
time to shift the emphasis with clients, documentation,
CARF and JCAHO surveys, and administrative review.
SKILLS
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
While online the other day, a pop-up screen blared
“Things that don’t make sense"
--- I didn’t even pursue what they were selling.
However it became the inspiration for this month’s
Skills section.
Tips:
Things
that don’t make sense- No.1
Agencies recognize that 50% of the client population
has co-occurring disorders, yet only one or two
clinicians on the treatment team is skilled or competent
in the other disorder.
It
is not unusual for me to ask a mental health program
how many of their clients have co-occurring mental
or substance use disorders. Most estimate 40% to
50% or even more. Then I ask who on the staff is
a certified addiction counselor. Again it is not
unusual to hear silence or: “I think Joe used
to work in a detox once. He’s here on weekends.”
And the same is in the reverse on addiction programs:
“I think Joe used to work on a psychiatric
unit once. He’s here on weekends.”
What
to do about it
If there are not resources to hire more people,
make sure that the next staff member who leaves
is replaced with whatever expertise is needed: someone
with addiction or mental health competency. Or start
trading staff to co-lead a group; or spend a week
at the other program.
Things
that don’t make sense- No.2
Agencies that believe that addiction is a chronic,
relapsing illness but then, on intake, tell a client
that if he uses alcohol or some other drug, that
he should not show up for group that day. Or if
he does show up for group, the policy is to send
him away.
I
have never heard of a program or clinician telling
clients, on intake, about a policy like this: If
you should get depressed or suicidal, manic or psychotic,
panicky or anxious, do not come to treatment that
day. I could not imagine a program turning someone
away because they showed up to a session with the
very problem for which they are getting help. As
William White puts it, programs/clinicians “punitively
discharge clients for becoming symptomatic.”
(White, W (2005): “Recovery Management: What
If We Really Believed that Addiction was a Chronic
Disorder?” Great Lakes ATTC. www.glattc.org
What
to do about it
First decide whether you really believe that addiction
is often a chronic, relapsing illness just as that
can be true for schizophrenic disorder, bipolar
disorder, major depressive disorder and panic disorder.
Examine whether we still hold some of the stigma
and attitudes of the lay public. They view addiction
as willful misconduct with a need for consequences.
It is hard to treat co-occurring disorders, if we
have such different attitudes about mental disorders
versus substance use disorders.
Things
that don’t make sense- No.3
Clinicians excluding an addiction client from group
treatment when she shows with alcohol on her breath.
There's a fear she might trigger other group members.
In contrast, they are quite comfortable with a mental
health client talking about domestic violence or
sexual abuse even though that talk may trigger others
in the group.
I
have never heard of a therapist asking someone to
leave group because their sobbing or severe anxiety
disturbed another group member and made them feel
uncomfortable or even angry. Yes we need to keep
the treatment milieu safe and therapeutic.
**Do
not misunderstand:
I am not saying that if a person is severely intoxicated
- slurred speech, cognitively unable to participate-
that we continue to do group or psychotherapy with
them. These are urgent needs that must be addressed.
You would do the same with an acutely suicidal and
impulsive person where establishing safety is also
the top priority. Nor am I saying that if the client
is intent on using substances and trying to get
others to use with them that we just ignore that
and continue treatment as usual. But if a person
is wanting help, what better place to be triggered!
Triggered in a therapy group with trained therapists,
right there to help both the client who relapsed
and any others who could identify with the same
struggles and loss of control.
What
to do about it
Make it clear to all clients that recurrence of
use is a treatment alert. Similarly recurrence of
psychosis, mania, depression or suicidal thoughts
and behavior are also significant events that need
professional assistance. If a client is willing
to reassess their treatment and change their plan
in a positive direction, then treatment continues.
Things
that don’t make sense- No. 4
Clinicians who have assessed a client as being quite
out of control, severe and a chronic relapser who
needs residential treatment. But then the client
is placed on a waiting list for anything from days
to weeks.
I
have never heard of a patient who needs the intensive
care unit being placed on a waiting list. I cannot
imagine a pregnant mother who is in labor and coping
with increasing labor pains being told to come back
later when a bed is available. By the Patient Placement
Criteria of the American Society of Addiction Medicine
(ASAM) a client who needs residential treatment
has one or more dimensions that are of such severity
that the client would be in imminent danger if not
in a 24 hour setting. How such a person can now
be placed on a waiting list is one of those things
that don’t make sense.
What
to do about it
Use residential treatment and 24 hour care for those
who are truly in imminent danger. This frees up
beds that allows timely admission of people who
really need a residential level of care. If someone
is safe enough to be on a waiting list, then by
definition, they don’t need residential treatment.
These clients still need services, but can be started
immediately through a combination of outpatient,
intensive outpatient, or partial hospital care and
structure; coupled with supportive living.
I
realize that I may be stamping all over your sacred
cows or core beliefs. Accept whatever stage of readiness
to change you select. My goal is not to step on
your toes, but to have you think about what you
or your agency does---and to ponder Things That
Don’t Make Sense.
SOUL
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Early this month, Steve Irwin, the “Crocodile
Hunter” died. He was doing what he loved most,
interacting with wild animals he respected and protected.
I watched the final tributes to this unique individual.
It was sad to realize that the contagious enthusiasm
and committed passion he exuded would only be seen
now in time-warped reruns.
I mention Steve not just because he was a fellow
Aussie from my hometown region in Queensland, Australia.
(There is a level of pride and admiration that a
down-to-earth, authentic, engaging man from way
Down Under could influence world opinion and millions
of viewers.) I mention Steve because he demonstrated
so well what just one person can do to “change
the world.” His passion and pure joy in what
he believed shone through. Yes, there was probably
some savvy marketing and skillful production thrown
in. But Steve Irwin’s unbridled energy and
total commitment to his mission attracted many to
hear and embrace his message.
This
writer, this Aussie guy from Queensland, Australia,
will never reflect the same level of raw authenticity
and risk-taking adventures as the “Crocodile
Hunter”. But Steve Irwin’s life and
death inspires me (and millions of others) to stay
focused and enthusiastic about what we believe and
to convey that in a way that attracts and engages
people. Advocacy for the thousands of just causes
and world-saving priorities is increasingly becoming
strident, divisive, adversarial and polarizing.
Unfortunately few political campaigns will actually
survive unless someone airs the first negative and
often vicious TV or radio ad.
Watching
the sheer joy of Steve as he raises our consciousness
about endangered species and other causes dear to
his heart, is in stark contrast to the mean and
angry ways of many advocacy efforts. The “Crocodile
Hunter” has shot his last piece of video.
Yet he still looms larger than life with his smiling
face and signature exclamation of “Crikey!”.
It is hard not to smile along with him and wish
for a world where standing up for what you believe
doesn’t have to mean cutting down whomever
disagrees. Thanks Steve, the world will miss you.
SUCCESS
STORIES
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Here is a success story that addresses how to engage
physicians on your team:
“Getting physicians to agree to provide
psychiatric care for persons with co-occurring disorders(
COD), particularly if they are still actively using
substances, can be a challenge. Whether it is starting
or continuing psychotropics regardless of use, being
cautious or developing discontinuation plans for
benzodiazepines or other addiction medications,
or prescribing medications to manage cravings or
detox itself, clinicians can often see doctors as
a barrier, rather than a member of the team. This
can create lots of frustration on the part of clinicians,
and a sense that "we cannot move forward in
effective treatment because our doctors won't support
our efforts.”
Although
every medical staff includes doctors from a variety
of perspectives, our medical staff tends to be highly
concerned about liability risk, and conservative
in prescribing practices, especially with persons
with substance use disorders. As a result, we seemed
to have lots of people with COD either not getting
any medication until they were "30 days clean"
(which they could never achieve of course without
treatment for their mental health disorder), or
on massive doses of PRN Ativan or Klonopin because
they had told the doctor they "couldn't sleep,
were anxious, and had racing thoughts." Although
these symptoms could very well have been accurate,
it didn't seem to the rest of the team that using
benzodiazepines was the best way to deal with it,
and then when the clients began abusing the addictive
medications by taking more than prescribed, getting
prescriptions from multiple doctors, or buying or
selling their medication, our doctors would cut
them off entirely after applying the "drug-seeking"
label, which was painful even to watch.
Over
a good period of time, we tried several unsuccessful
measures to address this issue. We would argue with
the doctors, and increase their resistance. We would
try to get more "COD friendly" doctors,
who quickly became overwhelmed with complex clients
without a team to support them. We would despair---always
a helpful strategy.
Then
one day, after developing an educational tool for
clients called a Benzodiazepine Client Agreement,
which our medical director bought into and even
recommended some fine-tuning to, I mentioned that
one of our agency teams was undergoing an Integrated
Dual Disorders Treatment (IDDT) fidelity visit.
I happened to mention that there were psychopharmacology
practices that were measured and scored. The doctor
asked how the scoring worked, and I explained that
it was a 1-5 scale, 5 being the most fidelitous
to the practice.
He
then said, "so, what does it take to get an
A?" I almost missed that, because I am so focused
on representing the fidelity process as a clinical
quality improvement tool, not a score or audit,
until I saw his eyes light up when he asked the
question. Our medical director, like many psychiatrists,
is very educated, very bright, and very focused
on achievement.
So,
instead of correcting him, I explained what an A
would mean:
Prescribing
medications to treat a psychiatric illness you are
reasonably sure exists regardless of substance use;
actively minimizing addictive medication usage;
and prescribing medications to manage the addictive
disorder. I also added that the whole team was charged
with supporting a doctor in their treatment, and
that issues such as screening, eligibility, client
directed care, and stage-wise interventions were
also "graded." That was music to his ears,
and not only did he fully support applying those
practices himself and educating and advocating for
the same practice with other physicians in the medical
staff, he also asked to pilot screening measures
(the DALI-14) to be used for all clients coming
to the medication clinic, so the doctors would know
which clients were more likely to have an SUD, so
they could be aware of this in their treatment.
I
had never thought that getting a good grade would
be what moved our medical staff along in their readiness
to change, but it seems to be working.”
A
Michigan Clinician, 2006
Until
Next Time
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Thanks for reading. See you in the next 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
