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TIPS & TOPICS from David Mee-Lee, M.D.
Volume 5, No.7
November 2007
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In this issue
-- SAVVY
-- SKILLS
-- SOUL
-- Until Next Time
Welcome
to the November edition; and if you are in the USA,
Happy Thanksgiving. We're glad you join us every
month. But if you find yourself with too much e-mail,
and want to unsubscribe, you can do that at the
links at the end of this newsletter.
SAVVY
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Earlier this month, I presented a workshop on motivational
enhancement strategies for people with co-occurring
mental and substance-related disorders. Frequently
those clients are mandated for treatment, so we
were discussing the interaction between mental health,
addiction treatment and criminal justice perspectives.
Tip 1
Maintain
the boundaries between criminal justice and clinical
work; between "doing time" and "doing
treatment"
The
three fields of criminal justice, addiction and
mental health are all actively involved in the treatment
planning process and delivery of services for mandated
clients with co-occurring disorders. How do we make
a difference without working at cross purposes?
How do we support and augment our impact on a client
to produce healthy results? It is essential we understand
and respect each field's background, mission, jurisdiction,
expertise and experience.
We
must advocate for each field's distinct roles and
responsibilities while simultaneously respecting
the unique mission of each other's field. Where
do we draw the line? When do we refer clients to
the other arena? How do we collaborate? What systems
should be in place to impact the lives of our clients
and society at large?
While
each field is separate, we all work for the same
purpose: to restore an individual to productivity,
responsibility and wellness. Our joint intent and
mission is to minimize, and hopefully eliminate
addiction, mental illness and legal recidivism.
Here
are some polarized perspectives and their implications
that work against integrated services:
-->
Mental health professionals not trained
in addiction treatment run the risk of viewing all
substance use problems as a symptom of an underlying
mental health problem - e.g. a person's compulsive
disorder, or low self esteem, or poor self-care,
or intrapsychic or interpersonal conflicts etc.
If the client would just work through those mental/emotional
issues, then the substance problems would take care
of themselves! For those who think this way, the
following 3 D's are important:
3
D's
*Deadly Disease
Remember that addiction illness can be deadly. Consider
addiction in the differential diagnosis of any mental
health presentation. Ask questions to screen and
diagnose.
*Denial
There are at least three aspects of denial:
--> conscious lying to give family,
friends or others what they want to hear, or to
protect oneself from nagging, sanctions or external
consequences of substance use.
--> the amnesia of blackouts where some
will deny their behavior, not due to lying, but
because they were in a blackout and don't have any
recall due to the organic effects of the substance.
--> unconscious survival mechanism where
an individual person protects himself from the pain
of owning the reality that drinking or drugging
is causing his physical, mental, social and spiritual
problems. There is major internal conflict over
accepting this self-defeating behavior. To resolve
this, survival mechanisms kick in. They range from
minimization, rationalization, externalization to
projection of blame. Combined they make up "denial."
*Detachment
As a helper, beware of pinning your professional
self-esteem to whether a client does well or not
in treatment. If/when a client relapses, it is easy
to blame the client so your clinical integrity and
skills are not threatened. The professional challenge
is to balance 2 equally important priorities:
(1) To create a healthy distance and detachment
to allow you to accept the client for whatever mistakes
were made.
(2) At the same time, to hold both yourself and
the client accountable for anything that was not
done which led to a poor outcome. Did you miss a
co-occurring disorder? Fail to engage the client
in a collaborative plan? Did you even ask the questions
to identify a co-occurring disorder? But also, what
did the client not do that they agreed to do? Did
they take their medication faithfully; or attend
recovery groups actively as they agreed?
-->
Addiction professionals untrained in mental
health have the opposite risk. They view mental
health problems as a symptom of an underlying addiction
problem e.g., the anxiety is really alcohol or benzodiazepine
withdrawal; the depression is just cocaine crash;
the suicidal feelings will pass when the detox is
over. The danger here is that mental health disorders
might not be addressed. For addiction counselors
who think this way, the 3 P's are important:
3
P's
*Psychiatric Disorders
Not all mental health problems are symptoms of addiction
and withdrawal. Consider a possible co-occurring
mental disorder in the differential diagnosis. Ask
the screening questions to identify any mental health
problems.
* Psychopharmacology
Not every medication automatically causes drug-seeking
behavior or an addiction relapse. Not only can psychotropic
medication be necessary to stabilize a co-occurring
mental disorder, but it can often prevent both a
psychiatric and an addiction relapse. An unstable
mental disorder is bad for mental health recovery
as well as addiction recovery.
* Process
It is easy to be impatient, to want the quick answer
or psychiatric evaluation to diagnose a co-occurring
disorder. Some clients have long histories, multiple
diagnoses and medications. There is no easy answer.
Time may be needed. You may need to process considerable
history data, family and collateral information.
You may need to move forward with assessment and
treatment with some uncertainty, based on a provisional
diagnosis and hypothesis. This may take weeks and
months to evaluate.
-->
Criminal justice professionals - judges,
probation and parole officers- untrained in addiction
and mental health run the risk of thinking that
everything can be dealt with from a criminal justice
model. Mandated treatment is viewed as a criminal
justice intervention - e.g. mandate the client to
a particular addiction treatment level of care for
a fixed length of stay. The parallel is ordering
an offender to jail for a term of three months.
"Doing
time" gets equated with "doing treatment."
Clinicians declare they cannot provide individualized
treatment because they must comply with court orders
for a particular program, level of care and length
of stay. For everyone involved with mandated clients
who thinks this way, the 3 C's are important:
3
C's
* Consequences
Criminal justice rightly ensures that offenders
take the consequences of their illegal behavior.
However if the court agrees the offender's behavior
was largely caused by addiction and/or mental illness,
they provide an alternative. The offender, as well
as the public, is really best served by treatment,
rather than punishment. Clinicians must remember
their job is to provide treatment, not custody nor
enforcement of consequences.
* Compliance
An offender is required to act in accordance with
court orders, rules and regulations, and criminal
justice personnel should expect compliance. Clinicians,
however, provide treatment where the focus is not
on compliance to court orders. They assess whether
there's a disorder in need of treatment. If there
is, a clinician sets an expectation for adherence
to treatment, not compliance with just "doing
time" in a treatment place.
* Control
The criminal justice system aims to control, if
not eliminate, illegal acts that threaten the public;
this control is appropriate for the courts. Clinicians
and programs aim at attracting people into recovery;
they center their work around collaborative treatment
plans with the client actively engaged in this process.
The only time clinicians are required to control
a client is if the client is in imminent danger
of harm to self or others. As soon as that imminent
danger is stabilized, treatment resumes with collaboration
and client empowerment, not consequences, compliance
and control.
SOUL
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TIME
magazine's very latest December 3, 2007 edition
contains a brief report on General David Petraeus
(p.24). Apparently Petraeus and 14 other Army generals
have been asked to do something unprecedented: to
review the files of about 20,000 colonels, and look
for about 40 worthy of promotion. What's new about
this? These generals are changing how promotions
are made because the ways in which modern wars are
fought have changed.
What caught my eye in the Time article was that
today's new battles use counterinsurgency skills
which "rely on persuasion and security as much
as on coercion and combat".
"Persuasion"
involves attracting people into recovery, providing
hope for something better, relief from pain and
turmoil. "Security" is about helping people
feel safe and empowered, free to make their own
choices and chart their own daily activities and
future dreams.
"Coercion"
focuses on compliance, doing time, control and consequences.
That is appropriate in a criminal justice approach.
"Combat" is about disempowering others,
fighting with their resistance and subduing them
into submission.
It
is time to move in new directions, away from conventional
methods suited to the "cold war" days.
We have much more knowledge about how people change
and how to attract people into recovery. With what
we know, it is our responsibility to create healing
treatment environments where people feel secure
and safe to be honest about relapse, and not have
to lie for fear of sanctions or being kicked out.
Treatment is all about persuasion and attraction;
not coercion, control and combating resistance.
If
the Army realizes there are new lessons for a new
generation of soldiers, surely treatment can do
the same. And incidentally, persuasion and security
works a lot better than coercion and combat in your
personal life as well.
