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TIPS & TOPICS from David Mee-Lee, M.D.
Volume 6, No.3
June 2008
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In this issue
-- SAVVY
-- SKILLS
-- SOUL
-- Until Next Time
Welcome to June's edition of TIPS and TOPICS (TNT).
Thanks for all your e-mail feedback and comments.
I do appreciate them, even if I can't respond to
all personally. If you have a SUCCESS STORY to share,
please send that along too.
SAVVY
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Certain topics always spark an enthusiastic conversation.
Disparate views on methadone treatment, harm reduction
and harm minimization, substance use or relapse
while in treatment - these are just a few. May's
focus was on cultural and ethnic issues. Similarly
this is also one of those topics which rarely gets
a neutral reaction. Out of diversity we get a richer
picture of the whole. To that end, here are some
comments from readers, building upon May's SAVVY
section.
Reader Comment #1
Hi
David,
Thanks
for another thought provoking newsletter. I realize
you were just reporting on the keynote about "Faith,
Race and Culture" and didn't create the content,
but it occurred to me as I was reading it that the
sexual minorities in the room were left out of the
discussion. How difficult is it to feel a part of
treatment when you are the only gay man, or the
only lesbian, or the only bisexual in the room.
The treatment community in general has not been
very effective at providing a safe atmosphere for
this segment of the population even though GLBT
folks have higher rates of addiction than the general
population. Just my 2 cents and some hope that you
might include this topic in a future edition of
the newsletter.
Rob,
LGSW
Reader
Comment #2
Hello
Doctor,
I
love your newsletter and enjoy it every month. I
just had a few comments about this one. While you
have reminded us therapists about certain cultural
sensitivities, most, if not all of us, are trained
to be (and required to be) culturally sensitive,
to address professional competencies. Here in southern
California, the focus is on Hispanic and Asian cultures,
whereas the others seem to get left behind. For
instance, I am a first generation Hungarian and
grew up with a cultural background, but I just look
like a white girl and my culture is ignored and
completely overlooked, especially here in this part
of the country. (I grew up in the Midwest). So I
believe we can also overdo it with cultural issues.
We all have the American culture in common, to various
degrees.
Jane,
MFT
Reader
Comment #3
Great
newsletter! I'd like to add that there's another
group of people who have dealt with being in the
minority for a long time and that's folks with developmental
disabilities. While it's an issue for them in general,
it's particularly difficult in counseling situations.
I'm frequently disappointed with the attitude and
the lack of ability of some counselors to see beyond
the disability and recognize and treat to problems
that can co-occur.
Denise
Reader
Comment #4
Thank
you, Dr. Mee-Lee, for including me on your mailing
list. I am encouraged by the breadth of your experience,
your energy, and the dedication you have to the
field of treating mental illness and substance dependence
problems. Ironically, the one place I have some
pause, is the deference you appear to give Dr. Hanes-Stevens
and her presentation of minority cultural issues
though traditional substance abuse treatment. Though
I did appreciate an increased sensitivity for cultural
issues that minorities (especially African Americans)
deal with during treatment and generally in this
culture, I was not encouraged by her seeming inability
to empower counselors to assist such a client to
work through the cultural biases that inhibit their
recovery.
For
example, regarding your "SAVVY Tip #2"in
May's edition. My experience is that however difficult
it is for an addict to admit to powerlessness over
the use of a substance (the inability to control
its use once started), it does not seem helpful
to the client for the counselor to be ambivalent
about assisting such a client with accepting what
is, in fact, already true for them. By analogy,
it may be hard for an Italian or a Hispanic male
to admit that his physical or verbal advances towards
an attractive female is actually being experienced
as boorish and insulting, and could be potentially
a legal issue for them. However, a caring counselor
would not surrender to the client's "need"
to feel it is OK to approach women this way; but
rather, the counselor might make attempts at motivating
such a client towards looking differently at his
behaviors, possibly from the perceptions of the
receiver (victim), rather than from his own feelings
or intentions.
DML
response
I
agree that the counselor would not just let the
client's perspective stay fixed without trying to
teach, attract and influence the client to shift
it to a more productive perspective. What I got
from Dr. Hanes- Stevens was that a counselor may
be unaware of the cultural perspectives in general.
But if the counselor is especially unaware that
the concepts and models we teach in treatment may
not fit for some clients, then it is hard to implement
the first principle of Motivational interviewing,
which is to Express Empathy. A counselor may be
unaware of how some African Americans view the disease
model. The counselor might interpret such a client's
resistance to accepting that they have a disease
and are powerless and need to surrender, as clear
proof that the person is in denial and needs confrontation.
If a counselor is aware that some clients may have
the usual readiness to change issues that any addicted
person might have plus cultural blocks that make
that resistance even more potent, then the counselor
can first explore the client's concerns about embracing
the disease model. This would improve empathy with
the client who may feel heard and respected for
their views. This would in turn be a good foundation
for helping the client see that to hold onto that
view will be counterproductive.
Reader
Comment #4 (cont)
Likewise,
for the individual who has been taught that he is
owed special treatment because of the years of mistreatment
his ancestors suffered by the prevailing culture,
it would seem a disservice to lose sight of the
therapeutic challenge (however daunting) of assisting
such a client in adopting a more humble (realistic)
view of himself, especially in the areas where his
actual loss of control is harming his life and the
lives of others. I think it is consistently true
that by admitting our weakness, we become aware
of where we need to focus our efforts towards improving
our lives, and thereby recovering lost power in
the important areas of our life. Especially with
regards to addiction, it seems that one must be
able to accept limits in our thoughts and behaviors
(based on clear behavioral evidence, such as repeatedly
failed attempts at controlling use) before committing
to a regimen of treatment makes any sense. Is it
really more important to be allowed to maintain
an illusion of health, when it is known by others
that you have a terminal illness? Will you not die
holding on to the belief that you don't really have
an illness?
DML
response (cont)
Again,
I agree that some clients may hold views arising
from the generations of mistreatment that, if we
do nothing to impact those views could lead to their
failure to embrace their illness and lead to death.
But I am not saying that the awareness of these
cultural perspectives would lead us to leave them
alone in their view of the world and how they have
been treated. We would work on changing these perspectives
to move in a healthier, productive view that allows
the client to get into recovery. But we often don't
know what we don't know. Raising our consciousness
to these issues allows us to check any blind spots
we might have. These blind spots may be purely due
to the fact that we didn't know what we didn't know
about cultures other than our own. Knowing these
perspectives does not mean we would not address
them, allowing the client to stay blind to lifesaving
awarenesses. It does mean though that we can address
and correct those perspectives from a position of
greater empathy for what makes it hard for some
clients to shift their perspectives. This empathy
allows the chance for a more effective and respectful
approach to approaching a client's cognitions, behavior
and beliefs.
Reader
Comment #4 (cont)
Working
in the field of juvenile corrections, I tend to
agree with Bill Cosby with regards to the abdication
of responsible parenting as a critical factor in
creating self-centered and entitled criminals, regardless
of the race of those in question. It is one thing
to be sensitive to the cultural issues that make
recovery more challenging for certain groups; while
it seems to be quite another thing to disbelieve
your paradigm of treatment and recovery just because
the client does not see it as valid or potentially
effective.
DML
response (cont)
Even
if Bill Cosby's perspective is the most effective
view to embrace, his message is more likely to be
heard by those whom he feels needs it, if his target
audience first felt acknowledged for their view,
no matter how faulty we might think it is. This
is what is meant by meeting the client where they
are at in their stage of change. You are much more
likely to attract a person into a different viewpoint,
if we start from a position of understanding and
empathy, rather than treating them as if their viewpoints
are faulty. Or worse still, as if their viewpoints
don't even exist because we are more immersed in
the prevailing cultural perspectives and don't even
know what we don't know.
Reader
Comment #5 (cont.) after receiving responses to
his comments
Thanks
for your thoughtful response to my concerns, Dr.
Mee-Lee. I am now back to not being able to think
of anything you have said that I can disagree with;
not that I am trying to find fault, or that I think
I know even a fraction of what you know, but I have
gotten pretty picky about what I view as essential
issues in treatment.
Don
Baranco, MA, ACADC
Clinician, JCC Nampa
Nampa, Idaho
SKILLS
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For the focus in SKILLS this edition, here is a
switch of gears. While reading over some client
assessments and progress notes, I noticed these
commonly used phrases that suggest attitudes we
have towards clients.
1. "More willing to follow
rules and be compliant with treatment activities."
Clinicians
usually believe they know what is best for their
clients to do, and set about getting them to comply
with treatment recommendations. Even if your recommendations
are worthy, the focus is not on cajoling a person
into being "willing" to comply with treatment.
Treatment is about helping people in their self-change
process (unless you plan to live with a person 24/7
and tell them what to do all the time.) Tracking
progress in a client's treatment is focused on improvement
in function to achieve their goals - not the success
or not of getting a client to obey rules, and comply
with others' wishes and recommendations.
Alternative Progress Note: "Able to
redirect his anger from punching others, and demonstrate
sufficient stability to transition more quickly
out of the hospital back to the community."
2.
"Client admitted that alcohol and
marijuana use sometimes interferes with her school
grades."
"Admitted"
implies the client was withholding the truth, that
somehow the clinician got the person to finally
admit what they have been hiding in the assessment.
While it is true that clients can lie and hide information,
there is no need for them to do that if you have
created an accepting environment which invites openness.
There is nothing for a client to defend and admit
to, if you are willing to start wherever the client
is at. We are not trying to get the client to say
the right answer. We want to know honestly what
they think and believe.
Alternative Assessment Note: "Client
does not think alcohol and marijuana is a problem
except sometimes when it did interfere with studying."
3.
"Client minimizes the extent of
his methamphetamine use."
Related
to the phrase above, "minimizes" implies
we know the client is lying and what information
the client does admit to is half the truth anyway.
Again, there is nothing for a client to shave the
truth about if you are open to whatever the client
is doing. When you approach the client with an attitude
that you assume they are lying, it comes across-
whether you say it directly or not.
Alternative Assessment Note: "Client
does not think his methamphetamine use is very great.
And does not feel that the effects on his life are
very troublesome."
4.
"Client denied any previous addiction
or mental health treatment."
"Denied"
again implies the client was lying about her past
history, and that the clinician knows the real truth.
Even if the clinician is not documenting this history
with that attitude and is merely saying that the
client said she had not been in previous treatment,
why is it necessary to use the word "deny"?
If your spouse or partner did not go to the store
to buy milk on the way home, we don't say "Joe
denied getting the milk." We just say: "Joe
didn't get the milk."
Alternative Assessment Note: "Client
said he has not had any previous addiction or mental
health treatment."
SOUL
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It may be true that there is nothing new under the
sun, and that history often repeats itself. But
a couple of newspaper items caught my eye, items
that would seem to be a twist on some old truths.
The
first one illustrates how even small changes can
have a huge impact when approached on a large scale.
This is a lesson that has many applications:
Southwest
Airlines has calculated that they can save $8 million
a year on flights between Houston and Los Angeles
by slowing the flight by just 72 seconds - just
72 seconds! (The Sacramento Bee, May 26, 2008)
The
second item shows how out of the muck of life can
come valuable information.
Environmental scientists can analyze raw sewage
to paint an accurate portrait of drug use in communities.
"Like one big, citywide urinalysis, tests at
municipal sewage plants in many areas of the United
States and Europe have detected illicit drugs such
as cocaine, methamphetamine, heroin and marijuana."
(The Sacramento Bee, June 24, 2008)
Other
versions of this lesson are: Making lemonade out
of lemon. No pain, no gain. "It's all good."
Until
Next Time
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Glad you could join us this month. For July and
August we will publish a joint edition as we'll
be in Australia most of August. And anyway, the
northern hemisphere readers will be at the beach,
or camping, or vacationing somewhere rather than
poring over issues of TIPS and TOPICS.
See you in late July, early August.
David
Contact Information
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email: info@dmlmd.com
phone: 530-753-4300
web: http://www.dmlmd.com
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