TIPS and TOPICS
Vol 1, No.5
August- September 2003
- STUMP the SHRINK
- SUCCESS STORIES
- Until next time
I have been in summer vacation mode, so this August edition of TIPS & TOPICS is a little later than usual. In fact, since this is already September, I’ve decied to give myself a break and give you less mail to read. So this is now an expanded August-September edition which has the usual sections, with two additional sections that appear periodically – “Stump the Shrink” and “Success Stories”.
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A few weeks ago, I listened again to Scott Miller, PhD and was also reading one of his books (Hubble MA, Duncan BL, Miller SD (Eds) (1999): “The Heart and Soul of Change: What Works in Therapy” American Psychological Association. Washington, DC). Whether you work in addiction or mental health settings, we all strive to help people change for the better. Reviews of over forty years of literature on what works in helping people change may make you think twice about your beliefs on what works in therapy.
There is increasing pressure for accountability, performance and outcome measures, and evidence-based practices. Accreditation and managed care organizations, county and state licensing agencies, payers and funders demand competence, credentials and credibility. Within this high pressured environment, clinicians can feel they are walking on eggshells trying to make their documentation perfect lest they not get paid; or following some manualized treatment and criteria or best practice protocols, lest they be considered incompetent.
While most would argue that we indeed do need to be more data-driven and outcomes oriented, a review of the work of the Institute for Therapeutic Change emphasizes a few important tips.
- Competence does not necessarily engender or equal effectiveness.
Duncan and Miller remind us about what happened to George Washington. The doctor, along with two other physician colleagues, skillfully and competently administered the accepted therapy of the day. When the patient did not get better, the three agreed more of the same treatment was indicated. Several hours later and two additional treatments later, the president was dead. The accepted “standard of care” for late eighteenth-century medicine was blood letting. (Duncan BL, Miller SD (2000): “The Heroic Client: Doing Client-Directed, Outcome-Informed Therapy” Jossey-Bass Inc. San Francisco, pp 12-13)
- Careful multidimensional assessment and a well- documented, individualized treatment plan and progress notes are necessary, but not sufficient to improve client outcomes.
A well-licensed, credentialed clinician may deliver care and documentation which meet all performance, licensure, and accreditation standards. This, however, does not automatically guarantee effective outcomes for the client. An obvious example of this – a “perfect-looking” treatment plan, in which the client has no investment and to which s/he relates as hoops to jump through, rather than as a guide to achieve his or her heart-felt goals.
- All our theories, ideologies, best practices, treatment techniques and manualized treatments only have value as they bring us closer to the patient and client.
What contributes significantly to effective outcomes? The degree to which theories, ideologies, practices etc.. assist us in hearing the client better. The degree to which we work collaboratively in sessions the client experiences as useful, and a connection a client feels is a good fit. Is the client actively engaged in treatment? Are they involved in assessing the effectiveness of their treatment? If not, all you might have is a “pretty plan” that meets performance standards, but the patient “died”. Remember George Washington.
So….. is getting closer to the client some soft, touchy-feely, gentler and wimpier way that endorses months of nebulous, therapeutic meanderings as we “form a relationship” with the client? Not if you follow this review of outcomes literature to its logical conclusions and daily treatment practice. In fact, it takes far fewer sessions than you would think to know if treatment is effective. By employing frequent client input and measurement of the weekly effectiveness of the treatment, the clinician is much better equipped to alter the treatment to prevent dropout and improve outcomes.
- Even important individualized models (like Stages of Change) can be misused to slot people into fixed tracks.
You probably understand that Prochaska & DiClemente’s stage of Precontemplation means the person does not think they have a problem and therefore is not ready for “recovery” strategies. A well- intentioned clinician or supervisor can inadvertently misuse this model as we have been so influenced by the program-slotting mentality. They set up a treatment protocol and clinical pathway that places the person into a six session, “discovery” series of educational sessions. The fixed nature of the program still results in the person doing “time” not “treatment”- with little collaborative feedback on how treatment is experienced and whether or not it is helping.
You may competently have identified the correct stage of change. You may competently have triaged them into a “discovery” track rather than forcing recovery on them. But how will you measure their degree of buy-in and boredom to prevent dropout?
- Frequent, honest feedback from the client on how they perceive the treatment experience is as important as, if not more important than, perfect compliance with standards and best practices.
But, you may ask, isn’t getting feedback on whether s/he feels heard and understood, giving the client too much say on where the treatment is going? Isn’t getting feedback on whether the client feels the therapist’s approach is a good fit or not, empowering the client too much? After all, aren’t we the professionals with a lot of training and experience that counts much more than the opinions of an out-of-control client and patient? Work done with the Session Rating Scale (SRS) and the Outcome Rating Scale (ORS) of Scott Miller et al and the Institute for Therapeutic Change would suggest we might think again.
- Diagnosis, ASAM six-dimensional assessment and criteria are not tools to label or pathologize the client.
They assist in identifying clients’ conditions and complications which repeatedly prevent them from getting what they want.
For example, a young person who wants to get their parents off their back and give them more freedom will shoot themselves in the foot if they don’t get treatment for their substance use behavior, poor school performance and impulsivity. The true spirit of person-centered diagnosis determines if that teen needs addiction treatment for a Substance Use Disorder, or mental health care for a Mental Disorder, or dual diagnosis treatment for co-occurring addiction and psychiatric problems.
Thus the diagnosis helps pinpoint what kind of treatment the client needs. It does not become their identity nor automatically place them in a specific level of care and length-of-stay program. The teen is a son or daughter who is a person with substance, emotional and behavioral problems. Their input into the treatment plan and level of care is essential to preventing dropout, and improving outcome effectiveness. They are not an alcoholic, an addict, a manic-depressive, a schizophrenic that you have to fix!
You may wonder why I am pushing the work of Scott Miller and his colleagues in this edition of TIPS & TOPICS. Partly it is because too few have assimilated the lessons that over forty years of research has repeatedly revealed. I wanted to share the information with you. But also, it is because I am stimulated by what these old findings (but relatively new to me) do to challenge my thinking on how to work with people to get and change what they want. And for me, new information that rocks the foundations of what I have blithely believed is an energizing phenomenon. It nudges and sometimes rockets you out of complacency and boredom.
At a conference a few years ago, I asked the speaker how he maintained his spiritual, “big picture” vision and sense of awe in the rush of deadlines, demands and the busy-ness of life. He replied that he was sustained by a small group of people in whom he could confide and who are dedicated to the same vision. His spiritual vitality was not something that could be enlivened alone and in isolation.
Earlier this month, I again experienced what that speaker was telling me. I was kicking around ideas with Scott Miller and the leaders of the Center for Alcohol and Drug Treatment in Duluth, MN, to which we both consult. We (Bill Plumb, Gary Olson, Scott and I) pushed each other’s thinking about how to integrate client-directed, outcome-informed therapy, ASAM multidimensional assessment and the daily practice of individualized treatment in today’s treatment environment.
Just singly reading the literature and mulling over thoughts in isolation would not have produced the constructive concepts and directions that just a few hours together produced – and it was much more stimulating and fun to bounce ideas off others and get immediate feedback. So find your vision; find your group; and as Gandhi said, “be the change you wish to see in the world”.
STUMP the SHRINK
I usually answer a question sent to me directly. This issue, I want to address a common and troubling issue for many. It appeared in August on the dual diagnosis listserv (To subscribe or unsubscribe to Co-Occurring Dialogues, email email@example.com)
Below is an exchange of comments that was forwarded to me for my response. I wanted you to benefit from Jerry Shulman’s response and my thoughts on the dilemma posed.
“My reason for asking is that when I once proposed that ASAM criteria be used in regional treatment planning, my proposal was laughed off as naive on the grounds that there were *no* treatment facilities available in the region for some of the critical levels of care. It is possible that I misunderstood what I was being told. But my point is, why use an ideal sorting system if that sorting system funnels people in recovery towards a level of care that is not available? I also wanted to know how common this situation is. That is, do you find that certain appropriate levels of care are not available in your community, and you have to refer persons in recovery to Timbuktu for treatment that meets their needs”
Bob Schacht, Ph.D. Research Associate
“This is exactly what happens in Washington, DC. The patient may be assessed for a certain level of care using ASAM criteria, but that level of care is JUST NOT AVAILABLE, either inside the city, or outside. If the patient is indigent, too bad. The indigent care and Medicaid will not pay for the appropriate level of care, in some other jurisdiction. So these are the men and women who attend the inner city methadone programs, for example, but also have other severe mental illness, for which they are not being treated. And for the most part, they live in the shelters or on the street. Here in DC we have no ASAM level III inpatient that will accept methadone maintenance patients…………One program has such a level of care available, with empty beds, but they will not accept methadone maintenance patients, same with another program in the area- empty beds, but they will not accept our patients.”
Advocates for Recovery through Medicine
Washington, DC Chapter
“The ASAM PPC and Treatment Levels By State:
As an author of all three editions of the ASAM Criteria, let me share some background about the development of the ASAM Criteria.
When we started the original process, we made a decision that it was more important to create criteria to optimally assess and place patients- even if the levels of care did not currently exist and whether those levels would be consistent with state licensing regulations and funded by states or reimbursed by private insurance/managed care. The hope was, as a result of the Criteria, that states and insurers would fund/reimburse for those levels of care, and that states would incorporate them into licensing standards revision. That decision has not changed through the development of all three editions of the Criteria.
In many ways, this was a very good decision. I think our hopes have been to some extent borne out.
The good news is……….. that providers began to develop levels of care that did not exist before, states began to fund and even write regulations for some of the new levels of care. (I have personally been involved with two states rewriting their regulations to be consistent with ASAM) and insurers began paying for them. How far we have come may be exemplified by the fact that “residential treatment,” a big “NO-NO” when speaking to a managed care organization (MCO), is now often reimbursed.
The bad news is ………….that ASAM cannot control what may go on with providers, states, or payers (e.g., the fact that automobile manufacturers put seat belts on cars, that people are provided information about the benefits of seat belts – up to and including fines for not wearing seat belts- does not guarantee that people will use them). Some of the issues that interfere with an ideal world in which all the levels of care would exist include:
>> Some providers may not want to make a particular level of care available (e.g., a hospital based program that refused to develop ambulatory detoxification, Level III.2-D, because of the belief that if they did so, it would siphon revenue away from their current Level IV-D detox.;
>> Payers that “reinterpret” (read as “distort”) the Criteria to limit access or continued service;
>> Providers that “reinterpret” (read as “distort”) the Criteria to justify admission or continued service to their particular program;
>> States, even those which mandate the use of ASAM, that have licensing regulations that are in direct conflict with the Criteria (e.g., fixed length of service programs);
>> Many states that have created their own Patient Placement Criteria (PPC), all of which are usually closely based on ASAM;
>> States which mandate a choice of ASAM or their own criteria, the latter of which may not have all of the ASAM levels of care;
>> States which do not wish to develop particular levels of care (e.g., Residential Detoxification, Level III.2-D) which means that those levels of care cannot be licensed and therefore usually not reimbursable.
>> Rural areas where there is simply not enough population density to support certain levels of care, particularly intensive outpatient and partial hospital programs;
>> Venues which have limited services because of lack of money and low populations and do not wish to use outside services (some Indian reservations which have only Level I).
The ASAM Criteria are the most widely accepted and used PPC. Originally, no states or payers and very few providers used them. Now with possibly 30 states, most of the large behavioral MCOs and the DOD for all active duty, retirees and dependents of the Military using/mandating the Criteria, it has come a long way.
As people in the Fellowships say, “It is a program of progress, not perfection.” The question – why have the Criteria if it is not more widely used in its entirety- is throwing the baby out with the bath water, and makes no more sense than not having seatbelts for motor vehicles just because not everyone uses them.”
Gerald D. Shulman, M.A., M.A.C., FACATA
Shulman &Associates, Training &Consulting in Behavioral Health
8658 Rolling Brook Lane
Jacksonville, FL 32256-9005
Ph. (904) 363-0667
Fax: (904) 363-0668
Exchange #4/ Comments by David Mee-Lee, M.D.
“A Few Further Thoughts on the ASAM PPC and The Levels of Care:
Jerry Shulman writes eloquently and accurately about the history and intent of developing criteria for a broad continuum of care. All I would add is that I understand the impulse to assess a client or patient and immediately decide where to place them in the available list of possible slots in the specific community.
In other words, in the busy real world, we plug people into programs that are available locally. This would seem to make criteria for levels of care that don’t exist locally, a waste of time. But imagine if we could first assess what level of care a person needs; document that as the level of care indicated by the assessment. Then document the actual level of care received as well as the reason for the difference – whether that be waiting lists, funding or benefit plan problems, transportation or childcare obstacles, mandated level of care, client preference or whatever.
You would then use 30 seconds to document when we can’t give a person the level of care they need and thus turn a frustrating clinical assessment and placement situation into a data gathering opportunity. You now become part of the solution of filling needed gaps in services and levels of care. By accumulating systems data that can identify how we are utilizing or mis- utilizing resources by giving people more or less intensity than they actually need.
If we continue to use criteria only for levels of care that exist now in the local area, we never gather the data to know what could and should be for the people we serve.
It is gratifying to hear how TIPS & TOPICS has been appreciated out there. Thanks for your feedback and here are a few of those comments:
“Thanks for the latest(July) Tips & Topics. I’m in Montana and enjoyed your description of rural Wyoming! I grew-up in San Diego and still remain “citified” despite being in Montana for 16 years. Our agency is in the middle of a paradigm shift in thought and deed regarding individualized treatment and your thoughts on this issue were a needed boost for me as I’m “emphasizing” the need for staff to get away from program driven treatment. I will share your thoughts with our director and staff.” Thanks again and I look forward to future Tips & Topics.”
Great Falls, Montana
“Tips and Topics are useful, practical, and thought- provoking. Your notes are an invaluable tool to our IOP team.”
Mental Health (California). Intensive Outpatient Program (IOP)
“Hi, Dr. Mee-Lee
I love this Tips and Topics website. I find it so “right on.” Keep it up I look forward to seeing it each time, this really keep me on target with how I treat our customers or consumers in treatment. Also this is fun to share with my boss and coworkers. Until next time”
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Bernie Lorenz Recovery Inc.
Halfway House for Recovering Women, Level III.1 and Continuing Care Level I
Des Moines, Iowa
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Vice-President, Director of Public Policy
Phoenix Houses of California
Lake View Terrace, California
Until next time
All the best as you get over the summer laziness and back on the treadmill. I want to hear your comments or Success Stories on implementing any of the TIPS and TOPICS. Please send any questions/dilemmas to “Stump the Shrink”. (Tell me how much identifying data you are comfortable with my sharing here.) Talk to you next month.