TIPS & TOPICS
Volume 6, No.4
July-August 2008

In this issue
— SAVVY
— SKILLS
— SOUL
— STUMP THE SHRINK
— Until Next Time

Welcome to our summer, two-month, merged edition so we can “smell the roses” and take some time off. Hope your summer (or winter) is going well too.

SAVVY

Since the last edition of TIPS and TOPICS, I’ve been involved with workshops and supervision cases where the focus has been on adolescents. So this is a good time to review a few highlights about preventing drug use among children and adolescents. The National Institute on Drug Abuse (NIDA) published the Second Edition of “A Research- Based Guide for Parents, Educators and Community Leaders” in 2003.

1. There are common elements found in research on effective prevention programs.

The NIDA guide outlined sixteen principles that have emerged from research studies funded by NIDA on the origins of drug use problems and what works in prevention (Pages 2-5 of “A Research-Based Guide for Parents, Educators and Community Leaders”). Here are a few principles with implications not only for prevention, but also for those involved in treatment and clinical services:

• Prevention programs should enhance protective factors and reverse or reduce risk factors – In the past 20 years of research, many factors have been identified that help differentiate those more likely to abuse drugs from those less vulnerable to drug use.

“Risk” factors are those factors that are associated with greater potential for drug abuse.

“Protective” factors on the other hand, are those factors that are associated with reduced potential for abuse.

• Prevention programs should be tailored to address risks specific to population or audience characteristics, such as age, gender, and ethnicity, to improve effectiveness – For example, early risks, such as out-of-control aggressive behavior, may be seen in a very young child. If not addressed through positive parental actions, this behavior can lead to additional risks when the child enters school. Or, withdrawn and aggressive boys often exhibit problem behaviors with families, peers, and others in social settings. If these behaviors continue, they will likely lead to other risks.
• Family-based prevention programs should enhance family bonding and relationships and include parenting skills; practice in developing, discussing, and enforcing family policies on substance use; and training in drug education and information – Bonding can be strengthened through skills training on parent supportiveness of children, parent-child communication, and parental involvement. (Kosterman et al. 2001) Brief, family-focused interventions for the general population can positively change specific parenting behavior that can reduce later risks of drug problems (Spoth et al. 2002).
• Prevention programs are most effective when they employ interactive techniques, such as peer discussion groups and parent role-playing, that allow for active involvement in learning about drug abuse and reinforcing skills (Botvin et al. 1995) – Interactive techniques are also important in changing behaviors in adults, as well as in improving clinical skills in adult learning for clinicians.

References and Resources

The National Institute on Drug Abuse (NIDA) Second Edition of “A Research-Based Guide for Parents, Educators and Community” NIH Publication No. 04- 4212(A). Available from National Clearinghouse for Alcohol and Drug Information (800) 729-6686; (301) 468-2600. Download at: www.drugabuse.gov/pdf/prevention/redbook.pdf

Kosterman, R.; Hawkins, J.D.; Haggerty, K.P.; Spoth, R.; and Redmond, C. Preparing for the Drug Free Years: Session-specific effects of a universal parent- training intervention with rural families. Journal of Drug Education 31(1):47-68, 2001.

Spoth, R.L.; Redmond, D.; Trudeau, L.; and Shin, C. Longitudinal substance initiation outcomes for a universal preventive intervention combining family and school programs. Psychology of Addictive Behaviors 16(2):129-134, 2002.

Botvin, G.; Baker, E.; Dusenbury, L.; Botvin, E.; and Diaz, T. Long-term follow-up results of a randomized drug-abuse prevention trial in a white middle class population. Journal of the American Medical Association 273:1106-1112, 1995.

2. Here is a framework for characterizing risk and protective factors in five domains, or settings.

The five domains in the middle column below can serve as a focus for prevention (and also treatment). (Pages 2-5 of “A Research-Based Guide for Parents, Educators and Community Leaders”)

• Some risk and protective factors are mutually exclusive. For example the Risk Factor of Early Aggressive Behavior indicates the absence of Impulse Control, a key Protective Factor. Helping a young child learn to control impulsive behavior is a focus of some prevention programs; and helps the child counteract the early aggressive behavior.
• Other Risk and Protective Factors are independent of each other. For example, in the peer, school and community domains, drugs may be available, even though the school has “Antidrug Policies.” What may be needed is to strengthen enforcement so that school policies create the intended school environment.

SKILLS

1. Here is a case example to help pull some of this together.

• The name and some details have been changed to protect confidentiality. Courtney is an 11 year old girl who lives with her father and step-mother. She was referred for mental health counseling by Child Protective Services because Courtney was having emotional outbursts and temper tantrums. She does have a stepbrother aged 7 who is the son of her father and stepmother. Her biological mother lives in another state, and is described as having an alcohol dependence problem.
• Courtney’s situation was presented to me in supervision because the therapist wanted help in how to engage and work with the step-mother who was becoming increasingly enraged with Courtney and at times could not control her frustration and impulses to hit Courtney.
• The therapist also wanted help in engaging Courtney to stop her angry outbursts.
• Father had also hit Courtney, which had resulted in her being removed from the home in the past.
• Courtney has witnessed domestic violence between her biological parents; sees her stepbrother well treated and loved by her stepmother; and has been in minor alcohol-related, car accidents with her biological mother.

You can imagine many other sad details, but father was “coming around” in therapy and working hard on improving communication and controlling violence. Stepmother was also coming to therapy and wanted help too. Courtney was regular in her attendance as well; and the therapist was working on self esteem and anger management.

Courtney’s case is where prevention and treatment intersect. Helping this family have a successful treatment outcome can prevent not only worsening problems for Courtney, but also prevent problems for her 7 year old stepbrother.

Look at the Risk Factors in this case:

• Early aggressive behavior
• Lack of parental supervision related to an alcohol- affected biological mother; and violence and ambivalent parenting from stepmother and father
• Substance abuse in the family with easy access to alcohol
• Poverty financially but also emotionally in inconsistent supports and love

Look at the Protective Factors that will need to be harnessed and addressed in treatment:

• Helping Courtney with impulse control – an also in father and stepmother
• Helping father, mother and stepmother provide consistent parenting, love and support
• Helping Courtney develop academic competence and self esteem in her “work” as an 11 year old
• Helping this family maintain a safe environment as regards alcohol and other drugs

So what was I interested to know first to help the therapist in supervision?

Clinicians I supervise may well get tired of the question I always ask, especially when the consultation question has to do with how to engage people and deal with poor follow through in treatment:

The question is: What does the client want that drove them to choose to come for help?

Frequently clinicians view formally or informally- mandated clients as just having to come to treatment. They feed into the client’s view that they have to be there. All clients who come to treatment or answer the door and talk to you if you make a home visit want something, or they would not be there. It is up to us to join them with what is most important to them, and do our clinical work in the service of those driving wants.

It didn’t take too much probing to clarify what each family member most wanted:

• Courtney wanted to stay at home and not be sent to a foster home again. She was also able to recognize that she wanted the same kind of love she saw her stepbrother getting
• Stepmother wanted to be able to come home from work with some peace of mind. She has found herself dreading coming home to an angry, lashing-out stepdaughter. She was also distressed about her level of violent impulses which were not how she saw herself , and not what she wanted to act on.
• Father wanted to continue the improvement in his own violent impulses and create some measure of family peace.

With these “customer” needs clearly in mind, the treatment will be driven by harnessing the strengths, resources and supports that will help:

• Courtney to understand and practice ways to deal with her disappointments and hurt without tantrums and outbursts that only frustrate her stepmother and father. The focus of treatment would center not on generic self -esteem building, but on specific methods to communicate her need for love and attention in ways that don’t alienate her family and shoot herself in the foot. “After all, aren’t we working on making sure you stay home and not get sent to a foster home?”
• Stepmother to do what she already knows to do, and is able to do with her own 7 year old son. While it is not easy to be loving to an angry, hurt stepdaughter, how can she see Courtney’s pain the same way she easily sees her own son when he’s hurt and upset? What limits does she need to set to help her stay centered and have enough emotional reserve to be empathic with Courtney? What does she need from her husband to work together as a united team in supporting each other and thus be there for Courtney as well as their son?
• Father to build on his successes so far in channeling his violent impulses in a way that will strengthen family safety and increase love for Courtney. What can he do to support his second wife in her frustration? How can he monitor and protect Courtney from any damaging interactions with her still actively alcoholic biological mother? Yet how can he help promote a relationship with mother so both of them can get the love they want?

It may seem that there are many more questions than solutions. Yet all the “customers” in this case example are ready to address these questions if we link these treatment issues to their hearts’ desires. They could, after all, just not show up. All have chosen to come for help. We have to help them with what they are motivated for, not what we are motivated for.

SOUL

I was passing through Denver International Airport last month and got some fries from McDonalds. As I waited in line, I noticed the five rules that were posted to remind the workers about customer service:

1. “Hi, what can I make for you? “
2. “Smile” – it’s part of your uniform
3. Sixty seconds or less
4. Eye contact – talk only to customers ( I took this to mean: Be interested in the customer and avoid side conversations with your co-workers while serving them.)
5. “Thank-you” -Have a nice day”

I know. We aren’t serving fries and anyway what is all this talk in healthcare about “customers”? We treat patients and clients who are out of control and need to comply with some good advice that comes from years of training and experience.

Trouble is, unless you plan to live with your clients 24 hours a day, seven days as week, and tap them on the wrist every time they make a questionable decision, you better help them harness their self-change process. They wouldn’t listen to you anyway even if you did live with them. (Anyone got teenage children?)

So here are my modified McDonald’s rules for client and patient service:

1. “Hi, what do you most want that made you decide to see me today?”

2. “Smile” – Or at least be welcoming and pleasant. It’s part of what makes treatment a safe learning environment

3. Sixty minutes or less – make the intake and assessment comprehensive, but focused and efficient.

4. Eye contact – talk only to customers. (I went to my primary care physician this week. At the check-in desk, I stood for two minutes waiting. One of the receptionists was helping another patient. The other receptionist arrived and chatted to her co-worker; booted up her computer; placed her belongings under the desk – all without acknowledging that I was two feet from her waiting. Finally she asked “How can I help you?” Apparently I was invisible to her until she was ready to acknowledge me.)

5. “Thank-you for coming today. Did this session work for you? Did I help you get what you came for?” (Engagement and retention increases chances for success)

STUMP THE SHRINK

Question:

“I always enjoy your Tips and Topics but found this last issue to hit at the ‘heart’ of our attitudes inherent in the language we use to both document services and to staff cases. I have been on the bandwagon of eliminating the word “compliant” but did not think as much about a word we use all the time “denies”. I work in an assessment unit and our triage form where we review lethality etc. is riddled with this word. My comrades and I are trying to think of other ways to address this and are finding it mildly difficult…. any suggestions? In our training we always want to make sure that we ‘cover ourselves’ thus”denies” is more of a legal risk management term. Hope you are well!”

Tasa

Tasa Isaak, M.S., CMHP
Screening Specialist
Access Department
Lakeview Center, Inc.
Pensacola, FL

DML Response:

Hi Tasa:

Good to hear from you. As regards the “denies” risk management issue, I understand people’s use of “denies” in that legal context. But I do think there are ways to address this:

1. Just documenting that the patient “denies” suicidality or homicidal thoughts or impulses does not absolve the clinician of any responsibility if something did occur later e.g., successful suicide or homicide.

2. There would also need to be documentation to the fact that the assessment indicated that there was no sign of impulsivity; that the client demonstrated good judgment and impulse control. This assessment in conjunction with the patient’s “denial” of suicidality or homicidality is what justified the patient being able to continue treatment at an outpatient level of care; and not needing treatment in a secure unit.

3. If the patient’s report is combined with the clinician’s assessment then it is just as valid and risk management friendly to say that “the patient answered, or said, or indicated that he/she was not feeling suicidal or impulsive.” Saying that the patient “denied suicidal impulses” is no more powerful or protective than the way I stated it above.

It may seem more risk management safe to say “denies” because if the patient does end up suiciding, we can kind of blame the patient by emphasizing that the patient “denied” it. This would be as if saying that the patient was being devious; and knew all along that he or she was going to kill themselves, but hid that by “denying” it.

4. However, this can set it up to approach patients as if they are always trying to put one over us; and that we have to document their responses in a defensive and risk management manner. Better, in my opinion, to just do as good an assessment as possible to rule out or rule in suicidal/homicidal risk; and use language with an attitude that is collaborative rather than adversarial.

Hope this makes sense and that all is well.

David

Until Next Time

Thanks for reading. While we will be Down Under, it is winter there and not exactly tropical this time of year. But I did like what Randy Huber of Augusta, Maine joked: “You could call the summer issue “Trips & Tropics.” Hope you enjoy your travels!” Thanks, Randy.

See you in late September.

David