TIPS & TOPICS
Volume 6, No.3
June 2008
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.
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
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.”
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:
The second item shows how out of the muck of life can come valuable information.
Other versions of this lesson are: Making lemonade out of lemon. No pain, no gain. “It’s all good.”
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