TIPS & TOPICS 
Volume 3, No.11
April 2006

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

Thank you for joining me in the April edition of TIPS and TOPICS. I appreciate the positive comments I receive either by e-mail or onsite when I am training. I’m not planning a formal survey, but if you are moved to express appreciation, this helps me to know what works with TIPS & TOPICS. If you write me, just say briefly what works for you, and what you find useful in general about this newsletter.

SAVVY and STUMP THE SHRINK

A recent workshop participant asked for more clarification on a table in one of my handouts; it concerned matching a client’s stage of change with services and level of care. So here is a combination of SAVVY and STUMP THE SHRINK in answering the question/issues this person raised.

Tips:

• Match the client’s stage of change with the level of care that will best help a client to progress.

A client in an early stage of change thinks he/she has a ‘people, places and things’ problem, not a substance use problem. They need “discovery” work not “recovery” work. As such, motivational enhancement treatment should occur in a level of care which allows them to face the real world. If this person is in intensive levels of care and residential settings, it protects them from doing the research that will help them internalize their awareness of loss of control. Outpatient levels of care allow the client to face friends who still use, or face situations that challenge their over-optimistic belief that quitting or cutting back will be easy.

Of course if some unstable situation exists which creates imminent danger to the client, then a more intensive level of care may be necessary to stabilize the crisis and then prepare the client for outpatient treatment in the community. Here is the table to which the reader referred:

Question:
Hi Dr. Mee-Lee,

I was at a training that you did recently and enjoyed it very much. I have a question about the Readiness to Change Assessment and Matching grid in the handout. As I read the Level of Care column, it looks like your thinking is that precontemplation, contemplation, preparation and action clients would best be served in Outpatient or Intensive Outpatient. This is very different from our current practice, and the current thinking of our addiction treatment residential providers. The current consensus among providers would be that clients in the earlier stages of readiness need residential in order to remove them from their using routine and environment. I can follow that placing precontemplation and contemplation clients in abstinence based programs can be a set up for failure (clients use, and get kicked out), and therefore a waste of money. Could you elaborate on your thoughts about preparation and action clients? Are you thinking that working on the problem in the client’s natural environment is the most effective approach?

Thanks,
LMSW ACSW

Note: For those of you unfamiliar with Prochaska and DiClemente’s Transtheoretical Model of Change and their stages of change, you can read some tips on this in the June 2003 edition, Vol. 1. No.3 of TIPS and TOPICS.  Also the first reference book below is easy to read, written for the lay public and suitable for recommending to your clients.

If you are unfamiliar with the Patient Placement Criteria of the American Society of Addiction Medicine (ASAM PPC), you can see more in the March 2004 edition, Volume 1, No.11.

My response:

Firstly, you are correct about working on the problem in the client’s natural environment for those in the Preparation and Action stages of change. They know they have an addiction problem, and really want to develop a new drug-free lifestyle and change their life. Education, new skill-building, integration into self-help and mutual help recovery groups can and should happen as close to home, in their local community, as soon as possible. Some people have already embraced recovery without even entering through the professional addiction treatment door.

In Preparation and Action stages, treatment can be done in a variety of outpatient settings. This depends on the severity of relapse cravings or stress in the environment. If a person needs to be separated from their environment because they cannot cope with the stress, this could be done in an ASAM Level III.1 level of care bundled with an appropriate level of OP intensity to assist in coping skills. ASAM Level III.1 is a 24 hour structured supportive living environment, not a full residential level of care with all the 24 hour clinical services and costs. If some immediate problems need to be stabilized, then a stabilization period in a 24 hour treatment setting may be necessary.

As you know, treatment and recovery is an ongoing process, not an event. So if there are no acute crises, treatment can proceed as close to the client’s natural environment as is safe and effective. That is why the chart emphasized the outpatient continuum of care.

Those in Precontemplation and Contemplation don’t even think they have an addiction problem, and are not interested yet in recovery. You have the best chance of engaging people in treatment if done in outpatient settings, unless there are clinical or environmental issues that put the person in some imminent danger. For those, a period of residential treatment may be necessary for stabilization and safety.

In outpatient settings we can develop a treatment plan that allows the person to “do the research” and test out their “I-can-control-it-cutting-back- drinking,” treatment plan. Or to try: “I can do this with willpower and exercise and don’t need those meetings and groups.” I know this is different from how we have thought in the past about using residential treatment. If we remove people from their using routine and environment before they even think they have an addiction problem, this increases the likelihood of resistance, negative interactions and dropping out of treatment. As you said, the likelihood of a failure experience is high because they have little interest to work on abstinence and recovery.

When it comes to those in Relapse or Recycling stage, the full continuum of care may be necessary. The relapse may have resulted in such heavy drinking or drugging that detoxification is now needed. Or intoxication may be exacerbating depression with suicidal behavior or substance-induced psychosis. Outpatient levels of care may not be intense enough to contain the relapse. However, sometimes a slip or a relapse can be arrested by resuming AA attendance and reconnecting with supportive friends. Low intensity outpatient support and/or returning to recovering peers may be all that is needed to get back on track. A relapse does not automatically require intensive and 24 hour treatment settings.

Yes- to increase the chance for clients to incorporate changes as close to the real world as possible, I am suggesting that more intensive levels of care be reserved for times when things become unsafe or ineffective in the client’s community. When you allow a person to test out peer refusal skills, form new recovery networks, practice non- drug ways to cope with stress, this solidifies recovery. It minimizes relapse issues which can occur with re-entry into the community from a safe, protected environment. Obviously with any dimension, if there is lack of safety or instability, a more intensive level will be necessary for whatever period of stabilization is needed.

The ASAM continuum of care is about increasing access to care; it’s about being good stewards of resources so we can give people as much care as is necessary to improve outcomes. All the levels of care are needed- from outpatient to residential to hospital. They should be included in insurance benefit plans, and funded by insurance and managed care. If we match clients to stage of change and multidimensional needs, we can preserve funds to give people more intensive treatment when needed. This will allow for much more outpatient treatment, case management and recovery support services in our communities.

References
Prochaska, JO; Norcross, JC; DiClemente, CC (1994): “Changing For Good” Avon Books, New York.

DiClemente, CC (2003): “Addiction and Change – How Addictions Develop and Addicted People Recover” The Guilford Press, NY.

Treatment Improvement Protocol (1999). “Enhancing Motivation for Change in Substance Abuse Treatment” The recommendations of a consensus panel. Chair: William R. Miller TIP No.35. DHHS Publication No. (SMA) 99-3354 Center for Substance Abuse Treatment, Rockville, MD.

Mee-Lee D, Shulman GD, Fishman M, Gastfriend DR, and Griffith JH, eds. (2001). ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition-Revised (ASAM PPC-2R). Chevy Chase, MD: American Society of Addiction Medicine, Inc.

SKILLS

Over the past month I either directly interviewed or consulted about a number of clients who raised challenging therapy questions. Below I highlight some issues raised and offer clinical tips. (Of course the identity and details have been changed to protect confidentiality).

Tips:

• Every client who is talking to you in an assessment, treatment session or outreach visit is treatment ready.

That may sound like a far-fetched claim from someone you may think has lost touch with clinical reality – especially after you read this vignette presented by a treatment team that declared her “Not ready for treatment”.

Inmate Jane Doe is a 23 year old, Caucasian, female, serving a sentence for Possession of Methamphetamine with attempt to Deliver. She is pregnant with her second child, due date August 28. She gave her first child up for adoption after his birth three years ago. She entered residential treatment on March 9. Date of last use of methamphetamine and marijuana was February 1.

Her only motive for entering the residential substance abuse program is to meet the requirements to enter the nursery program and have her child remain in the prison with her after its birth. She states she will sign out of the residential treatment program if she is not allowed to be in the nursery program. Jane denies that she has an addiction problem; she states she has been using recreationally and does not see a problem with it. She states she will use after she gets out of prison. Jane has a long history of abusive relationships. Admits that her current partner is physically abusive to her but is unwilling to consider paroling to any place other than his residence.

Before you dismiss any client as “Not ready for treatment” or “Not treatment ready”, reframe this in your own mind and how you engage her into treatment. Jane is not ready yet for treatment of what we think and know she needs to work on. But she is at action for getting admitted to the nursery program and keeping her new baby. She is ready for treatment to reach that goal, not the goals we think she should want. She is not “recovery ready”. But if she didn’t want treatment/professional help, she wouldn’t be sitting in your office. And remember she will leave, she says, if we aren’t going to help her keep her baby. What would be wrong with helping her work to keep her baby?

In that treatment and motivational enhancement process, she undoubtedly will bump up against the issues of substance use and who she lives with. Treatment will focus on helping her discover the connection between keeping her baby and drugs and partners. But if we stay close to the client’s goal, Jane will be ready for the kind of treatment that helps her decide she needs to change her life and choices if she is to achieve her goal- i.e. succeed in keeping her baby. Or she will discover that her drugs and partner are more important to her. Either way, she is ready for treatment.

• Stay focused on what the client wants and you will decrease your frustration level and won’t do more work than them.

Joshua is a 48 year old, African American, never married, unemployed homeless cocaine-using man with schizophrenic disorder. He was evicted from his apartment and wants housing. He denies a cocaine problem, but does show up for daily medication so long as he gets his $10 payment. The team has developed this plan to incentivize his adherence to medication.

The treatment team questions: Should they be helping him get housing when he only comes for medication to get money which he sometimes uses to buy drugs? Should they help him when he only attends groups to obtain shopping coupons from his disability income? In addition his random urine drug screens are often positive even though he denies using.

Assisting him to get (and keep) some housing will only have a chance of sustained success if Joshua can maintain mental health and substance use stability. So I reassured the team they were on the right track. They were correct in linking medication adherence, group involvement and drug screen monitoring to assistance in getting housing.

Joshua wants freedom and independence, and the team is helping him to achieve that. However, if the goal is not freedom and independence but rather shelter and caretaking, then there is a place for providing housing that does not expect the client to work on mental health and addiction stability. “Wet” and “damp” shelters have their place in such a continuum of care.

• As a clinician, one of the goals in helping people is to make ourselves as obsolete for the client as soon as possible.

Wendy is a 37 year old, Caucasian, divorced, unemployed, single parent of two children, both of whom have been diagnosed with Bipolar Disorder. The psychiatric, addiction and social history of this client is long and complicated: it encompasses sexual abuse in her teens, rape as an adult, physical abuse, Child Protective Services, chronic pain with overuse of narcotic analgesics, seven prior detoxification treatments, and notoriously poor adherence to appointments, medication and therapy.

When I interviewed Wendy, it was so easy to understand the frustration the team experienced. They struggled to get Wendy to comply with appropriate doses of pain medication, consistent parenting skills, alcohol abstinence, disruptive relationships with parents and her ex-husband etc. Her case was so involved: rich with psychodynamics, complicated systems and family issues, and addiction treatment interventions. There were enough significant clinical and case management issues to keep this team occupied for many years to come.

The process with Wendy is likely to be a long and volatile one. However we must continue to balance nurturance with responsibility. How do we give her enough support to satisfy deep longings for nurturance; at the same time, how do we expect enough accountability which maintains safe boundaries, and allays Wendy’s fears of rejection and abandonment?

” I will hang in with you, but I can’t do it by myself.” ” I will work hard to help you with your depression but I can’t do that if you are not showing up for appointments.” Nurturance and accountability all in the one sentence.

Clients like Wendy easily have a new crisis each session – if they even make the appointment! They can often say such things like: “I want to keep seeing you and I feel comfortable with you.” They forget they are also quite comfortable yelling at you and blaming you when things are not going well. Be cautious of offering what I once heard from an inexperienced clinician: “You can call anytime. We are here for you anytime.” Our job is to empower our client to be as independent as possible, and to make us obsolete – as soon as possible. It is better to say something like:

“That’s great that you find our work together helpful. What is the most important thing for me to help you with? What feelings and needs do you get filled in treatment with me? I want to help you identify those needs, and get them met in more than one place, not just in therapy with me. I will hang in with you, but I can’t be your main or only support.”

SOUL

I recently conducted a 2-day workshop for people working with mandated clients in corrections settings. Those of you who have heard me speak know I highlight engaging clients to “do treatment, not do time.” This is not just about techniques of Motivational Interviewing and using the Stages of Change. To me, it’s about inspiring our clients to see that they have choices, power over their own lives; to help them see they are not victims of people, places or things (including judges, courts or drugs.) I understand the pressures that exist to get people to comply with treatment, and to take responsibility and “complete the program”. We hear their sad, complicated stories. Their lives seem so out of control that we quickly accept the pressure of others to get our clients to behave and comply.
At the recent workshop, the Director of the Nebraska Department of Correctional Services gave a brief presentation. My ears perked up with one phrase Director Robert Houston said. That one little phrase captured for me what I had been trying to communicate all day. “Our work” he said, “is about freeing people, not turning them loose.” That one- liner said it all for me. I didn’t have time to process with Director Houston the implications of that phrase for him. I do know what that phrase inspired for me- not just in corrections populations, but in all our work with people.

It is about helping people to be truly free of the tyranny of substance use and mental disorders. We are not just putting people through programs, and then turning them loose if they comply and complete the program. Our clients -often mandated to attend treatment- may see their involvement with us as merely waiting to be turned loose, and to get us and others off their back. We feed into that sentiment when we say things like: “Well since you have to be here, you might as well get something out of the program.” Imagine if we could align with them to work on being free. Let’s thank our clients for exercising their freedom of choice to come to treatment, to be free of incarceration. Convey to them our commitment to help them live so positively that they never have to be locked up again; and to figure out how to do that now and forever.

Who doesn’t want freedom? Our work is about freeing people, not turning them loose.

Until Next Time

See you next month.
David