My three career bridge-building targets; Where to start in helping people change; 50 years for Elon Musk and me.

Welcome to the start of my 20^th year of writing Tips and Topics. The first edition was published April 2003.

In SAVVY, this edition of Tips & Topics begins the 20^th year of publication. I look back at what I’ve written before in three areas of bridge-building: Addiction as an illness – the general public and health care in general; Addiction and mental health – Co-Occurring Disorders; Justice and Treatment teams.

In SKILLS, it requires skillful bridge-building to attract people into lasting, accountable change, and cross the bridge from expecting compliance to treatment to collaborating in person-centered care planning: Start with what the person is at Action for, not what you are at Action for; Hold the participant accountable to their goal and track their engagement, good faith effort and outcomes.

In SOUL, this year is 50 years since I graduated from medical school and started my career. See my ASAM Educator of the Year award photo and video bio. Elon Musk is 50 years old. I’ve had a good career, but find out what drives Elon and what someone who was one year old when I started my career has achieved.

savvy

This month’s edition marks the beginning of the 20^th year of Tips & Topics. In the very first edition in April 2003, I outlined why I started Tips & Topics. In the April 2004 edition at the beginning of the 2^nd year, I wrote in SOUL a little background on why much of my career has focused on bringing together people and systems – addiction and mental health; therapists getting closer to clients as customers; helping teams resolve conflicts and build cohesion. I shared the mission statement I fashioned when I started my training and consulting practice: 

I am actively creating a unique forum using my talents of bridging the gap for people between disparate fields and concepts, in a very persuasive, challenging and inspiring manner; simultaneously influencing systems in a global way for the greater good, with rich personal satisfaction and financial reward. 

So at the beginning of the 20^th year of Tips & Topics, I am looking back at three main “bridges” I have focused on in my career.

Tip 1

Bridging the gap between the public and healthcare’s view of addiction as willful misconduct to seeing addiction as a disease.

In the April 2018 edition, I covered:

• What is addiction? What’s the role of choice in relapses – or as I like to call it “flare-ups”, “recurrence of signs and symptoms” or “acute exacerbations of the chronic illness of addiction?”
• I also addressed terminology: Is it the “addictions” or the disease of “addiction”?

In the August 2011 edition, I wrote about:

• Implications of what was then the American Society of Addiction Medicine’s new definition of addiction.
• How to check if you, your treatment team or your community really embraces addiction as a primary disease.
• What it would mean for clinical skills, healthcare and criminal justice systems’ change, funding and managed care organizations.

In the October 2020 edition, I addressed:

• How addiction is compared to other health issues.
• The September 2019 new ASAM Definition of addiction.
• A Harm Reduction approach to addiction versus a “medical model”.

Tip 2

Building bridges between mental health and addiction treatment to better assess and treat co-occurring mental and substance use disorders.

In the December 2004 edition, I suggested in SAVVY:

• Integrated treatment for co-occurring disorders is about services, not an organizational chart.
• A few questions to check if at the consumer level, there really is integrated treatment or not.

In the May 2010 edition, I addressed in SAVVY:

• Assessment issues for Co-Occurring Disorders.
• Diagnostic possibilities when clients present with mental health problems and are also using alcohol and other drugs.
• Guidelines to tease apart these diagnostic possibilities.

In the July/August 2005 edition, I suggested:

• When a system is moving to integrated co- occurring, recovery-oriented services, consider some of the challenges to attitudes, knowledge, skills and policies and procedures.
• Gather your team together. Brainstorm on all the policies, procedures, and agency culture traditions that interfere with integrated co-occurring, recovery-oriented services.

In the June 2019 edition:

• In SAVVY and STUMP THE SHRINK, I responded to a question on what to do about psychiatric prescriptions for benzodiazepines and amphetamines in addiction treatment.
• In SKILLS, assessment needs a skilled clinician who is savvy about addiction and mental illness who can evaluate specific diagnostic and treatment questions.

Tip 3

Bringing together justice and treatment teams to enhance accountable, lasting change in drug and treatment courts.

In the November 2007 edition I addressed:

• How to maintain the boundaries between criminal justice and clinical work; between “doing time” and “doing treatment”
• How it is essential we understand and respect each field’s background, mission, jurisdiction, expertise and experience.
• The three fields of criminal justice, addiction and mental health are all actively involved in the treatment planning process and delivery of services for mandated clients.
• How do we make a difference without working at cross purposes? How do we support and augment our impact on a client to produce healthy results?

In the September 2005 edition, I covered:

• What contributes to good outcomes in mental health courts and drug courts.
• Compare how drug and mental health courts work with participants and contrast that with traditional courts.

In the June 2018 edition I addressed:

• Nonviolent drug offenses and whether it is worth incarcerating people who committed nonviolent crimes due mainly to the disease of addiction and/or related social ills.
• Justice transformation by coming together to achieve public safety, promote recovery and justice for all.
• How to craft policies allowing for mistakes and promoting honesty; not zero tolerance.

In the September 2014 edition, I suggested:

• The importance of understanding the overlap of people in mental health, addiction and the criminal justice system.
• Approaches to sanctions and incentives in Drug Courts.

In the March 2016 edition I addressed:

• Addiction treatment is assessment and outcomes-driven, not program and compliance-focused.
• Structure the phases in drug and other specialty courts based on functional milestones, not on time and compliance.
• Give the judge and the court team robust information. Report on whether the participant is improving in function that increases public safety.
• Rethink sanctions and incentives to focus on engagement, improved function and recovery.

In the May 2017 edition, I covered questions that highlight conflicting perspectives on what is “addiction” and addiction treatment is:

• Is addiction really a disease or isn’t it just willful misconduct?
• If you do individualized treatment, won’t participants scam the system? If we don’t treat them with all the same expectations, won’t they all try to get around the rules as much as they can?
• These people have criminogenic thinking and antisocial behavior. How will they change if you are soft on them in treatment? Don’t they need to know who’s the boss?
• Using illegal drugs is criminal behavior. How can we just let that go without consequences? They picked up the drug and used.
• If they get a positive drug screen they need more than a tap on the wrist and “treatment that is all unicorns and rainbows.”
• I’m OK with cutting them some slack early on in treatment if they use and get a positive drug screen. But if they are further along their phases and haven’t used for months, then shouldn’t they be sanctioned for any use?

skills

To attract people into lasting, accountable change, it requires skillful bridge-building:

• To cross the bridge from expecting compliance to treatment to collaborating in person-centered care planning.
• To put to one side what you think the client should change to listen carefully and focus on what the client thinks needs to be done.
• To build bridges to create a treatment atmosphere that is conducive of change not coercive of change.

Tip 1 

Start with what the person is at Action for, not what you are at Action for.

In the July/August 2007 edition, I suggested in SKILLS:

• Figure out what will work for THIS person seated in this office on this day at this stage in their recovery.
• A woman may be at Action for staying out of jail, or getting her children back, or keeping her job.
• She is at Precontemplation for anger management, parenting skills training and abstinence. I need to get where she is at, not have them struggle to be where I am at.
• If your client is non-compliant and not invested in treatment, don’t look at the pathology of the client; look at the lousiness of your treatment plan, because it is probably your plan, not the client’s.

Tip 2

Hold the participant accountable to their goal and track their engagement, good faith effort and outcomes.

In the April 2019 edition I addressed:

• In SKILLS, how to identify what a poor outcome is for a client and hold them accountable for the success of their goal or not.
• If a client is trying to prove that they can cut back or stop using any time they want, then any substance use over the amount or quantity that the client agreed to do, is not a good outcome.
• If a client agrees to go to at least one meeting/week, then missing a meeting the whole week is not a good outcome.
• If a client signed themselves into treatment, but sits in group staring out the window, counting the minutes until a smoke break, that is not a good outcome.
• What to do when a client, patient or participant is not doing well in treatment.
• To treat poor outcomes in addiction e.g., positive drug screens, poor attendance, passive compliance, do what is done in the treatment of any disorder (diabetes, asthma, schizophrenia, major depression, bipolar disorder etc.).
• Every healthcare professional usually follows the same sequence: Evaluate what is going wrong with the current treatment plan; Identify with the patient what needs to change or be added to the treatment; Continue treatment with the new adjusted treatment plan and track the outcome.

soul

This year, it will be 50 years since I graduated from medical school. In December 2021 I announced that the American Society of Addiction Medicine (ASAM) had awarded me the 2022 ASAM Educator of the Year Award that recognizes and honors an educator who has made outstanding contributions to ASAM’s addiction medicine education. 

ASAM even reached out to colleagues to share a few words about me and produced a brief video Bio introduction just before the award. Too much work went into that video to have its first and last showing be at the conference.

So here, for your viewing pleasure, is that brief video!

Of course I am proud of and gratified by my 50 year career as a physician, psychiatrist and addiction specialist. But when I started my career 50 years ago, Elon Musk was one years old.

Elon Musk

The more “high profile” you are, the more detractors you attract. So whatever you think about Elon Musk, I invite you to hold judgement until you hear directly what Elon Musk has to say about who he is and why he does what he does.

I watched the hour plus interview by Chris Anderson, head of TED (as in TED Talks). I have never taken the time to listen and understand Elon. But as I watched the interview, I was impressed that his heart is in the right place and I marvel at how one man can execute so many mission-driven innovations so effectively.

In the interview “Musk details how the radical new innovations he’s working on — Tesla’s intelligent humanoid robot Optimus, SpaceX’s otherworldly Starship and Neuralink’s brain-machine interfaces, among others — could help maximize the lifespan of humanity and create a world where goods and services are abundant and accessible for all. It’s a compelling vision of a future worth getting excited about.”

It was recorded at the Tesla Texas Gigafactory on April 6, 2022, so this is hot off the press.

Chris Anderson asked Elon Musk (EM): “What drives you on a day-to-day basis to do what you do?”

EM: “I guess, like, I really want to make sure that there is a good future for humanity and that we’re on a path to understanding the nature of the universe, the meaning of life. Why are we here, how did we get here?….We must expand the scope and scale of consciousness……”

If you don’t have the time or interest to watch the whole interview (my recommendation) but want to dip into it, here is a minute by minute timeline of topics that you can fast forward to:

0:14 A future that’s worth getting excited about

2:44 The sustainable energy economy, batteries and 300 terawatt hours of installed capacity

7:06 “Humanity will solve sustainable energy.”

8:47 Artificial intelligence and Tesla’s progress on full self-driving cars

19:46 Tesla’s Optimus humanoid robot

21:46 “People have no idea, this is going to be bigger than the car.”

23:14 Avoiding an AI dystopia

26:39 The age of abundance

28:20 Neuralink and brain-machine interfaces

36:55 SpaceX’s Starship and the mission to build a city on Mars

46:54 “It’s the people of Mars’ city.”

50:14 What else can Starship do and help explore?

53:18 Possible synergies between Tesla, SpaceX, The Boring Company and Neuralink

54:44 Intercontinental travel via Starship

58:41 Being a billionaire

1:02:31 Philanthropy as love of humanity

1:03:39 Population collapse and birth rates as a threat to future of human civilization

1:04:13 Elon’s drive

1:06:06 “I think if you want the future to be good, you must make it so.”

So here I am 50 years since starting my medical career and here is Elon Musk just 50 years old. Both our careers have been mission-driven. But what Elon has achieved boggles my old mind. They say “The older you get, the less you know”. There’s some truth to that.