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December 2003 – Tips & Topics

Vol 1, No.8
December 2003

In this issue
– Until next time


Holiday greetings everyone! Thank you for reading this December edition of TIPS and TOPICS. I enjoy sharing some thoughts with you each month. I am glad that many of you find some tidbit to help you think about the work we do for the people we serve.


This month, I consulted on two patients who had been admitted to acute psychiatric inpatient units because of suicidal and homicidal ideation. One was a 26 year old, single, employed man who had violent thoughts and impulses towards his supervisor, but was more acute only when under the influence of crack cocaine. The other was a 37 year old, single mother of three and grandmother to a 3 year old girl whom she loved; but she had trouble caring for because of her heavy IV heroin dependence. I was struck again how our clients and families challenge us to look at how we assess their needs and develop services. In fact I was startled that what seemed like basic (not even best) practices were not utilized by the teams involved. We still struggle to bring together mental health and addiction treatment systems to serve their dual diagnosis needs.

These two cases highlight some important tips.


  • “The proper question is not: “Why isn’t this person motivated?” but rather: “For what is this person motivated?” (Miller, William R; Rollnick, Stephen (2002): “Motivational Interviewing – Preparing People for Change ” Second Edition. New York, NY. Guilford Press. Page 18)

Many people – especially those with co-occurring disorders – have so many service needs that it is easy to list ten problems of theirs without even trying. And too often treatment teams actually do that – they churn out the service plan with very little collaboration from the client. Wonder of wonders, the person doesn’t seem very motivated to follow through with the plan outlined for them. Both the above patients were not ready for action; not ready to do whatever it takes to achieve serenity and sobriety – even though it was obvious to the team that is what they needed to do.

The young man wanted to keep his job; and if he wanted any help in particular, it was to “get my medication straightened out”, he said. He was on Depakote, Risperdal and Paxil for the ubiquitous Bipolar Disorder. (Excuse my skepticism, but he’d also been using alcohol and other drugs since age 10 he told me). After his five-day stay in the inpatient secure unit, he was now in a psychiatric partial hospital program. He had also missed a day there because of a slip with his crack cocaine.

There was only one addiction counselor on the whole mental health team. She agreed that the psychiatric setting was not her ally in trying to attract him into active recovery. For example, the depressed women in the groups he was attending were coming onto this handsome young man, and did not challenge him in confronting him about his crack use and its relationship to his depression, impulsivity and job problems. Just being in a predominantly psychiatric setting made it difficult to focus on addiction issues. On the other hand, the psychiatrist was rightly concerned that the addiction intensive outpatient program available in the same hospital was not clinically savvy about mental health treatment. This explains the psychiatrist’s decision to keep this client in the mental health setting even though it was not meeting his dual diagnosis needs.

  • “Ambivalence is a common human experience and a stage in the normal process of change.” (Miller, William R; Rollnick, Stephen (2002): “Motivational Interviewing – Preparing People for Change ” Second Edition. New York, NY. Guilford Press. Page 19)

The 37 yr. old grandmother was clear about what she wanted: ” I want to get cleaned out so I can take care of my granddaughter”. Even though she has been involved in outpatient addiction treatment and Narcotics Anonymous meetings before, she had had minimal follow through.

The man (we’ll call him Bob) was also clear. He realized his crack use was a problem, stated he had stopped before for a year and a half, and expressed he might even want to be abstinent again. But when asked what would be the problem with stopping, it wasn’t that he didn’t know how to, nor that he didn’t think his use was a problem. His ambivalence stemmed from his experience that crack helped him “not to face reality about the world”, and that he had a lot of anger and resentment. He was worried that if he were clear-minded, he would be “ferocious” and violent. There was irony there. In fact, he only became impulsive – needing acute psychiatric care – when he was using crack cocaine. He had no such behavior or need for hospitalization in the previous year and a half of sobriety he had in NA.

Bob’s struggle was real though. His ambivalence was palpable. How was he to deal with his rage and resentment over past physical and emotional trauma from his father, who suffered from severe addiction and mental health problems? How safe would he be, he thought, if he was again drug-free facing the resentment and anger over the daily teasing he endured from his two older brothers? It would have been wonderful if he had ever had an addiction-savvy therapist. He needed someone who could be sensitive to his emotional pain, but also able to address his ambivalence and enhance his motivation for sobriety.

  • All clients who are in regular contact with family members can benefit from some form of family intervention at any or all of the different stages of treatment.” (Mueser KT, Noordsy DL, Drake RE, Fox L (2003): “Integrated Treatment for Dual Disorders – A Guide to Effective Practice” The Guilford Press, NY Page 195)

When Rochelle (let’s call her) was admitted to the psychiatric unit, she was explicit about what she wanted. Her granddaughter meant a lot to her, and her children and fiancé both wanted her to get sober. In fact she’d been having fights with them over her heroin use. Her three children (20, 18 and 15) all lived with her. So they knew what was going on, and she knew they knew.

Now three days later, Rochelle was about to be discharged from the acute psychiatric unit as no longer suicidal or impulsive. I worried out aloud to the team about the fact that Rochelle had not been told yet that a mandated report had been made to child protective services. She indeed was almost half out the door in the discharge process. Also the family, in particular her daughter and as the mother of Rochelle’s three year old granddaughter, had also not been involved in treatment, nor been told of the report to CPS.

How was Rochelle going to face this upsetting piece of information and a presumably angry family after three days off heroin while in a psychiatric unit? The combination of minimal outpatient addiction treatment support and no preparation of her and her family for the impending CPS investigation did not bode well. I wondered what a severely heroin-dependent person might do when faced with anger, pain and resentment. But I didn’t wonder too long.

Before we judge Rochelle’s team too harshly for the lack of family involvement when it was so clearly needed, the medical director of one managed behavioral healthcare company told me about a study of about 100 charts in their provider network. Rochelle’s team is not alone. Only 24% see the families in treatment; and only 40% assess motivation and readiness to change.


Here are a few tips prompted by these two clinically rich situations.


  • Ask: “What has been the longest period drug-free? And how did you do that?”

There are at least two reasons to ask these questions.

1. You want to explore whether the mental health symptoms may be closely related to substance use – whether the substance use has caused the psychiatric presentation as in a Substance-Induced Disorder; or perhaps exacerbated or aggravated an existing mental health problem.

2. In a solution-focused way, you may want to explore what the person has done that worked for them. How did they actually achieve abstinence even if it was only for a week? What strategies worked for them, because they could also work for them once again if they decide to quit using?

Of course it’s better if you expand on what you mean by “drug-free” when you ask that. For example you say: “By ‘drug-free’ I mean no alcohol, illegal drugs, uppers, downers, sleeping pills, pain pills, tranquilizers, other mood altering medications, over the counter or other drugs. I mean absolutely nothing”. If you don’t run through the categories of drugs, including legal drugs, some people will think you mean illicit drugs. They might happily declare they were sober for three months, not thinking of the Percodan or Klonopin they used every day.

Bob had achieved a year and a half of abstinence by active NA involvement, plus having one of his brothers take control of his finances so he would not have ready money to spend on crack. These strategies worked until his ambivalence about how to face reality and his rage overcame him and he relapsed. It can work for him again once he works on his ambivalence about abstinence.

  • Even if a person seems clear that they want to stop using, ask: “But why would you want to stop using? What are the pros and cons about stopping?” “What are the pros and cons for keeping on using?”

Of course make sure that it isn’t you that is more invested in abstinence when the client is actually very ambivalent. However, even if you missed checking that out the first time, you still get a second chance when you ask them about pros and cons. Bob was very articulate about his ambivalence and the pros and cons of abstinence. Not all clients can do that, but you won’t know unless you specifically ask them.

His concerns about facing reality and containing his rage needed therapy. But not in-depth, uncovering, insight-oriented, psychodynamic and cathartic work yet. Good psychotherapy will stir up strong feelings and affect. But now is not the time for that.

Expect these feelings to arise in early recovery. But if they are evoked too strenuously before the person has learned non-drug ways to cope with strong affects and emotions, then the therapy itself can precipitate a drug relapse. Talk about them with sensitivity and empathy. Don’t stir up and examine closely all the feelings of the historical resentments. As these feelings arise during abstinence, help the person cope with them in non- drug ways.

  • Link the family contact (and actually anything in the treatment plan) to what the person is motivated for.

Any evaluation should include assessment of the person’s Recovery Environment. Within that, not least of course, are questions about the family and significant others. For some clients, there might not be an immediate and obvious link between the presenting concern and what the client and the client’s family want. But it is critical to evaluate and address who are the individuals in the client’s “family”, and how they can or cannot be supportive in the treatment and recovery process. In Rochelle’s situation, the link was very apparent from the moment she stepped onto the psychiatric unit.

“If we are to help you clean out and be able to continue caring for you granddaughter whom you love so much, we better meet as soon as possible together with your family and especially your daughter. If she or anyone else like Child Protective Services are upset and concerned about your ability to safely care for your granddaughter, we had better meet and discuss what it would take to make sure you continue getting the opportunity of being with your granddaughter all the time.”

“Bob, if we are going to make sure we help you keep your job and help you stop your absenteeism and threats against your criticizing supervisor, we better meet with your mother and brothers and anyone else in your family as soon as possible. Now that your mother is staying with you for support in your apartment, she’ll need to understand for how long and what the best way is to help you. Also, if as you say, your brothers have been both a cause for a lot of rage and pain, but also an ally to have handled your finances at your request, we best help you know how you want to deal with them if you plan on staying sober.”


At this holiday season time, we read numerous articles and advice columns on dealing with stress, coping with ambivalent feelings about family gatherings, viewing the change of seasons as opportunity for renewal and New Year’s resolutions. So I also won’t talk here about how yours or your client’s aroused feelings of loss, abandonment and disappointment might be stirred by those cheery TV commercials of the happy family opening gifts around the brightly-lit tree.

I won’t talk here about how easy or hard it is to be generous and give to others if you or your clients feel deprived of home, warmth, caring and love. I won’t dwell on whether you or your clients feel pressured to cope with or make changes in behavior, location, career, relationships, finances, and lifestyle. Just because the seasons or the calendar changed, or the budget deficit ballooned, or your company or personal relationship folded doesn’t mean you or your clients are/were ready to embrace change.

And I certainly won’t talk here about pressures to eat or overeat, spend or overspend. Tightening your physical or fiscal belt is not easy this time of year.

So what will I talk about? I don’t know who said something like this first (if it was you, then thank-you): “Yesterday has past; tomorrow is not here yet; but today is a present.” Join me in opening the gift of today – it really is all you can be sure you have. I know it is hard sometimes to open the gift of today and be present. I too have lived a life of worries – and a couple of them have even come true!!


I recently trained on the ASAM Patient Placement Criteria at the Sacred Heart Rehabilitation Center in Memphis, Michigan. Two team members who had attended previous trainings brightened my day with unsolicited success stories. So I asked them to let me share some of their successes with you:

Success #1

“The way I work with clients has changed dramatically since I attended your conference on the ASAM criteria. For instance, I now meet the client where he or she is, rather than try to force my beliefs on them. This attitude is a lot less stressful for me and I am not working harder than the client. Their treatment plan is just that- “THEIR TREATMENT PLAN”! It is their problems and goals, in their words, and I ask them what they would be willing to do to achieve their goals. I make suggestions, but the client must agree to be willing to do the work. Moreover, the treatment plan is now a living document which clients bring to group therapy and share their objectives with the group to receive feedback and encouragement from their peers. Thank you for sharing your knowledge and expertise with me”.

Deborah Kokoszka, MSW, CSW
Therapist, Sacred Heart

Success #2

“Here are some thoughts about how helpful your class was for me:
1. Helped me to better my understanding of the client’s problems that act as a catalyst to bring them to chemical dependency treatment. By asking follow-up questions to their initial statements, they are better able to state what their immediate needs are for brief treatment, at the time of the initial assessment.
2. The area of the ASAM Dimensions 1 – 6 has expanded to include more details for the primary therapist to work with as they meet the client for the first time.
3. I am now able to use various approaches – psychoanalytic; reality therapy – to approach the client to facilitate a more detailed initial assessment.
4. Your examples of meeting the clients where they are at in their thought process helped to show me a new style – a way to assist the client to experience how their thought process contributes to some of their problems, and encourage the client to think in terms of what options are available for them to remedy some problems (choosing options for treatment and/or recovery for themselves).
5. My Diagnostic Summary has changed in writing style to be more brief; more to the point and provides a clearer sense of direction for the therapist as an indicator of what the client’s needs are at the point of entry when I first see them during the intake process and initial assessment.”

Gabrielle Hill, RN, BS, CAC
Intake Assessment, Sacred Heart

Success #3

Speaking of the ASAM Patient Placement Criteria, this is a different kind of success story about the influence of the ASAM PPC.

Appropriations Bill Provides $100 Million for Treatment Vouchers
By Bob Curley

“A House- Senate conference committee has approved a budget plan that gives impressive increases to federal addiction treatment and prevention programs, including $100 million for President Bush’s proposed treatment-voucher program.

The Access to Recovery treatment-voucher plan is one of the biggest non-military new programs in the FY2004 budget. While the addiction field embraced President Bush’s call for a $600-million investment in treatment, many have been wary about the types of programs that would be funded, particularly given the administration’s affection for faith-based interventions. But lawmakers stressed that voucher money should only go to programs with a proven record of effectiveness.

“The conferees expect that the new voucher program will support evidence-based practice and will provide medically appropriate treatment for individuals needing care,” the House-Senate conference report said. “To this end, the conferees expect that states and providers receiving funds under this program will use assessment and placement criteria developed by national experts, such as the American Society of Addiction Medicine.”

Click Here for the rest of this article.

Stay tuned for more on some of the successful research on ASAM Criteria Validity Studies published in the literature.


Last month I presented a workshop and took along ten copies of a book I announced in the October 2003 edition. “Maintain Balance in an Unsteady World” contains a chapter I wrote, along with 11 easy-reading, practically oriented chapters by other recognized national speakers. My chapter title is: “What Do You Want? – The Not-So-Simple- Question”. Lightheartedly, I did my best car salesman impression and offered a deal to the attendees to buy their holiday gifts right on the spot. I kicked myself for not taking a box of books, because all ten sold out in a flash. I even signed some for a personal touch!

So I thought – why not offer you the same opportunity? Who knows, you might get some of your holiday shopping done in one swift click of your mouse. Here’s how to find out more about the book and here’s the deal. You have to act fast, and now really fast – especially if you want a personal touch to have me sign it for you or for whatever name you provide me. I will only be able to sign your book until December 16, as I’m off on a plane to Honolulu. You may still place orders, but only through Thursday, Dec 18, so they can arrive for Christmas giving. (Sorry, I would have given you more time, but I got really behind in getting this issue out to you.)

Shop here for your holiday gifts.

Until next time

Stay warm, safe and serene. Talk to you next year.


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