TIPS & TOPICS
Volume 4, No.7
December 2006

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

Happy and Healthy New Year for 2007!

Thanks to all who responded to my request in last month’s edition for your TTT from TNT (Your Top Ten Tips from TIPS and TOPICS). It’s not too late to submit your list; read SUGGESTIONS in the Oct-Nov 2006 issue.

SAVVY

This month I was invited to speak at the Third Annual Joint Commission Conference on Behavioral Health Care in Chicago. It was sold out this year, and is gaining growing support. Consider attending next year. Speaking was great, but learning was even better. I heard about topics I don’t often see on other conference agendas.
Here are some nuggets that caught my attention.

Tips:

• Listen to research findings even if they may clash with conventional wisdom and shake up your ideology.

Michael J. Lambert, Ph.D. Professor, Department of Psychology at Brigham Young University opened with this common problem we have heard before: Research often just stays in the journals, and is not used to make a difference to patient care. Then he quoted from Michael L. Millenson’s book titled: “Demanding Medical Excellence: Doctors and Accountability in the Information Age”.

“The research documenting that the wrong choice of hospital could triple a surgical patient’s chance of dying was not used to improve the care of a single patient.” (page 159)

Moreover, he reported that such knowledge didn’t even affect the hospital where the research was published. We marvel at this. But before you judge the hospital, consider that the mental health and addiction fields have done the same thing. Conclusions from decades of psychotherapy research have still not been widely embraced and used.

Dr. Lambert summarized conclusions from the psychotherapy research:

–> Clinicians can be confident that we have an overall positive effect on client functioning (We like that finding)

–> Our treatments are efficient for many clients, and lead to lasting changes in a variety of important areas (That’s a finding we like too)

–> Outcome is largely due to client capacities and factors (such as severity of illness, motivation, capacity to relate, ego strength, psychological mindedness and ability to identify a focal problem) (We give lip service to a strength-based, empowerment, client-centered approach, but usually treat clients from a pathology-oriented, clinician and program-centered perspective)

–> Specific techniques are not the most important avenue to getting results (We definitely don’t like that finding. We believe that the program, the model and the techniques account for much more of the change than they actually do)

How well do practitioners predict treatment failure?

Dr. Lambert summarized these findings:

–> Clinicians are very optimistic about their clients. They believe that their treatments will produce a good outcome. (That is good, because you want clinicians and counselors to believe in what they are doing, and to feel that they can help their clients)

–> However, clinicians are usually wrong and don’t predict accurately which clients are not doing well in treatment. (That’s not so good. If you don’t pick up that your client is not getting much from treatment, you cannot intervene and tweak what you are doing. And you won’t fashion a more effective service plan. Think about the clients you treated who dropped out. How accurate were you ahead of time to know that they would drop out or relapse?)

–> In one study of 550 clients, therapists were asked to predict who would benefit from psychotherapy or not. (Hannan, Lambert, Harmon et al 2005)

–> Clinicians predicted that 3 would have a negative outcome when actually 40 had a negative outcome.

–> Of the 40 with the poor outcome, the staff had accurately predicted only one client.

–> In contrast, algorithms were correct 77% of the time in predicting deteriorated patients. (Algorithms are decision rules, based on a client’s expected progress, that help clinicians prevent treatment deterioration. Clinicians use formal measurements of client engagement and outcome; and monitor client progress on a session by session basis. Using the data from formal client feedback, the decision rules help identify which clients need special attention to tweak their treatment plan.)

How well can we predict treatment failure using real-time monitoring of alliance and outcome measures?

Dr. Lambert referred to this study:

–> Lambert, Whipple, Bishop et al (2002) studied 492 treated clients, and their response to treatment was categorized based on their scores on the Outcome Questionnaire-45 (OQ-45).

–> Practitioners were given feedback on which of their clients were not progressing well, so that something different in treatment could be tried to prevent deterioration.

–> 36 of these clients deteriorated, and formal client feedback measures predicted 100% of these worsening clients.

–> The predictions were sensitive, but not very specific, as 82 additional clients were predicted to deteriorate by the response categories based on the OQ-45, but did not deteriorate. (false positives)

–> Nevertheless, these kind of real-time alliance and outcome measures do far better than practitioners at predicting treatment failure.

The Bottom Line on What to Do About These Findings

Firstly, if you are unfamiliar with this line of research you can do some reading on it. There are formal feedback tools already developed:

* Lambert and associates’ Outcome Questionnaire-45 (OQ-45);
* Miller and Duncan’s Outcome Rating Scale (ORS) and Session Rating Scale (SRS);
* NIDA’s Clinical Trials Network Patient Feedback system; and
* McLellan and associates’ Concurrent Recovery Monitoring (CRM).

You may not be ready yet to use formal client feedback monitoring tools. However what you can do immediately is pay more attention, session by session, to seek direct feedback from the client. Ask the client if the treatment plan, the recovery or service plan makes sense to them. Is there a good fit between your suggestions and their viewpoint? Of course, don’t ask those questions unless you are actually willing to hear what the client has to say; and are actually willing to change strategies based on their feedback.

References

Asay, T.P., Lambert, M.J. (1999): The Empirical Case for the Common Factors in Therapy: Quantitive Findings. In M.A. Hubble, B.L. Duncan, & S.D. Miller (Eds.). The Heart and Soul of Change: What works in therapy. Washington, D.C.: American Psychological Association Press, 23-55.

Hannan. C., Lambert, MJ., Harmon, C., Nielsen, SL., Smart, DW., Shimokawa, K., Sutton, SW. (2005). A lab test and algorithms for identifying clients at risk for treatment failure. J.Clin Psychol. 61(2):155- 163.

Lambert, M.J., Whipple, J.L., Bishop, M.J., Vermeersch, D.A., Gray, G.V., & Finch, E. (2002). Comparison of empirically derived and rationally derived methods for identifying clients at risk for treatment failure. Clinical Psychology and Psychotherapy, 9, 149-164.

Lambert, M.J. Burlingame, G.G., Umphress, V. et al. (1996) “The Reliability and Validity of the Outcome Questionnaire” Clinical Psychology and Psychotherapy, 3 (4) Summer, 249-258.

Miller, S.D., & Duncan, B.L. (2000). The Outcome Rating Scale. Chicago, IL: Authors.

Miller, S.D., Duncan, B.L., & Johnson, L.D. (2000). The Session Rating Scale 3.0. Chicago, IL: Authors.
(Individual practitioners can download copies of the SRS and ORS for free at: www.talkingcure.com)

McLellan, AT, McKay, JR, Forman, R, Cacciola, J, Kemp, J (2005). Reconsidering the Evaluation of Addiction Treatment – From Retrospective Follow-Up to Concurrent Recovery Monitoring Addiction 100(4):447-58.

Patient Feedback NIDA Study CTN 0016, http://www.nida.nih.gov/CTN/Research.html. http://dmu.trc.upenn.edu/patientfeedback/pfweb2/

SKILLS

Years ago, a workshop participant had faithfully listened all day. He compiled a list of all the little phrases and “one-liners” he found helpful. I was impressed when he handed me the list. I set it aside in a safe place for future use. It was such a safe place that now I can’t even find it. Some phrases are sprinkled through previous TNT editions. I collated a few of my frequently-used clinical tips in this edition as my holiday gift to you. If you find them useful, you can use them, and it will be the gift that keeps giving.

Tips:

• “Thank-you for choosing to work with me. How may I serve you? What is the most important thing that you want that made you decide to meet with me?”

Initial engagement and collaborative treatment begins with a genuinely interested dialogue about what is most important to the client that prompted their visit.

Therapist:
“Thank-you for choosing to work with me. How may I serve you? What is the most important thing that you want that made you decide to meet with me?”

Client:
“I didn’t choose you, they made me come.”

Therapist:
“I didn’t see anyone drag you in. What would happen if you hadn’t come today?”

Client:
“I might lose my job, so I came because my boss told me to.”

The focus is on what the client really wants (to avoid losing his job), not just what others have said he needs (i.e. treatment for substance abuse, or angry outbursts and conflict at work.) Why now has the client come? What is his highest priority? Can we help him discover the link between his drinking or anger that affects his work performance?

Therapist:
“So you want to get the boss off your back. You want people to leave you alone. You feel people treat you unfairly and want them to stop. But why did you come now, and not last week or last month? “

Client:
“I came now because my boss said yesterday I could lose my job if I didn’t get some help.”

Therapist:
“Oh, so what you want most importantly is to keep your job, is that it?”

Client:
“Well yeah, but I don’t have a drinking problem or any problem with my temper. They’re just overreacting. It wasn’t as bad as they said.”

Therapist:
“OK, I am willing to work on helping you keep your job if that’s what is most important to you, and why you came now. Do you know what you are doing that makes them think you have a drinking or anger problem?

Client:
“All I did was come in late a couple of times and got into a little argument with a couple of people.”

Therapist:
“If we are going to help you keep your job, we could spend our time talking about how unfair your boss is, and how she’s misjudging you. Or we could work to show her that she has you all wrong; and that you are a productive worker who does not have a substance or anger problem. Let’s think together how we could gather the data that would prove you don’t have a substance problem. If all that data is squeaky clean, then I can write a very supportive letter to your boss and tell her all is well. If however, in the course of our work together we discover you do indeed have a problem, I can still write a very supportive letter. But we’ll have to work on showing her how you are taking care of any problems that interfere with your work performance.”

Clients are often difficult to engage because there is no agreed-upon treatment contract. To develop a “treatment contract” that fully allies with the client’s goals means clinicians must resist the urge to move quickly into the clinical assessment, and to prescribe what should be worked on and how. Especially when building the alliance in the first fifteen minutes, more time has to be spent on exploring what the client wants, on his/her ideas on how, when and where they feel they can achieve what is most important to them.

Reference
Mee-Lee D (2007). Engaging resistant and difficult- to-treat patients in collaborative treatment. Current Psychiatry in press, to be published January, 2007.

• “I’m in charge of the treatment plan, but you’re in charge of me.”

I doubt you plan to live with your clients 24 hours a day, 7 days a week, 365 days a year, and tap them on the wrist every time they make a wrong decision. The service plan you develop with them better make sense to them, or they won’t do it. If most of the outcome in helping people depends on client and extra-therapeutic factors, we best help them decide how they want to live their life. It is, after all, their life.

Therapist:
“I’m in charge of the treatment plan, but you’re in charge of me. So if there’s anything that doesn’t make sense in the strategies I am suggesting to you, please say: ‘It doesn’t make sense to me’ and I will explain why I think it will help you get what you want.”

Client:
“You mean I can really tell you if I don’t like the ideas you are suggesting?”

Therapist:
“Yes, of course. If after I explain why I think it makes sense to include these strategies in the treatment plan, it still doesn’t make sense, please say: ‘It still doesn’t make sense to me and I don’t want to do that’. Then we won’t include it in the plan.”

Client:
“Do you really mean that you won’t make me do things I don’t agree with?”

Therapist:
“Right. Because if you just say you agree when you really don’t, that is lying and we are an honest program. And anyway, I’m powerless over making you change. But whatever we agree to do in the treatment plan, you have to do faithfully with effort and commitment and it has got to work. If it doesn’t, then we’ll reassess. We will have to change the treatment plan to strategies that have a better chance of working. But you’ll be all part of that process, because I’m in charge of the treatment plan, but you’re in charge of me.”

Of course you can’t speak this way with clients if you actually do have a treatment plan and program with which the client has to comply. But then be honest and tell the client that you don’t really care about what they think – that it is their job to listen to you and do what you think is best and to comply.

• “I don’t know, I could be wrong, so what do you want to do?”

With our training and experience we do, of course, have insights and education that could help clients. Being client-centered doesn’t mean we abdicate our responsibility to assess, explain and suggest treatment strategies, some of which many clients will not like or agree with. We can persuasively explain what we think are the best things for the client to do – e.g., stay away from drug using friends; don’t hang around old criminal buddies; don’t be a bartender if you are trying to be abstinent; take this medication; get names and numbers; don’t beat up people if you want to stay out of jail etc etc.

But as David Powell, Ph.D. explained once: Learn to say – “I don’t know, I could be wrong”. You don’t know everything about everyone, and what is best for all clients. And a couple of times in your career, you may actually be wrong. So it isn’t lying to say: “I don’t know, I could be wrong.”

Therefore you can be very clear about what the client should do, and you can tell them assertively. But then you can take it back, as it were. The decision and responsibility is back in their lap to mull over.

“I don’t know, I could be wrong, so what do you want to do (about your friends, your leisure activities, about reaching out, about where you work and what you do etc. etc.)?”

SOUL

New Year’s Resolutions!

You could view them as being in the Preparation stage of change (in Prochaska and DiClemente’s Transtheoretical Model.) This means you will act on your resolution in the coming three to four weeks, not next year —–sometime—- perhaps— if I get around to it. If you truly feel like the latter, you are still in the stage of ambivalence (Contemplation). Now if you are in Preparation, you best declare your commitment to change to family, friends, to whoever will listen. This helps you get serious about your resolution. Others can help you stay honest – keep your feet to the fire.

So, here I go. 2007 is the year for achieving balance between work, love and play.

I realize I’ve made that resolution before. But this is the first time I’ve declared it to thousands of people. Maybe this year is the year for “walking the talk”. I’m already doing well for January 2007, as I will be visiting family in Australia (that’s the love and play part); and I have an evening presentation to doctors and clinicians in Sydney (that’s the work part). I’m not so sure about the rest of the year—-we’ll see.

If you have found a great balance with work, love and play, congratulations! Some of us are still a work in progress. Good luck with your New Year’s Resolutions. Are you going to tell anyone?

STUMP THE SHRINK

Here’s a question about substance use while in residential treatment:
“At my agency, we have been having some important discussions and would like your views, if possible. Our agency operates several 24 hour residential treatment programs. We have one that is specifically designed to be an integrated and comprehensive co-occurring treatment program and several that have specialized services for clients with co-occurring disorders but also serve substance abuse- only clients.

When a client relapses while in a 24 hour residential program, we continue to work with him/her to address the relapse etc. However, we have typically differentiated between someone who relapses and someone who brings drugs or alcohol into the program premises. When someone brings drug/alcohol into the building, we have seen this as a danger to other clients (and potentially the program). These clients have been discharged from the residential program and are not eligible for residential program services for 90 days. We continue to work with the client through case management services and emergency services at detox if necessary. We have seen this as important:

• for the client who needs to understand that his behaviors have impact and consequences
• for the other program clients who need a safe place to live and recover
• for the program which needs to maintain order and not be subject to NIMBY (Not-In-My-Backyard) issues, complaining neighbors etc.

Clients are aware of this upon admission to the program. Please let me know if you think this approach is reasonable. Do you think there is a difference between programs specifically for co- occurring clients and programs for both substance abuse and co-occurring clients? Do you see any difference between alcohol and drugs? We would appreciate any guidance you can give.

Director, Residential Services

My response:

I agree that there are times when discharge is reasonable and necessary. Some clients are not invested in treatment and just want “three hots and a cot” (3 hot meals a day + a bed to sleep in). In that situation, if a client brings alcohol or other drugs into the facility and influences others to use too, then you discharge. The residential program is a “treatment place” – not a hotel, resort or “marketplace.”

On the other hand, a client is doing treatment to the best of their ability. He/she gets a craving, and uses on a pass or on the grounds. In their desperation, they may even arrange for someone to drop them off drugs, and bring them to their room. While using, this might influence their roommate to use with them. This is when you “continue to work with him/her to address the relapse etc.” – as you do already. Like you, I would reassess and change the plan accordingly – not just automatically discharge.

You would do the same with a mental health problem. If a client has impulses to hurt themselves or self-mutilate, in their desperation they may bring in a razor blade to the residential program, or use the kitchen knife to cut themselves. Obviously this is a danger to other clients and the milieu also. Again, I would reassess. Explore what the person is willing to do to try to prevent that behavior. If they recognize this is not the best way to respond to their impulses, and are willing to try a more productive plan, you keep going. This process should be the same for addiction treatment in my opinion.

Clinicians can still achieve safety goals for clients and the milieu with a community meeting/group as soon as possible. This safety message is communicated: It is not OK for anyone to bring in drugs, razor blades, engage in cigarette-burning, using or cutting in the residential program. The person is expected to share/talk openly about their crisis. They are expected to apologize to those who might have been triggered by their actions.

The focus then moves to a positive treatment direction: 1. What does the client intend to do differently to deal with this craving or impulse; 2. How will they keep themselves safe, plus other clients and the milieu.

This approach is important for all clients – whether addiction only or co-occurring disorders.

Hope this helps.
David

Until Next Time

Thanks for reading. See you in late January.
David