TIPS & TOPICS
Volume 5, No.8
December 2007

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

Welcome to the many new subscribers, as well as those who have read TIPS and TOPICS for over four years now.

SAVVY

Over a year ago, my malpractice company sent out a special report alert titled “How do I say I’m sorry? Let me count the ways”. I kept it aside to read, as doctors often have a hard time apologizing. Then I opened the November issue of Behavioral Healthcare and noticed Dr. Mary Cesare-Murphy’s article “It’s important to say you’re sorry”. In a recent case consultation the issue came up – about whether to say sorry to a client who had felt wronged by the agency. Then I knew I just had to cover the topic this month.

Tip 1

• Expressing apology and saying “I’m sorry” is much more effective than silence or defensiveness. For a real or perceived mistake or poor outcome, apology is likely to defuse anger, minimize or eliminate violent outbursts, and prevent legal or malpractice suits.

Defense attorneys historically counseled physicians to avoid saying “I’m sorry,” assuming that the patient or their attorney would argue that the words were an admission of guilt and increase the likelihood of a malpractice suit against the doctor. While this seems a reasonable assumption, there is no evidence to support this fear. In fact, the patients most likely to sue or threaten are those who:

• have been injured or believe they were injured
• are angry about not having their questions answered; about being given too little information about their condition and treatment; about being treated coldly or dismissively; and for other real or imagined slights during the course of treatment (Page 2 MIEC Special Report Claims Alert, 2006)
• did not have a comfortable, solid rapport and trust from the outset of the doctor-patient relationship

Patients who are injured or believe they’ve been injured want at least three things:

• Sincere sympathy and/or an apology
• A show of concern
• An explanation for what happened and why; or a commitment that every effort will be made to understand the circumstances and to follow through with that promise

Reference: Medical Insurance Exchange of California (MIEC) Special Report MIEC Claims Alert. No. 38, June 2006.

Tip 2

• “Disclosing mistakes and offering apologies are ethical responsibilities supported by various professional, regulatory, and accrediting organizations including The Joint Commission” (Mary Cesare-Murphy, Ph.D.)

“Many behavioral health professionals—– have had little experience communicating mistakes because of feelings of shame and guilt.” (Page 38. Behavioral Healthcare, November 2007). When I was a young resident in psychiatric training, I treated a depressed and suicidal man whose care I transferred to the team in a locked psychiatric unit. A few days later, I read in the newspaper that he had suicided by jumping out the window of the hospital. I remember saying to my supervisor that I didn’t think I had done anything wrong. Even though I had transferred his care appropriately to a secure psychiatric unit, and was in no way responsible for his death, my first reaction was to somehow feel guilty and wonder what I had done wrong.

Many years later, a patient of mine felt he was doing well enough to see me less, and in fact missed his last scheduled appointment. A few weeks later, I received word that he had gotten drunk and died in a single car accident – most likely speeding and driving out of control. Again my immediate thoughts were about what I might have done to prevent that terrible outcome. But I quickly called his father and brothers to convey my sadness; to offer to answer any questions that I could ethically respond to; and to be available should they wish to talk. Not only was that the compassionate and thoughtful thing to do, but also an important step to minimizing any anger, legal action or blaming.

Dr. Cesare-Murphy outlined the fundamental elements on how to disclose an error (Page 38):

* An apology
* A prompt explanation of what is understood about what happened and its probable effects
* An assurance that the error will be analyzed to learn what went wrong
* Follow-up conversations to explain what is being done to prevent the error from happening again

Reference: Cesare-Murphy, Mary (2007): “It’s important to say you’re sorry”. Behavioral Healthcare November, pp 38-39.

SKILLS

But what if the client is angry and threatening and feels wronged, but you don’t think there was an error? Shouldn’t the client be the one to realize that their angry accusations, or veiled (or not so hidden) threats of harm are inappropriate and unjustified? Shouldn’t the boundaries be set and even have the police warn the client about the consequences of violence or threats?

Tip 1

• If there are immediate threats of suicidal or homicidal and violent behavior, prompt police action or containment is necessary. But with angry threats and accusations about real or perceived wrongs, assess, address and apologize for any mistakes made.

Case in point:
A client was required to receive therapy for depression and an alcohol problem as a condition for stopping the “welfare-to-work” clock. He would continue to receive benefits so long as he was deemed unable to work due to mental health and addiction problems; and was addressing his issues in treatment. In this case, the client was attending all appointments regularly, had maintained a few months of abstinence, was improving in his depression, but continued to be ambivalent about his readiness to move to a work experience setting.

–> Now here is where the client felt wronged, angered and started making veiled threats of violence in “anonymous” phone calls:

It was one team member’s job to complete the form stating whether the client was indeed ready to work or not. This team member felt the client was malingering, scamming the system and declared on the form that the client was ready to work. This declaration was not discussed with the therapist working directly with the client; nor was there discussion with the client about the impending loss of benefits. Upon receiving notice of the impending loss of benefits, the client became enraged, and began a series of four anonymous calls to the agency. They finally figured out who was likely making the calls.

–> The consultation questions were: Should the authorities be called to visit the client and warn him of his crossing boundaries with his anonymous threats? What should be done to protect staff who felt threatened by this angry client?

My Response

• First rule out any imminent danger, and address that if present.
• If the team assesses that the client is not about to imminently arrive and threaten staff with violence, then the safest way to protect staff is to defuse the anger as quickly as possible.
• Do this by talking to the client on the phone, but preferably in person if possible.
• The goal is to avoid any actions that would further inflame the client’s sense of having been wronged. Would sending the police or sheriff to the client’s home defuse the anger and calm the client? Or would it inflame the situation? Would silence and closing his case – after his wife reported he was angry and would not attend appointments – decrease his resentment and any further acting out? Or would this leave a smoldering fire?

Tip 2

• If you step on someone’s toes, even if you had no intention of causing pain and turmoil, still apologize, open conversation and defuse anger.

When you step on a person’s toes literally or figuratively, most of us would immediately say “sorry”. If we were clear we had no mal-intent and that it was a pure mistake, we would have no hesitancy in saying: “I’m so sorry I hurt you. I didn’t mean to step on your toes. What can I do to help the pain go away?” This may not be so easy to do if there was a part of you that wanted to “sock it” to the person; and/or when the person reacts with anger and threats.

It is an occupational hazard of the helping profession that there may be clients who are actually (or appear to be) malingering or scamming the system to get benefits, stay out of jail, get their kids back, keep a job etc. However, this is a treatment issue to be directly addressed with the client, rather than a bad behavior to be punished. Addressing what looks like manipulative, selfish and irresponsible actions is not easy and often needs the team to assist. But it is a treatment dilemma with the client at the center of the discussion.

In the short run it may seem easier to set a limit; administratively discharge the client; close the case; sign off on the form that the person is ready for a work activity; or whatever gets the person off your case load. But the problem will not go away and he or she will be back – hopefully not with a gun.

There are all kinds of mistakes we can make in behavioral health treatment. We didn’t mean to step on the client’s toes, but people can, and do, feel wronged if we:

–> Prescribe a medication that produced severe or uncomfortable side effects
–> Keep them waiting a long time for their appointment
–> Confront them too strongly or prematurely about a sensitive vulnerability
–> Exclude an anxious and concerned family member or significant other who needs understanding
–> Don’t explain the treatment protocol and the client feels rushed or intimidated
–> Ignore the client’s goals believing our assessment is right and the client has poor insight anyway
–> Get distracted by our own issues and quit listening to the client for a moment
–> Set them up to be honest about substance use, then get them sanctioned for their substance use
–> In your quiet moments you can take your own inventory and add to the list

Even if the “milk of human kindness” is not at this moment flowing through your veins, it still makes good sense to reach out to an angry, wronged person (real or perceived)- from a risk management, malpractice prevention, and personal safety point of view. Not to mention it might just be one of the most healing actions you can do for the client (and yourself). Start with an apology for stepping on their toes. I know it’s easier said than done. Feel free not to do it. Maybe I’ll see you in court or the hospital.

STUMP THE SHRINK

Question #1

Hello Dr. Mee-Lee:

I am the clinical supervisor for a small residential substance abuse treatment program in Michigan. I would like to know if you could give me some direction in regards to documentation of group and didactic sessions. Please bear with me as I am stuck in the middle between my therapists who feel constantly overburdened with paperwork and the payers who focus on paperwork for the last 15 years. I certainly agree that documentation should be individualized and client-centered. We provide theme-focused group therapy sessions covering a vast array of early recovery issues. Obtaining input from the clients over the past years on what would be some of the more critical issues to be confronted in treatment has driven the specific themes. We have printed these themes and associated information on group notes to save redundancy of writing. This is followed by a therapist summary specific to client participation in the session. I have been directed not to preprint anything on the documentation and each note be individually hand printed or typed. Being a veteran of many program reviews, (they used to be called audits), and accreditations, it would be very nice to get some direction so my therapists don’t lynch me, or worse yet, leave to go to another agency and keep the payers happy so we can keep fighting the good fight. I realize you are very busy but any guidance would be greatly appreciated.
Thank you very much,

Larry D. McCarrick,
Clinical Supervisor,
Eastwood Clinics, Residential Site,
Royal Oak, Michigan.

Response to Question #1

Larry:

I know it is tough to find the right balance between documentation of the groups people attend and individualizing the notes, without doing a lot of writing. The treatment plan should be individualized, and indicate how each client will use the group and didactic sessions. The treatment plan strategies will depend on the client’s stage of change, goals for treatment, and what they can get out of the group session.

The Progress Note should not just list the “theme and associated information” covered, and then the counselor adds a few lines about whether the client was attentive or not, contributed or not, was present or not.

If your agency feels a need to document a list of “theme-focused group therapy sessions covering a vast array of early recovery issues,” that specific information need not all go into the Progress Note. What should be written about is whether or not the client worked on, benefited from, improved skills from engaging in the strategies they have agreed to do in their treatment plan.

Here are the kinds of strategies that clients might use in group:

1. In group this week, I will role play an angry situation and get feedback on my level of skill and effectiveness of anger management methods.
2. I will write down all the times I was arrested; and identify which times I had used or possessed alcohol or other drugs within the previous 24-hour period. I will share my list in group therapy.
3. I will attend an AA meeting or group session, and note down two thoughts or feelings expressed by another member that I identify with. I will share these in group and discuss.
4. In group this week, two fellow clients will role-play with me, offering drugs and persuading me to party with them. I will receive feedback from others on how I handled the peer pressure.
5. I will review the progression of addiction and associated losses chart. I will circle any descriptions with which I can identify, and will discuss in group.
6. I am to identify what happens if I don’t comply with probation requirements, and report this back to group.
7. I will verbalize in group what things need to change in my life or not.
8. I will share in group what has been working to prevent relapse.

There’s more on this in TNT February and March 2006 issues. Hope this helps.
Click to read February and March 2006 issues.

Question #2

Dear David,

I am a long time member of Al-Anon. I am also a psychiatrist working with challenging cases on an Assertive Community Treatment (ACT) Team. For the most part I truly love what I do. But some of my cases are dually diagnosed and I struggle with the question of just what is my responsibility and what isn’t when it comes to addressing their addiction issues as a professional.

For example, in Al-Anon I learned the three C’s as they pertained to the addicts/alcoholics in my life: I didn’t Cause it; I can’t Control it, and I can’t Cure it. I learned Detachment with (or without) love. I came to accept that no matter what creative approach I tried (and there were many) I could not get my loved ones to stop drinking/using, but I could regain some of my serenity by prayerfully surrendering their care to my Higher Power, and by minding my own business.

As a physician I am conflicted by what I perceive as professional pressures to “do something” with the patients with substance issues, as I once felt pressured to do something with my loved ones to “save” them. I am feeling like I am responsible for coming up with new strategies and pill combinations and the latest therapeutic techniques to introduce to my patients who use, whether they want to quit or not. And I fear if any harm should come to them (because of their own behaviors) if I have done little or nothing to intervene, I will be sued for abandonment or neglect. I get to be just as torn up on the action versus inaction issue with my patients as with my family.

What am I missing here?
Thanks,
Bonnie

Response to Question #2

Hi Bonnie:

I understand your dilemma. As a physician, we are interested in treating all conditions that compromise a patient’s well-being. So for co-occurring mental and substance use disorders, I believe we should engage the patient in a self-change process for all disorders, including their substance problems. As is usual, many patients don’t see how their substance use is causing problems. That’s when we use motivational enhancement strategies, which may be necessary even for the mental health problem too.

Detachment is important for all problems. We should never over-ride a person’s will unless they are in imminent danger of harm to self or others; and then only for the time of de-stabilization.

The Serenity Prayer can guide us for all conditions:
–> Assertively and courageously change what we do have control over (i.e. assessment, diagnosis, motivational enhancement and use of systems leverage, case management etc.)
–> Detachment to accept what we cannot change (i.e. we can’t make a person accept their mental health or substance problems and make them stop)
–> It takes the team’s wisdom to be clear on what we can and can’t change.

Mental health people who have not had addiction treatment experience can sometimes overlook or minimize the substance problem; or they fail to use motivational strategies to engage and attract a person into recovery. But I believe we do need to work as actively on the addiction issue as we do with the mental health problem. I hope this addresses your thoughts, but let me know if not.

Follow-Up Response

Thank you, David. I will learn more about the stages of change and motivational interviewing/enhancement strategies as the concepts are new to me but profoundly bell- ringing. I suspect I will struggle with “knowing the difference” in both personal and professional instances. And I hope to get clearer about the timing of offering each tool I have, including meds, to the person with a substance problem as I seem to be cookie- cutter concrete and in need of guidance on many of these challenging issues.

Bonnie

SOUL

I do training and consulting full-time. Nobody wants a workshop or client or systems consultation during Thanksgiving week or over the holidays. So it is nice to use that time to catch up on sorting those piles of unread journals or filing accumulated mail and papers. This year, I took that to a whole new level. My office has been a nightmare for months, if not years. Our garage has been chocked full of file boxes of articles, old committee Minutes, past projects and memorabilia.

All this “stuff” just must be kept for that possible time when I might want to look at them. None of the boxes has been opened in years and we have carted them between Massachusetts, Hawaii and California.

So Thanksgiving week was the week. This was the cleansing. Slash and burn; sort and dump; discard and recycle. I don’t have a hoarding addiction, but some might accuse me of that. I know I don’t have that problem after that week, because our city recycle center had a dumpster full of paper I threw out.

With the end of the year coming quickly, it is a good time to be thankful for what we have, but to simplify and focus on what we really need. The office and garage cleansing has been concretely necessary to unclutter our space. But it has also been symbolic of creating “psychic” space to allow new and creative ideas and directions to germinate and blossom.

With the heavy consumerism pressure of the holiday season, it might seem this is not the time to downsize and buy less. But then again, this might just be the right time to be mindful as you hit the shopping malls– –mindful of the impulse to buy more, clutter up more, hoard more. I hope I can keep visioning that open space to make sure I don’t need another massive cleansing next year.

Until Next Time

Have a safe and happy, healthy holiday season. See you next year.

David