The Substance Abuse and Mental Health Services Administration (SAMHSA) just announced a new working definition of recovery from mental disorders and substance use disorders on December 22, 2011. SAMHSA dialogued with consumers, persons in recovery, family members, advocates, policy-makers, administrators, providers, and others to develop the definition and guiding principles for recovery. They recognized that “there are many different pathways to recovery and each individual determines his or her own way.”

The new working definition of recovery from mental and substance use disorders is as follows: 

A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.

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Note the specific aspects of SAMHSA’s Recovery definition and the four major dimensions that support a life in recovery.

Over the past decade in the behavioral health field there has been a lot of talk about “recovery”. Addiction treatment has been focused on recovery even longer than that, mental health more recently. SAMSHA has long promoted integrated co-occurring disorders services. With this new definition, they continue that initiative.

On several occasions I have presented a keynote on “Recovery in Co-Occurring Disorders: What Do You Really Mean and Walking the Talk about Recovery”. The new SAMSHA definition clarifies “recovery”. What seems more difficult to actualize is “walking the talk about recovery”. So I was interested to read the quote from SAMHSA Administrator, Pamela S. Hyde:

“Over the years it has become increasingly apparent that a practical, comprehensive working definition of recovery would enable policy makers, providers, and others to better design, deliver, and measure integrated and holistic services to those in need.”
“better design, deliver, and measure….” Now we are getting closer to actually knowing how to walk the talk about recovery.

Through the Recovery Support Strategic Initiative, SAMHSA has delineated four major dimensions that support a life in recovery:

Health: overcoming or managing one’s disease(s) as well as living in a physically and emotionally healthy way;

Home: a stable and safe place to live;

Purpose: meaningful daily activities, such as a job, school, volunteerism, family care-taking, or creative endeavors, and the independence, income and resources to participate in society; and

Community: relationships and social networks that provide support, friendship, love, and hope.

So to quit talking about recovery and actually get busy operationalizing and promoting recovery, here are some specific steps this recovery definition and dimensions highlight:

1. Clinicians and providers need to be focused on facilitating a process of change.

2. The goal of treatment and recovery services is to improve health and wellness, not just stabilize signs and symptoms. Thus the focus is not just on pathology and sickness, but also on strengths, skills and resources for wellness.
3. Patients, clients, consumers, and participants are actively involved to live a self-directed life, not a passive recipient of a treatment plan with which they must comply.
4. The ultimate outcome of our partnership with participants is to have them reach their full potential involved in meaningful daily activities that provide a sense of purpose in the safety of their home and community of friends and loved ones.

References:

For further detailed information about the new working recovery definition or the guiding principles of recovery please visit: http://www.samhsa.gov/newsroom/advisories/1112223420.aspx

Talk is cheap. Action and successful outcomes is a more challenging proposition. Let’s now focus on making recovery a reality in the design, delivery and results of services.

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How “to better design, deliver, and measure integrated and holistic services to those in need.”

1. Clinicians and providers need to be focused on facilitating a process of change.

Clinical Implications:
How well do you assess a person’s stage of change for each issue of importance? No client is at the same stage of readiness for all the addictive substances and for all the varieties of mental health issues. So if a colleague asks you “What stage of change is your client?”, the correct answer is: “For which issue do you mean?”. What is the client at Action for- not what you think the client should be at Action for? What does the client want?

Change, treatment and recovery are a process, not an event. Yet many programs still design and deliver services as if change just happens in “primary treatment” (often in an intensive level of care like residential). Then the client completes treatment and graduates to move onto “aftercare”. Even though the ASAM Patient Placement Criteria have been published for over 20 years, providers and payers still struggle to design and deliver a broad, flexible, seamless continuum of care which best fits the process of change.
The Change Companies has hundreds of participant journals that help initiate a process of facilitated self-change. See more specifics below and in SHARING SOLUTIONS.

2. The goal of treatment and recovery services is to improve health and wellness, not just stabilize signs and symptoms. Thus the focus is not just on pathology and sickness, but also on strengths, skills and resources for wellness.

Clinical Implications:
Take a fresh look at your intake and comprehensive assessment instruments and forms. Examine the balance between a focus on pathology and problems versus strengths, skills and resources. More recent assessment forms have a place to document a participant’s recovery goals or strengths. But all client records I’ve viewed relegate a few lines, almost as an afterthought.
The American Society of Addiction Medicine’s (ASAM) Patient Placement Criteria describes six assessment dimensions that are holistic, biopsychosocial and multidimensional. They provide the structure to assess what is working, or not working, pertinent to achieving total health and wellness. Assessing needs, along with skills, strengths and resources, helps create a comprehensive recovery plan.

Identify skills, strengths and resources by asking clients: “Tell me about the times in your life when you have had the health and wellness you want.” or “Tell me if and when there was a time, however brief, when you did not have the problems and symptoms you are now presenting with.” “What was working in your life then which helped you not be depressed or using substances or be anxious or have relationship difficulties?” “What skills and strengths worked for you? Who were your supports and resources?”

Here is a chart from The Change Companies that demonstrates the flow from assessment through service planning to achieve outcomes of health and wellness.

3. Patients, clients, consumers, and participants are actively involved to live a self-directed life, not a passive recipient of a treatment plan with which they must comply.

Clinical Implications:
The Transtheoretical Model (TTM) illuminates the process of natural recovery and the process of change involved in treatment-assisted change. But “treatment is an adjunct to self-change rather than the other way around.” “The perspective that takes natural change seriously…shifts the focus from an overemphasis on interventions and treatments and gives increased emphasis to the individual substance abuser, his and her developmental status, his and her values and experiences, the nature of the substance abuse and its connection with associated problems, and his or her stage of change.” (DiClemente CC -2006)
Choose twenty of your clients at random and ask them: “Tell me about your treatment plan”. Measure what percentage look at you blankly and even say “What treatment plan?”. What percentage responds with a meaningful explanation of their goals and methods? If they can’t, then you know their focus is more on compliance than an active, collaboration to change their life.

If you run groups try starting off with: “Before we start group, let’s go around and each of you say what you want to get out of group to advance your treatment plan.” If you again get blank stares; or a client says “I just have to be here” then again their focus is on compliance, not recovery and a self-directed life. Measure how many of your group clients can be specific like: “I want to role play with someone an angry situation and demonstrate how to manage anger in productive ways so you can help me prove I don’t have an anger problem.”
Do you know about Interactive Journaling® of The Change Companies? Do you want to quit doing all the work and instead, help facilitate a client-directed, self-change process? Interactive Journaling can be used individually or in groups. If you are unfamiliar with Interactive Journaling, take a look: https://www.changecompanies.net/ij.php

4. The ultimate outcome of our partnership with participants is to have them reach their full potential, involved in meaningful daily activities that provide a sense of purpose in the safety of their home and community of friends and loved ones.

Clinical Implications:
If you work with severely mentally ill or addicted people, it is easy to be skeptical and cynical of recovery possibilities. “How can this person ever work or live independently when they can’t even be medication-compliant or stay sober!” So the treatment becomes focused on stabilization and low expectations, rather than hope and inspiration to attract the person into recovery.
“Full potential”, “meaningful daily activities” and “purpose” are very individualized personal interpretations involving a willingness to really listen to the other, free of our agenda for that person. “Home” and “community” are equally person-driven. What if a client really is not interested in Alcoholics Anonymous? Can we help them find a community meaningful to them, no matter how much you believe in AA?
I become concerned with how frequently I witness staff trying to get clients onto disability (especially young people with addiction and mental health difficulties) . Sometimes this is in order to assure funding for services. But what a message to send to a person! A message that you are disabled, with no hope or expectation to work , with no sense of power and purpose that you can self-direct your life to your full potential. Even if someone indeed needs to be on disability, the focus should be on function, not medication compliance. The focus should be on meaningful daily activities, not hanging out watching TV and smoking. The focus should be on purpose and community, not being a patient and chronic. I have seen the power of peer mentors and coaches; of peer-led resource and drop-in centers; of creating a community of mission-driven purposeful people.

References and Resources:

1. DiClemente CC (2006): “Natural Change and the Troublesome Use of Substances – A Life-Course Perspective” in “Rethinking Substance Abuse: What the Science Shows, and What We Should Do about It” Ed. William R Miller and Kathleen M. Carroll. Guildford Press, New York, NY. pp 91; 95.

2. The Change Companies Interactive Journals – MEE (Motivational, Educational and Experiential) Journal System provides Interactive journaling for clients. It provides the structure of multiple, pertinent topics from which to choose; but allows for flexible personalized choices to help this particular client at this particular stage of his or her stage of readiness and interest in change.
To order: The Change Companies at 888-889-8866. www.changecompanies.net.

There’s nothing like a sudden family death to jolt you into examining your priorities and squeezing your loved ones more deeply and often.

The day after Christmas, our beloved sister-in-law tragically, unexpectedly succumbed to a massive cardiovascular event while doing what she loved – snorkeling in Hawaii. I know you probably don’t know her and thus, in a sense don’t much care. But I am writing this as much for me as for you…..in fact more for me than you.

It is just so recent that I struggle to get my head and feelings around how one moment we are laughing and conversing on Skype Christmas night, and the next day she is gone. My cousins who enjoyed a lunch prepared by Valerie drove away not imagining that three hours later they would never again enjoy her cooking and company. I know now how it must be for the thousands of families who lose loved ones every day in fatal car accidents.

Too many people around the holidays feel depressed, lonely, disheartened. Their reality doesn’t match the TV images of loving families gathered around the tree excitedly exchanging gifts, or enjoying a meal together. Or the contentious, prickly live interactions they are having with family they see only at the holidays reminds them why they only see them at the holidays once a year!

You don’t have to have actually lost a loved one to death to feel the impact of loss of family and community. As they say, you can be in the most crowded, bustling city with people all around and yet have it be the loneliest place in the world.

So in this holiday season with the anticipation of a brand New Year, our family is struggling with loss. Maybe yours is too….whoever you consider to be “family”.

In Hawaii there is a bumper sticker: “Have you hugged your keiki today?” (Keiki, pronounced “kay-key” is the Hawaiian word for “baby” or “child”, literally meaning “the little one” – Wikipedia).

Have you hugged your keiki or loved ones today?

I’ve been training and consulting on the ASAM Criteria for 20 years. It has been rewarding to help clinicians and systems re-think how to design and deliver services that are cost-conscious yet high quality and effective. However many still struggle with how to actually implement the spirit and content of the ASAM Criteria. Until now, I haven’t had enough accessible and affordable resources to help.

So it is exciting to let you know some SOLUTIONS coming in January to help implement the ASAM Criteria:

Around mid-January you will be able to access a brand new e-Learning Training module on “ASAM Multidimensional Assessment”. It is an interactive online training so participants will understand, assess and implement the six dimensions of the ASAM Criteria. Each section has information interspersed with video clips where I explain various aspects of the assessment dimensions. There are knowledge checks and case application exercises to reinforce the information.
Five hours of NAADAC, CAADAC & NBCC Continuing Education (CE) have already been approved. Physician, psychologist, employee assistance professional, social work and nursing CE is pending.

Also in January, you will be able to have your clients work though a brand new Interactive Journal – “Understanding the Dimensions of Change”. Clients and patients will be able to assist your multidimensional assessment as they work through exploring their needs and strengths and skills in each of the six ASAM Criteria dimensions.
Some of you already use journals from The Change Companies. The chart below lists 22 available journals on the left. It lists the 6 ASAM Criteria Dimensions across the top. It cross references which Interactive Journals match best with a particular ASAM Dimension. Some journals focus primarily on one or two dimensions- see dark blue boxes. Secondarily, a journal may also focus on any or all six of the ASAM dimensions- see the yellow boxes.For example…the first journal listed, “Getting Started”, primarily supports Dimension 4, Readiness to Change. And secondarily covers Dimensions 3, 5, and 6.

The final SOLUTION to share for now is a new website, www.asamcriteria.com. It will eventually have all things ASAM Criteria at your fingertips. It is not up and running yet, but soon will be. There will be an ever-increasing array of resources to help you understand and use the ASAM Criteria. We will start small with resources you can buy or get for free. Stay tuned for its launch and let us know what you might want to see on that website to help you implement the ASAM Criteria.

Happy New Year! See you again in late January.

David