TIPS & TOPICS
Volume 3, No.9
February 2006
In this issue
– SAVVY, SKILLS and STUMP THE SHRINK all in one
– SOUL
– SHAMELESS SELLING
– Until Next Time
Thanks for joining us for the February edition of TIPS and TOPICS. This month’s edition has a few twists and turns. Firstly, it is arriving well and truly before the end of the month rather than my usual last minute deal. The reason is I am training in the UK and Germany in February-March, and aiming to complete my “to do” list before I depart.
Secondly, I am beginning this month with a reader’s reactions and responses prompted by the January edition. I felt “Another Frustrated Substance Dependency Counselor” really articulated well the sentiments and frustrations I hear often around the country as I travel and train.
So this edition is a mix of SAVVY, SKILLS and STUMP THE SHRINK all in one. “Not sure I’ll have any magic answers— I wrote her, “—but these feelings and issues need to be articulated and raised, so thanks for facilitating that.” She responded: “Dr. Mee-Lee, I’m not expecting any fixes. As I said, I think it’s important to just trust the process. Peace.”
I would like that: Trust and Peace. See what you think and feel about all this.
Dr. Mee-Lee,
I just can’t pass up the opportunity to comment on the irony of reading your assertions about the importance of client-counselor alliance and your commentary about the frenetic pace of life. Why do I say irony? Primarily because the agency that recommended we read your newsletter is the same agency that, for our area, holds the purse strings to provide care to people struggling with substance dependency. That agency seems, to many counselors and clients, to be the mother source for a load of paperwork requirements and hoops that make it ever more difficult to build relationships with the people we serve.
I try to put myself in the shoes of someone seeking help. When making the call to simply schedule an appointment, the client is questioned about income, any involvement with CPS (Child Protective Services), and drug use. Does the client already begin to associate our agency with feelings of shame and, thereby, self-protection? When the client arrives for the first session we hand him/her a pack of paperwork that would send me running – streams of records about records, requirements about requirements, and forms about rights. Signing and signing some more is followed up by a computerized assessment, the idea of which terrifies those with computer phobia. Questions about psych. history, employment, substance use, medical, legal, and family history – and “I’m supposed to answer all these questions honestly to something that isn’t even alive and that’s going to do…what with my information?”
A client might wonder: “Was there anything in that rights brochure regarding the right to have someone take time to really find out what I care about or need or will invest in? What about the right to keep a little information to myself until I feel safe enough to share?” (I think we can all relate to the feeling that comes with having shared more than we wanted to. It’s kind of like being robbed and it isn’t something you really want to experience again next week.)
By the time the client finishes with the hour and a half of paperwork he/she gets a few minutes to see the counselor maybe still thinking there’ll be a chance to share what’s important. But now-reviewing the paperwork, a little more paperwork, a couple more signatures, and then…what do you want to accomplish in counseling? (Counselor thinking: I’ve got to get to this treatment plan.) At this moment, if I’m the client, I’m not thinking I’m going to get much at all out of this process-it’s obviously about them trying to get information and me trying to protect a little of my privacy and dignity.
My point here isn’t only to vent-though that’s part of it I admit. My point is also to connect with you around your feelings about the need for us to slow down. I’m saying, “Yes, I feel that pain.” I make an effort in my everyday life to cultivate space. Our culture continues to undervalue the process in the search for greater efficiency, immediately measurable outcomes, a quick buck that lacks integrity. Day in day out, we begin to lose sight of real relationship, of quality, of the value of investing in people in a way that honors their process and, thereby, fosters lasting change. Counselors and administrators alike fall prey to the same cravings for immediate gratification that so many of our substance- dependent clients struggle to overcome. (You mentioned the term “non-compliant”. Isn’t this how we label the client who isn’t giving us what we want as quickly as we want it?) Of course, counselors feel particular pressure about outcomes because of the managed care system and its expectations for the instant miracle?
So again, what the heck is my message? I’m responding to say, you can chalk up one more person who sees a need for SOUL in what we do, in how we live, in how we work with people who want to know there is hope. Hope? Meaning…maybe that’s a better way to say it. It’s no wonder people are going crazy from meaninglessness. Where’s the meaning in those forms? Where’s the really deep meaning, the SOUL, in that computer assessment? “I came to your office looking for hope and you gave me this? Things look even more hopeless than before.”
To honestly address these issues of meaning and quality and relationship in our work, however, we have to be willing to honestly address the issue within our deepest selves – to take a searching inventory so to speak. If the activities and relationships in our personal lives lack depth, we’ll be more likely to tolerate “surfacy” relationships and activities in our work and, perhaps, even to ask others to sell out.
I can be overly cynical. (You’d never guess I’m quite an optimist.) Truth is, in the midst of all the hoops and paperwork requirements we still manage to convey A LOT of concern to people and to do some really good work. But the system that should serve to keep services running is running the services and seems to eventually suck the soul out of things. It gets more and more difficult to survive without having to sell your SOUL (the soul of the agency, of the staff, and of the clients). We all know the burnout rate of counselors isn’t just due to the fact that chemical dependency is a “highly relapse prone disease”.
My response here is, in some small way, how I am taking responsibility. By attempting to fuel, in a constructive way, I hope for a continuing exploration about the mess we’re in and how we can begin to take our lives and the SOUL of our work back.
Thanks for indulging me.
With best intentions,
Another Frustrated Substance Dependency Counselor
Here are some TIPS and TOPICS prompted by the sentiments expressed above:
TIP 1:
Documentation will not disappear. Healthcare involves many stakeholders from clients and patients to clinicians, case managers, funders, regulators, accreditors and family members. All have an interest in accurate records. You would not want to go to a doctor who kept generic records and could not remember the specific diagnosis and medical care s/he had prescribed for you. You wouldn’t pay for a long and expensive list of automobile repairs without careful documentation that the work was needed and then completed. And the next time you fly on a plane, I bet you and your family would like to know and believe that regulatory agencies are making sure the mechanics thoroughly checked all nuts and bolts, and that the pilots are well-rested and sober.
But it is true that too often well-intended assessment processes and documentation standards have worked against engaging and caring for the people we serve. It is time to make paperwork work for the people we seek to help. It will not change overnight, but with a unified interdisciplinary approach, we can start on making documentation a living, dynamic process.
Here are some beginning suggestions:
–> Eliminate any duplication of information in all the assessment instruments and data gathering tools and forms.
Place all your forms and data collection instruments on the floor. With a highlighting pen, identify all places where you see a duplication of data. The goal is to identify assessment and treatment planning data which can be consolidated or eliminated.
–>Prioritize assessment data. First evaluate high risk areas which need immediate care.
In five minutes or less, you can rule in or rule out any acute intoxication or withdrawal dangers, any pressing physical or mental health needs, any dangerous relapse or continued use emergencies, plus any actively toxic and unsupportive living environment factors. In the first session it is not necessary to know a client’s military history, age of first use, or how old his siblings are. On your data- gathering tool or form, asterisk only the most critical information you should assess in the first session, and do only that. The remaining data can be gathered later on once you have engaged the client in treatment.
–>Use a variety of colored forms to “house” sections of the assessment information.
Often several team members ask the same substance use history and record that on their specific intake or social work or medical assessment form. You could have one green form for example, where any substance use history is documented. If another team member needs to check or update the substance use history, they can go to that particular form, read it and add to it. If new information is gathered a bit later, then buried in a Progress Note or another form, it is too easily missed and becomes non-useful. A colored form concept can mean a client does not have to be asked all the very same questions again by yet another team member.
Any psychosocial data could go on the yellow form, and medical or nursing information on the blue form etc. The rainbow forms can provide efficient data collection in a manner that shields the client from repetitive questioning. Even better would be to have this information follow the client to their next level of care instead of harassing the client with all the same questions from a new set of clinicians. I have even seen new assessments done on the same client in the same agency when they have just been transferred from intensive outpatient to outpatient care.
Paperwork can be designed both to meet documentation requirements, and also be friendly to the peoplework we do.
TIP 2:
The person who should know his/her treatment plan best is the client! He/she only has their one chart to worry about while you may have ten or twenty client records you are documenting in. Find ways to involve the client more in the assessment process, ongoing treatment planning and progress documentation. Here are some ideas:
–> Use the first five to ten minutes to focus on what the client is a “customer” for.
If the client shows up for an appointment, we know they are motivated and want something. They are at action for something that they perceive you have to offer, otherwise they would not be in your office chair. Identify what they want and why now. This sets the stage for assessment and treatment planning with them. Read more on “What, Why, How, Where and When” in the May 2004 issue.
–> Focus the assessment process around that primary concern which prompted the client to show up.
You can still ask all the same assessment questions, but do so in the service of building the alliance around what the client is a “customer” for. For example, “If you want help with depression, do you find yourself trying to cope by drinking or drugging; and what substances do you use?”
If there are a number of questions that don’t easily link to their presenting concern, alert the client to this, then bracket a series of questions by saying: “To make sure I have all the information we need to collect, I’m going to ask you a number of questions that may not seem important to what you want to work on. But hang in with me and we’ll get through them as quickly as possible.”
If your agency uses self-administered assessment software or forms, you might say: “Now that I’m clear on what is most important to you that brought you here today, I’d like you to tell me more about yourself so we can do a comprehensive assessment. We do not want to miss any of your needs or strengths that would be important in helping you to get what you want.”
–> Bring documentation into the treatment groups.
There is no reason all the treatment planning paperwork has to be done by you in the last 30 minutes or hour of your day when you are tired and rushing to get home. That’s the reason you scribble in every client’s chart a Progress Note that sounds like: “Attended group. Gave positive feedback to others. Gaining insight into his disease. Continue current treatment objectives.”
How about—–
You could have a “What Do I Want?” treatment group? Or a “Why Am I Here?” treatment group which is designed to have each participant focus on what is driving their treatment process.
Clients could write their own progress note and share it with group members for constructive feedback. The client ought to know what they want to get out of group to advance their treatment plan. Let the client actually do the documentation: Write out their wants and goals under your guidance; note down whether they followed through, adding notes on whether it worked or not.
For example, they could document: “I forgot to get feedback from two sober AA members as to what’s wrong with hanging out with my old friends. I am willing to do it and will report back next week.” As the clinician, if you find their documentation true and accurate, you could countersign it. Imagine if the same client wrote: “This is the best program I have ever been in and I am sick and tired of being sick and tired and want to surrender and take one day at a time” and then shared that in group. I suspect there would probably be one peer who might challenge such a glowing progress note, especially if the client was overheard in the parking lot discussing how to get some stuff smuggled in. Positive peer feedback.
You can add to this list. Brainstorm with your team on ways to make paperwork a living document.
TIP 3:
All regulations have been person-made and can be person-changed. Many current auditing procedures and quality assurance activities create a compliance- and-fear mentality which saps both clinicians and administrators’ energy.
The time has come for more creative methods focusing on client outcomes, not process compliance. For example it seems reasonable to be assured that clients will give informed consent and understand the medications they are prescribed. It seems reasonable then to have a standard that requires that all patients sign a consent form indicating that the medication and its risks and benefits have been explained. It also seems reasonable to audit charts to see if such a signed consent is present.
So an agency could scurry around ensuring every chart has a signed consent form. They might even receive 100% compliance rates on the next audit. However, consider a different, new and improved audit process. What would it be like if 5 clients were selected at random and asked to explain their medication and side effects? This might reveal a different story. Would they actually be able to say the name of their medication, what it is supposed to do, and describe the risks and benefits? This new audit process would focus on whether clients are informed consumers, not just passive compliers signing a form hurriedly explained to them.
Much more dialogue is needed at a large systems level, beyond the scope of what we can do in this Tips & Topics forum. However we are not victims of some oppressive paperwork machine as though inflicted from outer space. Provider organizations, counselor associations, State Directors, managed care organizations, professional organizations and government entities must find a way to quicken the pace of reform, and reengineer paperwork procedures and process.
Could we dare to dream that there is a way to meet the realities for documentation, quality review and risk management while maintaining the SOUL of our work?
I heard a while ago someone say: “I’ve had a lot of worries in my lifetime—and one or two of them even came true”. A few years ago, I started tracking situations I worried about and then noticed what actually happened. I even wrote some of them down thinking that one day I could do a statistical analysis on what percentage of wasted worry-energy I had expended.
I was reminded of this as I was worrying we had missed out on free tickets to London using some mileage points. By waiting a day to make a decision on an available ticket, we lost the seats. However in talking to another travel agent to check for departures from other cities, we snagged a non-stop from Los Angeles to London. Not only was this a better itinerary, it fit in with visiting the kids in Southern California for July 4—a plan we would not have thought of had we taken the first option.
Then just the other day, when I checked into my hotel, they could not find my reservation. Looking more carefully at my internet reservation confirmation, I noticed I had booked it for the wrong check-in date, and for one night only when I needed two. I started imagining having to find another hotel, and berating myself for such a silly mistake. (It’s not like I book a hotel once a year!) Not to worry. There was indeed a room available for the two nights I needed. And when I noticed the price the front desk agent gave it for, the rate was $10 less per night than the guaranteed lowest price reservation I had booked on the internet.
I’ve had a lot of worries in my lifetime—the return on investment of worry energy is very low. Don’t Worry– – Be Happy!
There are groundless worries and there are real concerns. My son recently introduced me to what might be seen as an insurance policy for when you need a lawyer. I agreed mainly to help him out in his new venture. When would I need a lawyer? But I was surprised that in the first few months, I have actually called them a couple of times to ask about a speeding ticket and a legal question about real estate. The Identity Theft Shield additional service is a worry buster too. They send you your credit rating and monitor any credit activity to alert you if someone has tried to access your credit. That certainly is a worry-buster.
You might find it useful too if you are a worrier like me. Take a look if you want. Contact my son. He’s not hard sell, so don’t worry. To watch two short 3 minute videos introducing the legal plans and identity theft protection, check out the website. If afterwards you would like more information, feel free to email him at taylormeelee@gmail.com
If you want to get something free from Taylor, enjoy some of his songs at http://www.taylormeelee.com
Thanks to all who send along words of appreciation. Send me any Success Stories you want to share with others. See you in March.
David