I always appreciate comments from readers who may agree or disagree with what I’ve written. With a more controversial proposal like “The Farm” in the January edition, I hoped we could stimulate some brainstorming about a topic not discussed enough in my opinion. The comments were too thoughtful and substantive to keep to myself in my Comments folder. If you didn’t see last month’s edition, go to www.changecompanies.net and click on Tips and Topics to see the January 2012 edition.

So here are edited excerpts from readers’ comments plus my commentary on their feedback and ideas.

Comment #1

“I like the vignette of the client with a severe co-occurring disorder in early readiness served by an Assertive Community Treatment (ACT) team. Some feedback I would add to the SAVVY recommendations:

1) Sometimes we have to get our ‘skin out of the game’ – as behavioral health practitioners, we tend toward the bleeding heart variety. We ache for our clients, who are clearly being self-destructive. It is important in these situations that we don’t create iatrogenic effects based upon that worry. It is difficult when you wake up in the middle of the night concerned about whether a particularly difficult client might die, freeze, overdose, be stabbed, contract or pass on HIV or Hepatitis C, get hit by a car, tonight.

It is important that we do not base our clinical decisions on that or any fear though, because if we act on it we also give our clients something to push against, thus creating discord.

2) We also have to make sure our agency policies and practices are not creating discord – No one wants to go to the mortality and morbidity conference. Sometimes, the results of that are a jump to ratcheting down controls on a client who is not moving toward recovery, or worse yet, actively snubbing their nose at our attempts to be helpful. This path, of representative payee, guardianship, structured residential or foster care settings, and outpatient commitment is well-intentioned, and sometimes works, but sometimes backfires.

Some clients, even though they are very ill, will resist harder the more pressure is applied to them (none of us professionals would ever do that). Plus, our taking control over aspects of our clients lives for their safety does nothing for our relationship with them. They resent us, and are less likely to engage. So think carefully about arbitrary “send them for a guardian” decisions that your agency might have.

3) Sometimes less is more. I have worked in and with ACT/Integrated Dual Disorders Treatment (IDDT) teams. When people are having lots of symptoms and using lots of resources, we first think of upping the intensity. The problem with ACT/IDDT is there aren’t many ways to up the intensity; you already have a full team of professionals, plus all of the community resources for higher levels of care, pouring it over people.

It is hard to think about, but consider a “holiday” from ACT/IDDT as a trial in some of these cases. Just set them up with housing first. Just have a peer outreach worker check on them twice a week. You can sometimes replicate “the farm” by lowering the intensity instead of raising it. Be clear with your client about why you are doing this. You are very concerned about them, but more services, more resources, more intensity seems to be back-firing. So, ask them to engage with you in the experiment of trying less.

I have seen people be willing to engage more after realizing that some of the services were actually what they wanted, and I have seen others respond at least no worse to much less service. I also had one client die of an overdose, and I still think about that and wonder if it would have happened either way. My gut tells me no amount of intervention could have prevented it. Sometimes, people die of the chronic illness of substance use disorders, just as sometimes they do of heart disease.”

My Commentary

Hi Jennifer:

Thanks for your experienced thoughts and perspectives. Point #3 is an interesting way to reach the same goals of doing something different from the intensive ACT teams. What it wouldn’t do is give the consumer a chance to respond to the power of a therapeutic community on The Farm where there would be expectation for some level of work and responsibility. Do you think the idea of The Farm would ever fly?

David

“I think The Farm is a tough program for lots of audiences. People who are committed to treatment don’t like it because it’s not really treatment. People who are more interested in punishment don’t want to spend the money on it, so you really have to establish that these farms are truly self-sustaining. And even then, people who don’t want those with serious illnesses in their neighborhood might be opposed.

I do like the framing of it as a behavioral medicine hospice…I find that challenging ethically but important for us to consider. ”

Jennifer Harrison, MSW (and awesome secondary author).

(See Tips and Topics: Opening the Toolbox for Transforming Services and Systems by David Mee-Lee, M.D. with Jennifer E. Harrison, M.S.W. – A collection of insightful clinical, systems and personal growth information can be found in Tips and Topics.
https://www.changecompanies.net/products.php and type in “Tips and Topics” in the “What can we help you find?” search window.)

Comment #2

” History and the recycling of ideas either good or bad notwithstanding, would the “Farm Model” be considered valid if it were called the “campus model”, “ranch model”, or “plantation model”? Whatever it is called the model is based upon coercively (either mildly or via legal force) putting someone at an isolated facility location because of their behavior or “care” needs, i.e. they are expensive or difficult to serve with the available resources.

The Farm Model misses the point of Housing First, in that if individuals are provided with housing that is their choice it forms a basis for stability and supports the recovery process. Housing is part of the base of Maslow’s pyramid, where the choice of how to meet basic needs builds the foundation of the self-actualization process. Telling people where to live is no more effective in engaging them than is telling them what to eat or drink is. Now, if the individual wants to live on a farm as one of their preferred* choices of housing, this provides a great opportunity to meet their housing need and a chance to engage with them while doing so.

* Side note on housing preference. People frequently have more than one preferred type of housing that they will live in. Helping them identify what these preferences are and how to meet it from the available options is a basic element of providing housing choice.”

Gary, expert on housing and homelessness for persons with mental illness, Minnesota.

My Commentary

I support Housing First projects and mentioned that in the January edition. It can decrease health, social, emergency and legal costs of homeless people in need of services. Debates about initiatives like Housing First and the suggestions of Jennifer Harrison (above) to sometimes do less, not more, as an engagement strategy, are in the same vein as debates about Harm Reduction or Minimization versus Abstinence-mandated, recovery-oriented services.

The use of representative payees, guardianships and The Farm as a part of the continuum of care are proposed as “raising the bottom” incentives for wellness rather than waiting for people to “hit bottom” when it might be too late to salvage their health or even prevent death. Addiction treatment has moved from waiting for people to “hit bottom”. With Intervention methods, we have learned how to “raise the bottom”. Such strategies can be framed as “coercive” or reframed as matching the level of independence and autonomy to the level of ability and function of people who are dependent on public funds for their survival and well being. We always want people to be free to be who they want to be and do what they want. When people either can’t or won’t embrace recovery and wellness and are reliant on public funds to support them, what level of responsibility and accountability do we, as helpers, have to match the resources to their level of function?

The pain of many families who have loved ones with severe mental illness and co-occurring disorders is to see how reluctant helping professionals are, it seems to them, to intervene and do anything for their homeless, intoxicated, psychotic son or daughter. As helpers, how do we respond to such families’ concerns; and how do we balance consumers’ rights with how active we intervene or not?

Comment #3

“The Farm – Soteria – is this the catchall for those unable to maintain a stable life in the community? Does the Olmstead Act address this solution if you are aware?”

Cheryl – Consumer, Delaware.

My Commentary

“In Olmstead v. L.C., 527 U.S. 581, 119 S.Ct. 2176 (1999) (“the Olmstead decision”), the Supreme Court construed Title II of the Americans with Disabilities Act (ADA) to require states to place qualified individuals with mental disabilities in community settings, rather than in institutions, whenever treatment professionals determine that such placement is appropriate, the affected persons do not oppose such placement, and the state can reasonably accommodate the placement, taking into account the resources available to the state and the needs of others with disabilities…. the ADA require public entities to administer their services, programs, and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities.”

(http://www.worksupport.com/resources/printView.cfm/376)

“Soteria” was new to me. Google it to read more.

Thanks for your comments, Cheryl. Yes we would need to consider the Olmstead Act. But my reading of it would not preclude The Farm. But this would be one of the issues to discuss with all stakeholders.

I certainly wouldn’t want to create a farm as a prison or disempowering institution. This would be a safe compassionate place only for the sickest of the sick who can’t take care of themselves; or who keep demonstrating that they can’t make it in the community safely. If a person didn’t want to be there and was able and willing to improve their function and outcomes, we would never want them to go to The Farm. We are trying to think of alternatives for people who can’t or won’t improve their outcomes despite much expense and help in the community. For that small population, what can we do besides keep taking them to detox and emergency services and multiple admissions to acute psychiatric settings?

David

Comment #4

“David, I ran an NIMH Dual Diagnosis Demonstration project in the late 1980s; and for six years was Oregon’s state mental health and addictions commissioner. You’re right about this being a real dilemma for clinicians and programs. There are two things that stand out in my mind:

1) We have to think about working with people using a ‘stages of treatment’ approach–I conceptualized 5 stages, each with their own unique set of interventions: Engagement, Crisis Intervention, Stabilization, Active Treatment, and Recovery. People don’t progress, necessarily, in rapid or uninterrupted courses, but this helps frame what you do, when, and how.

2) Dual Diagnosis Anonymous (DDA) is something I helped support in Oregon starting about ten years ago. Corbett Monica is the founder and executive director. He, Bob Drake and I published an article describing how DDA works about a year and half ago in Psychiatric Services. We’re continuing to work with Dartmouth on two follow-up articles – next one on what it’s like from a participant’s perspective and the third on some outcomes research.

I read up a little on the idea of The Farm approach. Going back to the early 1970s, I actually worked for a couple of years on one of these–Meadowlark Homestead in central Kansas…modeled after the healing farm communities in New England.I think these kinds of programs are very good, with a few caveats:

• They are very expensive 
• They are relatively small in capacity compared to the massive need 
• They don’t necessarily prepare people very well for a return to more urban, non- healing communities 

I’m not negative about the concept of healing farms but just believe the majority of people with co-occurring disorders are never going to have access to them. We have to keep plugging away.”

Bob Nikkel, MSW, Orgeon

bobnikkel@gmail.com

My Commentary

Bob:

Thanks for the resource suggestions. I guess I envision a modification of the therapeutic farms you describe, especially with your three caveats, which would be in the opposite direction of what I had in mind, which may be idealistic and impractical. But would like to keep throwing the idea around.

David

Comment #5 and My Commentary (in italics)

Here are Kevin’s comments and my commentary interspersed:

“David, what would be the response to a person who was on the farm and then said I don’t want to be on the farm anymore?”

Whenever a person has such a clear goal i.e. ‘Get off the farm and back to the general community’, it makes it easier to develop the therapeutic alliance. Now the client and clinician can work on the thoughts, feelings and actions that will prepare the person to get back to full function in the general community. Gradual community reintegration transitions would be implemented at a pace that fits the client’s proven level of function on the Farm and also on passes into the general community. This is being done with patients who have been in State hospitals for years too.

“Overall I endorse your idea David. If an individual has something to work towards then
they will be more likely to step up to the plate and participate in their own development and rehabilitation. There will always be some individuals who will say why should I? –it is working for me just fine thank you!”

Yes, we are powerless over making people change. We just need to be intentional in what we do to make sure we aren’t harming them. There can be unintended negative consequences of doing too much for people so that we don’t help them to help themselves.

“In the farm system – (it sounds like baseball terminology) – an individual can have the services and support they need at the farm that will meet all their basic needs without society needing to support an irresponsible and non-participatory lifestyle at an exorbitant cost. This incentivizes the process of change through which individuals can improve their health and wellness, live a self-directed life, and strive to reach their full potential (if they want to). It gives them a real option that they can control. If not they still can be treated respectfully and humanely in an environment that will meet them where they are in terms of willingness, ability, and functioning. They can then learn the self-respect that comes from contributing to the welfare of their fellow travellers and peers in an alcohol and drug free environment.

I realize that this raises huge issues of civil liberties, etc. However, if we open the conversation up and brainstorm, we might be able to reconcile what seems like impenetrable barriers to making this a reality.”

Yes, I think you summarize well what I am envisioning. And yes, we need to get all opposing views and stakeholders at the table. I hope that we can come to some solutions that are politically, clinically, fiscally and socially effective.

Comment #6

“Hi David, The Farm is a great idea. After my mom died and my dad was deep into his alcoholism I was well on my way to being a juvenile delinquent at 10 years old. My dad in a moment of clarity sent me to live with my aunt and uncle on the “farm”. They only had two rules…stay away from your bad friends and everyone pulls their own weight on the farm. I hated it…couldn’t smoke…couldn’t drink…couldn’t sneak out at night and wreak mayhem on the village.

What occurred of course was a transformation. I became physically fit, started getting good grades in school (for the first time), learned personal responsibility and became a good role model to others. Of course I went on to become a highly functional alcoholic in my own right, but the foundation that was built on the farm was still there when it was my turn to sober up.

I had completely forgotten that for a long time I believed everyone should work on a farm in their life for its wholesomeness and strong work ethic. Thanks for reminding me about the power of the FARM!”

Scott C., avid Tips and Topics reader!

My Commentary

Thanks, Scott for highlighting what could be empowering about The Farm. Rightly done, this small piece of the continuum of service options, for the right population of the people we serve, could just be what gives people a chance for wellness and recovery.

Out of the comments there are some clinical lessons:

TIP 1
If you are working harder than the client, sometimes doing Less is More.

Jennifer’s comments remind us that when we are invested in recovery more than the client and push our agenda more than theirs, we create “push back” and resistant behavior. Motivational Interviewing’s ‘Rolling with Resistance’ can engage consumers better by doing less, rather than more.

TIP 2

The path to recovery might begin with meeting basic needs first.

Gary’s comments remind us that it’s hard to focus on wellness and recovery if you have nothing to eat and nowhere to live. Learning about impulse control, medication adherence, relapse triggers and sobriety pale in comparison to being hungry, cold and destitute. Initiatives like Housing First and other harm-minimization strategies can engage and attract people into recovery starting with basic needs. It’s all about promoting and celebrating progress, not perfection.

TIP 3

Empower people to develop the outlook and skills to achieve the reality of recovery.

Cheryl and Scott’s comments remind us that there are balancing and competing goals in The Farm idea. On the one hand, it can damage and disempower people when we restrict their choices on where they live and how they manage their lives. On the other hand, people can grow and learn from limits set. The supports we give to a person should match their ability to self-manage. When consumers experience the results of their efforts in a compassionate, safe and supportive environment, they are empowered. Accountability brings freedom of choice. Improved self-management makes recovery possible.

TIP 4

Bring all stakeholders to the table to fashion and tweak new approaches.

Bob and Kevin’s comments remind us that there are often competing interests and priorities of all stakeholders in the treatment of severe mental illness and co-occurring conditions. With the input of family members, clinicians, peer specialists, consumer advocates, justice personnel and politicians, we can harness the rich variety of experience and resources these all bring. We need everyone’s input to fashion a system of care that balances all stakeholders’ goals, not least of whose goals are those of the client, the consumer, the patient.

Anyone who has e-mail knows how often you are the victim of people lurking in the cybershadows – “Gone fishing”. Or rather “Gone phishing”. (Phishing is a way of attempting to acquire information such as usernames, passwords, and credit card details by masquerading as a trustworthy entity in an electronic communication – Wikipedia).

Take a look at this lame attempt from so-called “Wells Fargo” Bank:

“Dear Valued Customer,
Starting from February 30th, 2012 Wellsfargo plans on introducing new authentication procedures in order to better protect private information of our account holders.
Login Here”

First of all, I am writing this Tips and Topics on February 29, February’s extra leap year day. But imagine February 30 – a leap leap extra day! Some criminals are so dumb. Then right after the date, February 30th, 2012, they spell Wells Fargo “Wellsfargo”. Dumb twice, all in the same sentence. If you are going to be a con artist, try not to advertise in your con-pitch that you are a dumb criminal.

But it is not just criminals and scammers who do dumb things.

My daughter foolishly left her cute Mac Air laptop computer, iPhone, purse and credit cards on the backseat of the car in downtown San Francisco for all to see, while she went to a company Christmas party. Of course the car was broken into. All was stolen. Her company had slyly installed in her laptop tracking software that photographs anyone using the computer, their address and what websites they are surfing. (Perhaps it isn’t just to track robbers who steal the computer!)

Regardless, in this case, the high-tech “detective” installed on the now stolen laptop sent back full-face photos of the robbers; their address; and the website surfing they did- presumably to research what they could get for the Mac Air laptop on the Craigslist. Armed with this evidence, you would think the San Francisco Police Department would be happy to expedite this open and shut case. Wrong!

Reports of such non-violent crimes fall to the bottom of the priority barrel. Now weeks later, nothing has been done, nor will anything be done. I know there are more important fish to fry, but I think it is just dumb and certainly sends the wrong message to citizens and criminals alike.

It’s always easier to see the dumb things other people do. One day, right here in Tips and Topics, I’ll write a piece on Dumb Things Clinicians Do. Until then, Gone fishing.

I will be leading a one-hour free online NAADAC webinar -details below. It is designed to explain the underlying principles of the ASAM Criteria plus help utilize the ASAM Criteria in assessment, tailored treatment planning and broadening services to provide a more flexible continuum of care.

“Understanding and Utilizing the ASAM Placement Criteria”
March 14, 2012 at 3pm – 4pm EST (12pm – 1pm PST)

Clinicians involved in assessment, referral, planning and managing care often lack a common language and systematic assessment and treatment approach. The Patient Placement Criteria of the American Society of Addiction Medicine (ASAM) first published in 1991, provided common language to help the field develop a broader continuum of care. The second edition (PPC-2) was published in 1996 and a revised second edition (ASAM PPC-2R) was published April 2001.

For more information:
http://www.naadac.org/component/content/article/45-knowledge-center/582-naadac-institute-webinar-series

Glad you could join us. See you again late in March.

David