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January 2009 – Tips & Topics



Volume 6, No.9
January 2009

In this issue
— Simple Website Q & As
— Until Next Time

Welcome to the New Year and a couple of significant events: a new President of the USA with all the accompanying hope and optimism (at least for the over 50% of voters); and equally earth-shattering, the launch of my new website More on that later.


Recently I was asked to present a workshop to help keep the behavioral health team healthy, especially in these tough economic times. I use a very illuminating exercise I heard about 8 years ago at the University of California, San Diego (UCSD) Summer Clinical Institute in Addiction Studies. It uses the familiar image of an iceberg to show that there is a visible culture and a much larger invisible culture hidden below the waterline. Problems you see on the surface are impacted by deeply held attitudes and beliefs- under water, out of view.

If you Google “culture iceberg” you’ll find many ways this metaphor has been used. I heard Dr. Schiff use a version which has become very useful for teams to discover what lies beneath common surface problems like high staff turnover rates, or treatment and service plans that are general and non-individualized.

In SAVVY, let’s look at high staff turnover rates; and in SKILLS, we’ll take a look at general and generic treatment plans.

  • Identify the hidden cultural norms, assumptions and beliefs of your treatment culture by looking below the surface of the Culture Iceberg.

Imagine 10% of the iceberg showing above the surface and the huge 90% below. You see the polices, procedures, symbols and rituals in your treatment culture but not the norms, assumptions and beliefs that profoundly influence and affect what really is happening.

On the surface, you have a policy and procedure to be welcoming to all clients and consumers. On the wall is the framed Mission Statement saying people are the agency’s most valuable resource. Then we have to lay staff off or give them unmanageable case loads. Clients call and get an answering machine with complicated prompts that even a sober, mentally-stable genius would struggle with. Then, if a caller does reach a person, they are placed on a waiting list as if their problems were no more important than a football fan waiting to get a ticket to the Super Bowl.

Take a look at a common organizational problem —> high staff turnover rates.

That is the visible, surface problem. Here’s how you get to the hidden cultural norms and assumptions fueling and perpetuating visible problems. You can get to hidden norms by completing the sentence: “It’s OK to…….”, and you can get to hidden assumptions and beliefs by following that with: “Because…..”

So, for example, beneath high staff turnover rates problem might lie: “It’s OK to have staff leave after a short period, because we pay low salaries and can only attract entry level candidates.” Here are some other possible hidden norms and assumptions and beliefs beneath this surface problem.
Hidden Norms and Assumptions

* It’s OK to not orient new staff well because they will leave soon anyway.

* It’s OK to bad-mouth management and each other, because we don’t have respect for each other.

* It’s OK to be overworked because we can’t turn clients away and they have to be seen.

* It’s OK to be discontent and complain because nobody in management cares anyway.

Feel free to add more if this is an organizational problem where you work. But you can see how getting below the surface can identify what might be fueling the visible issue. Sometimes what is beneath everything cannot be changed immediately and it helps to just know what is going on, so you can decrease expectations for a swift resolution.

For example:
If you cannot turn any client away and the demands for service are immense, staff can anticipate that they will be overworked until a solution can be found to have more manageable caseloads. Similarly, supervisors and clinicians will understand that they are in “crisis mode.” They may not be able to do as thorough clinical and documentation work as they would like. Naturally this will not make life easy. However these realizations can relieve some of the stress that comes from feeling bad about not doing your best work; and to understand that your supervisor is not a heartless slave-driver.

On the other hand, if the hidden norm is identified as a lack of respect for each other and no policy or procedure for conflict resolution exists, then this can be addressed immediately. With the commitment to develop and use a conflict resolution policy and procedure, the team can begin to turn around a culture of disrespect, gossip and back-stabbing.

(See TIPS and TOPICS, February 2007 for a sample Conflict Resolution Policy and Procedure – keep checking back for this to be on the website shortly)

References and Resources:

1. Steven Schiff, Ph.D. “Organizational Culture and Treatment Implications”. Presented at 30th University of California, San Diego (UCSD) Summer Clinical Institute in Addiction Studies, La Jolla, CA. August 1, 2001. The Culture Iceberg is work of Dr. Steven Simon, Culture Change Consultants, Inc. 2005 Palmer Ave., #105 Larchmont, NY 10538

2. NIATx – Network for the Improvement of Addiction Treatment


Concern about general, generic and non-individualized treatment plans is almost a universal issue in accreditation surveys and quality audits as well as in documentation supervision and paperwork reviews. Clinicians also struggle to make treatment and service planning meaningful. This is one issue the whole team can look at; or if you are a private practice clinician, this is also an occupational hazard for you too.

  • General and generic treatment plans may have multiple causes. Expose the invisible culture beneath this problem.

Some of the causes may be: skills-deficits, feeling overwhelmed with caseloads, ignorance, laziness, lack of critical thinking, philosophical rebellion against documentation, fixed, program-driven perspectives or more.

Here are some ideas to get you started. Participants in past workshops have raised these.

Hidden Norms and Assumptions:

* It’s OK to write general treatment plans because we don’t really use them anyway.

* It’s OK to just get the paperwork done because our caseloads are too high.

* It’s OK to write the problems without the client because they aren’t thinking straight anyway.

* It’s OK to give everyone basically the same plan because the program is pre-scheduled with a set curriculum and manual.

* It’s OK to write the plan for the client because the client is in denial, mandated and doesn’t want treatment anyway.

* It’s OK for treatment plans to look much the same for all clients because everyone has the same basic problems.

* It’s OK to have the same plan because the client keeps relapsing and has been here five times with the same problems.

* It’s OK to write general plans because we’ve been doing it this way for years.

* It’s OK to not individualize treatment because that’s the only way I’m willing to get the paperwork done.

* It’s OK to put less effort into treatment planning because treatment plans don’t help clients recover anyway.

Maybe these aren’t your team’s top ten hidden assumptions. See what you come up with. Solutions will follow if the team can get to Preparation and Action.


A few weeks ago, I watched an interview with the National Transportation Safety Board’s spokesperson on NBC’s Today Show (January 16). She was talking about the “Miracle on the Hudson River” where the US Airways flight “landed” safely with all 155 passengers and crew safe, sound and soggy. She said that “usually we are focusing on what went wrong. But in this case, there was so much that went right; and we want to learn from that too.”

That same day on National Public Radio’s Talk of the Nation, Science Friday program, the discussion was about how copper can decrease microbial counts and perhaps help in preventing hospital infections which kill more people than HIV and breast cancer combined!

In one experiment, patients’ beds, surfaces in their rooms, and other equipment are being changed to copper to gauge if this will improve infection rates. Apparently you have a 1 in 20 chance of contracting a hospital infection just by checking yourself in for inpatient treatment; and a 1 in 20 chance of dying.

All this got me thinking about what a risk patients and clients take to get treatment. It shouldn’t be that they get sick and die, even as they come for help. Obviously I want people to keep coming for help. I believe treatment heals many more than it harms.

We work in behavioral health, not physical health. We may not amputate the wrong leg, take out the wrong kidney or leave surgical forceps in a patient’s abdomen. But we all create a treatment culture: it can be a healing one or not. Does it inspire, attract and welcome people? Encourage them to embrace recovery?

Does it “infect” individuals, discourage them, dishearten them?

There is a lot of pressure on us to treat problems and pathology. As when a plane crashes, we do want to identify what went wrong. But, just like Flight No. 1549, we want to focus equal time and energy on learning from what went well in people’s lives. Doing more of what works is as instructive and effective as doing less of what hasn’t worked. And it is a lot more hopeful and attractive to engage people around what works than around what is wrong.


Thanks to everybody for your feedback on the website. More is welcome. Your comments and suggestions are appreciated. I’ve received many common questions which are answered in the next section.

If you haven’t already clicked on the new website, it’s still a Beta version and new things will be coming.
I hope you will take a look. It’s a good beginning of what I hope will eventually be a place for us to:

–> get information
–> share information
–> create open source assessment and treatment planning forms and software; policies and procedures; treatment supports and whatever else our social community sees useful
–> get consultation and learning opportunities
–> buy useful products and services
–> link with other resources and people; Take a look at a video interview about co-occurring disorders at in Archived Shows.

It’s not Facebook, MySpace or It’s It will be evolving over time.

Simple Website Q & As

Q: With the new website now, do I need to re-subscribe to Tips N Topics?
A: No! Your email address is the same and still in our database as before.

Q: When will be all the Tips N Topics issues be up on the website?
A: Very soon! Keep checking back as we’re updating that section regularly.

Q: On the calendar, how can I tell if trainings are open to the public or not?
A: The perfect solution has not yet been finalized, but we intend to state “Open to Public” right in the date box. Details on the training will be available as well.

Q: I don’t see a “Home” tab on the website?
A: You can always click on the logos in the upper lefthand corner to get to the Home Page. There is also a link to “Home” at the bottom of every page.

Q: Will your email address change also?
A: Yes very soon- but emails to the ‘old’ address will still get to us. We’ll let you know when the address changes.

Q: Are you going to add other things to your site?
A: Yes. Coming soon- products to buy, more free resources, links I recommend among other things.

Until Next Time

Thanks for reading. See you later in February.


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