Readers speak; Direct, follow or guide?

savvy

In the May 2013 edition, I discussed ways to prevent harm and improve patient safety in addiction and mental health treatment. 

I asked for feedback:  What’s on your Top 10 list of ways to improve patient safety and behavioral health care NOW!? – especially if you have any supporting evidence or data.   

I promised to share readers’ suggestions.  

Here are three and some editorial comments:

Reader #1 

Hi Dr. Mee-Lee:  

I read your latest Tips & Topics (May 2013) with great interest. As you know, approximately 90% of clients seeking treatment in community mental health centers have been exposed to trauma. Safety is absolutely enhanced by resisting the urge (from oneself but also the patient) to engage in premature trauma retrieval work. This advice has been repeated over and over by such luminaries in the field as Bessel van der Kolk, Judith Herman, Joan Turkus and Lisa Najavits.

Regards, 

Harry Ayling, LCSW, diehard devotee to Tips & Topics  (Harry’s words, not mine).

–> Comment from David Mee-Lee 

There has been a lot of attention over the past 15 years on co-occurring mental and substance-related disorders.  The more recent refinement of that attention is to be trauma-informed: to be aware of how many addiction and mental health clients present  with past histories of trauma.  When people with addiction sober up, intense feelings can rise to the surface.  It is always a fine balance to know how to address intense feelings which can’t be ignored.  Yet, at the same time it is important, as Harry says, to make sure that our clients are safe to deal with trauma; and not cope by returning to substance use or other self-destructive behaviors like cutting.

Of course, trauma-informed work is even more in our consciousness as we face the thousands of veterans returning home.   

Take a look at a brand new journal from The Change Companies: “Coming Home: A Warrior’s Guide” 

Reader #2 

Dear David: 

Thank you for your excellent comments on our health care costs and the Affordable Care Act (ACA).  I am personally offended by the size of the executive compensation packages, and the large bureaucracies funded to try to get paid (medical facilities) and to avoid paying (insurers).  A Google search of executive compensation packages in the insurance and medical care industries show many senior execs make over $1million per year, with some getting more than $40 million per year.  Soon the taxpayers will be contributing even more to their life styles.  Steven Brill documented many key issues in his fine article Bitter Pill: Why Our Health Care Costs So Much (Newsweek, Feb 20, 2013).  A big part of what impedes our ability to solve problems in this and other arenas (guns, food habits, worker safety) is the commandment “Thou shalt not interfere with profit.”  I think all of the measures designed to bring down costs will also produce a lot of howling and attempts to sabotage full implementation of the ACA.  The more people can be made aware of what goes on in other countries, the better.  It does not have to be this way.  

Joan Zweben, Ph.D. 

Berkeley, CA

–> Comment from David Mee-Lee 

In Overview of the Uninsured in the United States: A Summary of the 2012 Current Population Survey Report, the “Census Bureau released data on health insurance coverage and the uninsured for 2011 on September 12, 2012.  Although there are four major government surveys that produce estimates of health insurance coverage, the Current Population Survey (CPS) is the most widely cited and receives national media attention. …. During 2011, an estimated 48.61 million people were without insurance, a statistically significant decrease of 1.34 million from the estimated 49.95 million uninsured in 2010.” http://aspe.hhs.gov/health/reports/2012/uninsuredintheus/ib.shtml

Regardless of your political leanings (right or left); or where you stand on the continuum of individual rights (right to buy health insurance or not) to collective action for the greater good (requiring health insurance of all so as to pool resources to allow universal coverage), the fact remains:  There are 40 to 50 million people who do not have health insurance in the USA.  This creates huge human costs, as well as significant healthcare costs, as scarce resources are used inefficiently and ineffectively.

As Joan says on this and other related issues, “It does not have to be this way.”

Reader #3 

Dr. Mee-Lee: 

Number One Way to improve patient safety and behavioral healthcare now: 

Address the stigma in the 12-step based treatment community against methadone and Suboxone (buprenorphine and naloxone) maintenance for the treatment of opioid dependence (now opioid use disorder in DSM-5).  About 95% of treatment programs in the public sector are based on the 12-step philosophy, and are staffed by people who are undereducated about medications, and either covertly or openly biased against medication-assisted treatment.

There is NO scientific controversy that for established opioid dependence, medication- assisted treatment is the treatment of choice.  Clients must receive informed consent regarding this treatment option, but in my 25 years of experience in publicly funded treatment in California, this rarely happens.  This MUST change, as we are in the midst of the largest epidemic of opioid dependence since heroin use rose in the 60’s.

Please, devote not just one, but several issues of your newsletter to educating your readership on improving delivery of evidence-based treatment of opioid dependence.  You are a thought leader whose opinion is respected in the field; you are well positioned to lead the efforts to improve the treatment of opioid dependence. Young people are dying from overdoses after completing abstinence-based treatment programs; this needs to stop.  

Sincerely, 

Nancy Friel MFT 

Senior Mental Health Counselor 

County of Sacramento DHHS, DBH, Alcohol and Drug Services 

 –> Comment from David Mee-Lee 

There has been lively discussion on methadone and Medication Assisted Treatment (MAT) in previous editions of Tips and Topics.  Take a look at Jerry Shulman’s piece on MAT in the October 2008 guest tips edition.  

In the May 2007 edition, we discussed harm reduction and methadone treatment followed by some readers’ comments in the June 2007 edition. 

In the new edition of The ASAM Criteria, there is an expanded section on Opioid Treatment Services (OTS) to include opioid agonist medication like methadone and buprenorphine in Opioid Treatment Programs (OTP) and Office Based Opioid Treatment (OBOT); and opioid antagonist medication like naltrexone. Take a look at the updated website all about the new edition at www.ASAMcriteria.org

skills

One of the skills I address very often in Tips and Topics is how to do truly individualized, person-centered work.  The recent third edition of Motivational Interviewing (MI) explains a  continuum of communication styles.  This distinction has really helped me understand MI. 

Here’s the reference: Miller, William R; Rollnick, Stephen (2013): “Motivational Interviewing – Helping People Change” Third Edition, New York, NY., Guilford Press. Pages 4-5 and some resources on the third edition:

TIP 1

Identify where you are on the continuum of communication styles from Directing to Guiding to Following

Directing <————-> Guiding <————–> Following

• Here is an example of a Directing style for working with a client who says they want help to stop drinking:

“It’s good that you want to stop drinking because you’re an alcoholic and you need to really accept that you suffer from addiction and develop a supportive recovery network. Here’s what I want you to do: go to an AA meeting every night this week and get some names and numbers so you can start calling people and developing that network. It is also important for you to stay away from those three friends of yours you usually drink with and start hanging around recovering people. Any questions?”

• Here is an example of a Following style for working with a client who says they are depressed:

Clinician: So I understand you have been feeling down and blue lately.

Client: Yes, I’ve been really feeling depressed and don’t know what to do.

Clinician: So you feel lost and not sure how to handle your depression.

Client: Yes, I have no energy and can’t concentrate at work. Is there medication that can help me?

Clinician: So you having trouble with work in your concentration and energy level and wonder if medication would help.

Client: That’s right. What medication should I take because my primary care doctor’s medication didn’t seem to work well?

Clinician: You’d like me to tell you what medication would help.

Client: Yes, should I see a psychiatrist or is my family practitioner OK to prescribe?

Clinician: You’re wondering whether to see a psychiatrist or a family practitioner?

Client: Yes, I’m really depressed and don’t know what to do.

Clinician: You really feel lost and not sure how to handle your depression.

Client: Yes, what should I do – see a psychiatrist or is my family practitioner OK to prescribe?

Clinician: You’d really like to know whether to see a psychiatrist or a family practitioner.

At this point the client is really depressed and hopeless.  You’ve done nothing except follow the client around their presenting concerns, reflecting back what you hear.  

There is some following that is important and necessary to do at first with a client so you know what they want and what to focus on.  But if that is all you do, they understandably get frustrated as you act like a therapy robot.

• Here is an example of a Guiding style for working with both these clients. Guiding is a combination of Following and Directing in what Motivational Interviewing calls a “conversation about change”.

Clinician:  So I understand you want help to stop drinking. (Following)

Client: Yes, I’ve been trying to do that on my own for six months and am not getting anywhere.

Clinician: What have you tried that hasn’t been working? (Following)

Client: Well I went to some of those AA meetings, but I’m not as bad as those people.

Clinician: How many meetings did you go to? (Following)

Client: Two or three, but I didn’t get anything out of it except for one person I spoke to who seemed to really understand me.

Clinician: Did you get that person’s name and number? (Following)

Client: Yes, but I haven’t had any more contact.

Clinician:  Would it be OK with you if I gave a suggestion? (Seeking permission to be Directive)

Client: Sure, go ahead.

Clinician: How would you feel about calling that person and seeing if they would go to a different meeting, because sometimes certain meetings fit certain people better? (Directing)

Client: I guess I could do that.

Clinician: You sound a bit unsure if you want to do that (Following).  Do you need to think about it a bit more; or would you like to give it a try, at least one or two times? (Guiding).

And for the depressed client:

Clinician: So I understand you have been feeling down and blue lately (Following).

Client: Yes, I’ve been really feeling depressed and don’t know what to do.

Clinician: What has been most troubling about your depression? (Following)

Client: I have no energy and can’t concentrate at work. Is there medication that can help me?

Clinician: Have you taken medication before? (Following)

Client: My primary care doctor’s medication didn’t seem to work well.

Clinician: There are other methods besides medication that we could try if you were interested. (Directing)

Client: What do you mean?

Clinician: We could try cognitive behavioral therapy and exercise? (Directing)

Client: I’d rather take medication.

Clinician: So you feel more confident that medication would help the best. (Following)

Client: Yes, I’d like to see a psychiatrist to get my medication changed.

Clinician: So let’s arrange for a psychiatric consultation and track how you are doing. If medications don’t seem to be the full answer, maybe we could try some of these other approaches I mentioned. (Guiding)

Directing is easy to do, as it involves just telling people what to do to change regardless of whether they are ready to do that.  You have taken little time to listen to what goals and methods are important to them.

Following is also easy to do, as it involves just reflecting back what you hear they are saying.  This can be frustrating to the client if every interaction is a question and summarizing without moving forward to get some sense of direction of what to do next.

Guiding is the art of using both Directing and Following to ask enough questions to clarify what goals and methods are important to the client, but then building on that knowledge to collaborate and Guide the person in a facilitated self-change process.

soul

If you’ve ever done touristing in a foreign country, it’s a relief to have an informative guide, especially an English-speaking one.  Actually, only an English-speaking guide for me.  A good guide is one who knows how to balance “directing” and “following”; to get you where you want to go in the most efficient, effective and enjoyable way.  

(That sounds a lot like good person-centered treatment – no wonder Motivational Interviewing is founded on good guiding.)

In May, we were in Yangon (Rangoon) for just a day!  There is no way anyone could see all the major temples, pagodas and top tourist spots.   So it’s really important to have a guide who can “follow” your lead about the sights you are most interested in seeing, in the limited time available.  At the same time, what we needed from Nandar, our female guide, was also to “direct” us- by listing the top recommendations for what could be done realistically in six hours.  Then collaborate with us on:

• what sightseeing goals were important for us (which temples, markets and local crafts caught our fancy)
• what methods would best achieve those goals (taxi, walking, timing at each spot)
• what was the plan for the day – Now that sounds like a therapeutic alliance and a great service plan.

Imagine if Nandar had told us we had to go to the top five tourist spots whether we wanted to or not; stay there for a fixed amount of time, whether we had seen what we wanted or not; and then kicked us off the tour if we weren’t able to be the perfect tourist. (I know, it’s not the perfect analogy, but sounds a bit like some addiction treatment programs).  Nandar, I thought you were our guide, not a director/dictator!

What if we had a guide who followed us around all the time, passively walking in our footsteps?  

We ask: “Where should we go next?”

“Well where would you like to go?”

“I can’t decide which would be better – another temple or the silversmith crafts.”

            “Well they are both interesting.”

“So what would you recommend?”

            “You want me to decide for you?”

At this point, I would fire the guide who is not a guide.  She must have missed the Guide School training class on how to balance directing with following.

There are no perfect guides, perfect tourists, perfect counselors and clinicians plus no perfect patients and clients.  However if you can join up with someone who has a good sense of balance between directing and following, you can enjoy both the journey and the destination.

Whether you tour Yangon or Yakima, the museums of Florence, Italy or New York, New York,  or the temples of Thailand or Salt Lake City, may you find a good guide.