Rules or Treatment Plans? Relationships and Hooking Up; Medicare story

savvy & stump the shrink

Earlier this month, I received a question prompting this combined SAVVY and STUMP THE SHRINK.  This is especially relevant if you work in a program that focuses on rules and regulations, consequences for breaking the rules, and behavior contracts.

Even if it is the treatment plan that focuses your work with the client, it is easy to become distracted by behavior which disrupts the group and treatment milieu. Here is what Bob Fox of St. Paul, Minnesota wrote:

Question

Dr. Mee-Lee:

“I work in Level 2.1 Intensive Outpatient, mixed gender group. What is your view on policies about treatment peers forming exclusive, romantic relationships, or plain old sexual intimacy (hooking up) in treatment?”

Bob gave me three multiple choice options, but as you can see further below, I waxed eloquent and expanded way beyond the offered choices:

“a.   Should the relationship be prohibited and one or both clients be discharged (referred to another program?)

b.   Should the relationship be allowed, but the involved clients be separated into different groups? And then a focus of treatment is learning about healthy relationships, boundaries, etc.?

c.   Or some other option?”

TIP 1

Think about how you deal with emotional, behavioral and cognitive issues that are potentially disruptive to the group and treatment milieu.

My response

In general, my view is to see all emotional, behavioral and cognitive problems as treatment issues needing to be dealt with in the context of an individualized treatment plan.  That plan should be frequently and collaboratively changed depending on what is working well (or not working well) in the client’s progress in treatment.  

So in this case…. if peers are forming relationships and hooking up, that is behavior which is going to happen while a person is in treatment and certainly occurs when people are not in treatment.  I suspect that for many clients in treatment the relationships and sexual behavior they engage in has created problems in their lives previously – both substance-related and non-substance-related.

In outpatient and residential treatment, we have an opportunity to create:

• A safe, therapeutic environment.
• A therapeutic milieu which seeks to engage and attract people into an exploration of what has worked well for them before and what has not worked well.
• An opportunity allowing clients to develop and practice new and healthier ways to deal with their behavioral health problems.  

In addiction treatment and sometimes in mental health as well, we have had a tradition of creating a safe environment by having rules, policies and consequences if clients break the rules: like behavioral contracts; set back a level or phase in residential settings; loss of privileges; writing tasks; separating people into different groups; discharge etc.

We need to rethink our attitudes about what treatment is meant to do:

• Meet people at the stage of change they are at. (What is the person at Action for? Identify their issues. Are they possibly still in a Precontemplation, Contemplation or Preparation stage of change?).
• Help them self-identify and own the issues that keep “shooting themselves in the foot.” What behaviors are counterproductive to recovery and getting them what they want? Is it health and wellness? Maybe getting their children back? Getting off probation? Keeping a job? Retaining a relationship? Keeping their housing? Being sober and embracing recovery? Whatever it is that brought them to treatment- find it out.
• Work compassionately with them to facilitate a self-change process using a collaborative, accountable treatment plan.
• Fashion with them an updated treatment plan whenever progress stalls or new issues arise e.g., exclusive relationships and sexual behavior. The new strategies should move in a positive direction.

TIP 2

Help clients assess and evaluate the “differential diagnosis” of their emotional, behavioral and cognitive issues and the effect on their lives.

The answer to the STUMP THE SHRINK question centers around having a talk with the clients in the exclusive relationship. In addition, talk with all their peers in group regarding the dangers of becoming distracted by exclusive relationships and sexual behavior. Explore with all the clients about how this type of situation has distracted them in the past, how it distracts now in the present setting. Converse about how it can ‘de-focus’ people from recovery, from attending to their “work” of embracing new ways of being and doing.  

1. Engage the group in talking. Where has this been an issue in other peers’ lives? What have they learnt from those experiences?

2. You can also discuss the dangers of forming intense new relationships early in recovery, especially if the new “love of my life” is also new in recovery and may even be less interested in recovery than I am.  

3. How easy it is to turn to relationships and sex as a way to deal with pain e.g., regrets of past mistakes, lost relationships and jobs, mental health issues? Discuss this angle.

4. Pose this question for discussion: How can sex or a new relationship avoid the hard work of recovery? Can people avoid taking “a searching and fearless moral inventory of ourselves” (Alcoholics Anonymous 4^th Step)? Looking at your life, whether in addiction or mental health treatment, can be a very hard thing to do.

5. Identify if certain mental health issues are contributing to such behavior e.g., unresolved issues with parents; or trauma or sexual abuse.

In other words, there is a whole “differential diagnosis” of what forming relationships and sexual behavior can mean.  These are assessment and treatment issues to be opened up for the clients involved.  There is also a rich opportunity for the other peers in the group to explore these issues for themselves for “there but for the grace of God go I.”  

TIP 3

Consider what happens to treatment if the focus is on rules, consequences and discharge.

You can “prohibit” the exclusive relationship and sex, but are you also going to “prohibit”:

• Substance use and relapses (we still do this often and I have written before about discharging people for having the symptoms and signs of their addiction illness).
• Angry outbursts.
• Cravings to use with irritability and isolating behavior.
• Disrespectful talking and interactions with peers and staff.
• Hanging out with drug-using friends.
• Telling war stories about drugs etc. etc.

Treatment is not about us making people behave. It is about helping them make the right decisions in the dark of night when nobody is watching.  If people do the right thing only when in our program, have we helped them to help themselves when we are not around?  Have we facilitated a self-change process which enhances sustainable recovery? Or have we externally imposed compliant behavior that too easily falls away after “graduating” from treatment?

TIP 4

When is it appropriate to discharge people for their behavior?

A. There may be mandated clients who say they want treatment, but end up just “doing time”.  They occupy and distract themselves by forming relationships and hooking up. They are not, in good faith, looking at the meaning of their behavior, the negative effects on their life and on others.   Just sitting in a chair is not doing treatment. They are not choosing the work of treatment. At that point, you can talk about discharge.  

• So you would be discharging them not because of bad behavior or breaking rules, but because they are not being open and willing to change their treatment plan in a positive direction. They have a right not to do treatment. As the clinician, you have a right to keep the treatment milieu therapeutic and “discovery” and “recovery”-focused.

B. If you ascertain someone is a sexual predator focused on disrupting treatment for themselves and others through forming relationships and hooking up, then discharge is appropriate. Why? Because you run a treatment place, not a dating place.  

• Let’s say you determine a client’s behavior is part of their biopsychosocial-spiritual illness with implications for addiction, mental health and physical well-being. Then these are important treatment issues to pursue with further assessment and treatment. Do not discharge and hope you can just prohibit human behavior. If the person is willing to deal head on with this behavior and attitudes, then treatment is what they need. To discharge them for having problems to work on doesn’t fit my vision for treatment.

A friend and colleague recently said this:

“My mantra is, ‘this is the place where you don’t have to be at your best.’ If people are out of sorts or have a bad hair day, all the more material for the staff to work with.”  

Andrea G. Barthwell, MD, FASAM

Oak Park, Illinois

708-613-4750

www.twodreams.com

If we expect people to behave and be at their best, then they probably don’t need treatment and have nothing important to change.

skills

In June 2003, the 3^rd edition ever of Tips and Topics, I wrote about “Discovery, Dropout” (D/D) prevention plans for people in early stages of change, those not yet interested in recovery. I also wrote about “Recovery, Relapse” (R/R) prevention plans for people at Preparation and Action for recovery.  In 2015, you still find most treatment providers in general health, mental health and addiction treatment creating treatment plans which assume the client/patient is committed to recovery and relapse prevention.

• The doctor or nurse writes a prescription for the patient expecting adherence and healthy living. Actually medication non-adherence is widespread with rates ranging from 25% to 50%. Between $100 and $300 billion annually of avoidable health care costs in the US have been attributed to non-adherence.

(Aurel O Iuga and Maura J McGuire: “Adherence and health care costs”. Risk Management Health Policy. 2014; 7: 35-44. Published online 2014 Feb 20. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3934668)

• Psychiatrists and mental health clinicians document problem #1 as “Psychosis” and problem #2 as “Medication Compliance” in the treatment plan.  However the patient thinks they are not mentally ill, it’s a conspiracy and the medication is poison and part of the plot. No wonder the patient doesn’t take their medication nor show up for sessions.
• The addiction counselor documents strategies of abstinence, AA meetings and changing drug-using friends when the client simply just wants to cut back, hates AA and sees nothing wrong with his friends. No wonder he drops out of treatment.

What patients and clients actually need is a Discovery, drop-out prevention:

• To discover for themselves (with our help) that what they are doing with their emotions, behavior and thinking is not getting them what they want.
• We need to do all we can to prevent them from dropping out of services, so we have a chance to attract them into recovery.

TIP 1

Consider these Sample Strategies for Treatment Plans

1. List three reasons the court sent you to treatment (D/D).
2. Write down the most recent incidents involving alcohol and other drugs (D/D).
3. Identify what happens if you don’t comply with probation requirements and report to group (D/D).
4. List the positive and negative aspects of substance use (D/D).
5. Attend at least one AA meeting and see if you can identify with anyone’s story (D/D).
6. In group, verbalize what things need to change in your life or not (D/D).
7. Discuss the positive and negative consequences of continued substance use (D/D).
8. Explore early childhood history of violence through individual therapy once per week. Focus on what kind of role models the client had then, and how this affects relationships now (R/R).
9. For the next incident of rage and anger, track it. Fill in the date, trigger, physiological signs and your behavior. Then discuss how you could have de-escalated the incident (R/R).
10. In group, share what has been working to prevent relapse and obtain other suggestions (R/R).

For more on Discovery plans, see SKILLS in the March 2006 edition.

Related past editions explain aspects of this too if you want to take a look:

February 2013

November 2012

TIP 2

Treatment Plan Strategies for Working on Relationships and Hooking Up

Referring back to Bob’s question: if the clients are interested in treatment, they will be willing to change their treatment plan in a positive direction using such strategies as:

1. Talk with a counselor about where relationships and hooking up has affected their life and addiction in the past. Share that in group to receive feedback.
2. In group, explain what is so great about the new, exclusive relationship. Obtain feedback on whether this relationship will help, hinder or jeopardize recovery.
3. Have a trial of staying away from the other person for a week. Then have each person in the relationship talk in group about what that experience was like.
4. In group, talk about examples of past relationships and sexual behavior they got into quickly. Examine how that contributed to problems in their life, both addiction-related or not.  

Once you have done more assessment, there would be many other strategies that might fit better for this client. If they are willing to do this work, treatment continues. Don’t separate them or discharge them. Use the power of the group to implement these strategies. Note of Caution:

You’ll notice that I define good faith working in treatment as “being open and willing to change their treatment plan in a positive direction.” Or as they say in AA “progress, not perfection”. We would like every person from Day 1, to be:

• perfectly sober, with no cravings or impulses to use and no actual use
• perfectly delaying gratification for relationships and hooking up and totally focused on recovery
• perfectly non-depressed, non-psychotic; non-anxious; non-manic
• perfectly non-angry, irritable and isolating
• perfectly non self-mutilating, suicidal or impulsive etc. etc.

But if our clients and patients could do all that, they wouldn’t need our help in the first place! So if you have a notion to change their treatment plans by inserting: “Bob and Jane will end this inappropriate relationship and sexual behavior and focus on recovery” and then discharge Bob and Jane when they break their treatment plan, that is “perfection” not “progress”. It is not changing their treatment plan in a “positive direction”, it is expecting perfection and the final outcome immediately.

soul

I just have to tell you my Medicare story. (So now you know I’m a senior citizen.) Last year when I joined Medicare, I was looking forward to that much lower monthly premium for health insurance…and yes, it was quite a bit lower. But then new notices came informing me that the bill was going to be higher because of my income. (So now you know I’m not a minimum wage senior citizen.)

I was OK with that, because I don’t mind contributing to the greater good if I can afford it. But then the amount I owed kept changing and I dutifully paid what the monthly invoice said. Here’s where the story gets interesting (or is a better word “frustrating”).

• Invoices would come late with a due date that had already passed; or were so close to the date I received the bill, that it was bound to be delinquent.
• You can’t pay online, so by the time snail-mail arrived, it was surely late, plus the three weeks it takes for their department to process the payment.
• So now, each monthly invoice was showing either delinquent amounts owed and/or unprocessed payments I had already made.
• Then I didn’t receive any invoices for two months. Had I already paid too much in advance, so they didn’t send me a bill? Or did it get lost in the mail? Or had I lost my Medicare? Who knows, because you can’t check your account and payments online – like every other business.

Time to call and talk to someone at Medicare. I called on a whim one night to see what hours they were open and amazingly you can talk to a “live” person- they are open 24 hours a day, 7 days a week. And it is not someone in the Philippines or India. Sounded like a regular ole American.

• Nice helpful man, but after 7 PM he can’t check the computer records to see what I owe or not. I could call back the next morning and then find out what I owed. But he did tell me I could sign up for Medicare Easy Pay where the payments would come directly out of my bank account. That sounds more like it in the 21^st century.
• But not so fast. He would have to mail me the form to fill out, and that could take 3 weeks; then it could take up to 8 weeks to process my application for Easy (or not so Easy) Pay. Faster, he said, to sign up with my bank for online payment directly.
• Went to my bank website and in 5 minutes I had signed up and paid a couple months’ premium just to be sure I wasn’t behind. “I’ll check in the morning to see where my account stands”, I said to myself.
• Next morning at the Medicare call center, there was a nice helpful lady and not a long wait to get to her either. However, she can see what premium I am being charged, but has to send a special request to another department to tell me whether my account is ahead or behind and what has happened to my monthly bills.

“Is there no way that I can go to a website, see my payments and what I owe, just like I do with my credit card, electric and phone bill etc.?”

“No, I’m sorry, we can’t even see that. I have to send a request to another department and they will call you to let you know where your account stands.”

“Could they not send me an email, because what if I miss their call?”

“Oh, well if they don’t reach you, they will send information in the mail.”

“You mean, regular snail-mail, not email?”

You get my drift. Now I think it is great that Medicare is open 24/7 and the hold time was very reasonable. BUT I spent at least a half an hour or more with people who receive more than minimum wage and nice government benefits only to find out that they can’t help me. The information I need will take much more time being spent by more government workers who will use last century’s methods to communicate with me.

I better stop here and recite the Serenity Prayer. But if any of you have the courage and wisdom to make government more efficient, please step forward. This old guy feels a bit hopeless.