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May 2010 – Tips & Topics

TIPS and TOPICS from David Mee-Lee, M.D.

Volume 8, No. 2

May 2010

In this issue

SAVVY   Assessment Issues in Co-Occurring Disorders
SKILLS   What does the client want?  Understanding retention and resistance
SOUL A recovering Speeder
SHARING SOLUTIONS Innovations from Readers
Until Next Time

Thank-you for joining us for this month’s edition of TIPS and TOPICS.


Each month for the past three years, I have had the privilege and opportunity to train and consult in the state of Delaware.  I am a consultant to their Federally-funded Co-Occurring State Incentive Grant (COSIG) to improve systems and services for people with co-occurring mental and substance-related disorders (COD).  As such, I have visited almost every outpatient, inpatient and residential addiction and mental health agency- (Delaware is not a large state as you can imagine if you’ve never looked at a map of the USA).

This month in SAVVY, I share some common themes I believe apply to just about everyone and every place which serves people with COD and other behavioral health problems. This edition I’ll focus on clinical themes; later on I’ll address some Systems issues.


*Consider these Assessment Issues for Co-Occurring Disorders

1.  When clients present with mental health problems and are also using alcohol and other drugs, there could be three (not mutually exclusive) diagnostic possibilities:

The person may be attempting to self-medicate a psychiatric disorder with substance use.
The mental health problems may be signs and symptoms of the addiction illness e.g., depression because of the crash after a cocaine binge or mood swings because they are getting high on uppers and downers.

The person may indeed have both a co-occurring mental and substance use disorder.

2.  Of the above three evaluation conclusions it is not always clear which applies to any one client. Here are some guidelines to help make a hypothesis on what might be going on:

Examine timelines to see if addiction problems preceded mental health problems. Did the client first start experiencing mental health issues before problems with substances?

If the addiction illness came first, you might begin with a focus on the addiction; then observe what happens to the mental health problems.

If the reverse is true, begin working on the mental health problem rather than sending the client to addiction treatment. Notice what happens to the substance use. The client could be self-medicating a mental disorder.

Review the time relationship between substance use and mental health signs and symptoms.  If your client was using substances at the time of, or not long before, the acute mental health presentation, you could be looking at a possible Substance-Induced Mental Disorder directly related to the pharmacological effects of the substances being used at the time – (an methamphetamine-induced depression, or an alcohol-induced anxiety disorder.)

Check for any drug-free periods in the person’s life. Inquire about what happened during those times.  Did mental health problems still exist strongly even though the person was abstinent?  Perhaps this indicates a Substance-Induced rather than a Substance Dependence diagnosis.

If the psychiatric problems dissipated after some drug-free periods of weeks to months, then it could be that the mental health problems were substance-induced.

In your clinical decision making, these guidelines are prompts to use. This is not a computer algorithm that spits out the diagnostic answer without your clinical judgment. Using such guidelines can help prevent calling everyone who uses substances and has mental health problems a co-occurring disordered client.

It is easy to label people with a mental disorder and prescribe psychotropic medications.  It is better to medicate diagnoses not signs and symptoms.

3.  We speak of “signs” and “symptoms” in our clinical language often.  But when I recently asked a group of clinicians to define “signs” and “symptoms” it wasn’t easy for them to do. Signs and symptoms are diagnostic “tools” that help the assessor determine the condition of the client.

• The Online Medical Dictionary defines them as:  “Objective evidence of disease perceptible to the examining physician (sign) and subjective evidence of disease perceived by the patient (symptom).

• In other words, “symptoms” are client complaints of pain, depression, anxiety, hearing voices and the like, whereas “signs” are what we see as observable evidences of pain- (doubled over and sensitive to abdominal pressure); depression- (tearful, speaking in a slow monotone); anxiety- (trembling, sweating)


One advantage of training and consultation in smaller states and counties is the ability to include onsite visits with the clinical team.  There we can role play, discuss cases and dilemmas; on many occasions I can interview an actual client “live” with the team who is struggling to engage them into treatment.


*To engage a client in treatment is as important as assessing his/her needs.

This may seem such an obvious statement. However it is almost irresistible for clinicians to rush through the initial appointment(s) in order to complete the assessment, the permissions and informed consent forms- to quickly fill in the diagnostic impression and paperwork.

  • People before Paper

Before you get to filling out your assessment form on paper or electronically, spend whatever time is necessary to figure out and drill down deep with the client. What brought you to see me? What do you want me to help you with?  This is about empowering people to be honest about what is important to them.

  • Tuning in might be simple or more challenging

Depending on how well they can articulate that, it might be as simple as: “They made me come and I want to keep my job or children or benefits so I am here”.  Or it might be that you have to dig more with: “You say you don’t know what you want, but if you hadn’t come today, would anything bad happen?”  If the young person says something like: “Well my parents would be really mad”, then maybe what she wants is help to avoid getting her parents mad at her.

  • Gaining emotional permission

Actually, you really don’t have permission to be probing every area of someone’s life unless they have invited you to do that.  Getting clear what they want is empowering to them and it results in their giving you permission to do your assessment.  Just because they signed your consent for treatment form doesn’t automatically mean they have given emotional permission for you to probe sensitive and painful areas of their life. When you link the assessment to what is most important to the client that is both respectful as well as more effective. It also increases client accountability and self-change.

  • Monitor and check at every visit 

At every visit, deliberately monitor if your clients are getting what they want.  Check yourself for whether your work with them is a good fit. We want to “keep them coming back” until they are showing self-propelled, improved function and outcomes.

  • Always ask- What’s working? What’s not? 

When working with clients, it really is “all about them” and not you.  When you start with what is important to them, and stay with what is important to them, the assessment and treatment process falls into place.  You are simply assessing and collaborating with them on what has worked (and what has not worked in the past) in getting what they want. Furthermore you are checking in with them on their experience since your last session with them, whether an individual or a group session.  You are continually asking: what has worked or not worked in reaching their goals.

  • What’s important right now? 

Engage the client by a focus on the treatment contract which can be developed using the What, Why, How, Where and When.  Identify what is most important to the client at this point in time.

You can read more on the What, Why, How, Where and When in a previous edition:

  • Here is “Bill”, who I interviewed in a residential program. 

He wants to get a job. He’ll need help coping with his self-esteem issues of feeling he is slow cognitively. He has a work history of not keeping up the pace of work and getting fired.  You will want to identify with him the times he was able to keep a job and what worked, so you can build on those successes

  • Here is “Bob” who I interviewed in an outpatient program. 

“Bob” wants to save his marriage. He needs help to identify all the things he is doing that threatens his marriage. Again, you want to identify the good times of his marriage and use that information to build a success plan.

*Be proactive about retention in treatment and change how you view resistance

Possible reasons clients stop coming to treatment:
1. Feeling better with no perceived need for more treatment
2. Feeling worse and therefore not confident that help is available
3. Money concerns and inability to pay;
4. Barriers that extensive paperwork creates for engaging clients
5. Poor fit of the client with the therapist and no client confidence that he/she can be helped with this counselor.
6. Readiness to change issues: a client may not believe he has a mental
health or addiction problem
7. If someone thinks they have a problem they may be ambivalent about
getting treatment.
8. Psychotic illness is affecting their judgment and adherence.
9. Relapse can be embarrassing and there’s shame to return to treatment.
10. Poor alliance with the clinician- client is not interested in the goals or
methods used by the clinician.

· Avoid viewing resistance as pathology
When you observe resistant behavior, don’t view this as pathology which resides in the client, and is to be confronted, interpreted or analyzed.  See it as an interactive process that you can increase or decrease depending on how you address the apparent lying, ambivalence or readiness to change problems.

· Use motivational strategies
To change how you deal with resistance is where you will need your knowledge and skills in motivational enhancement. When you build an alliance with your client, they will experience that their lying, negative and resistant behavior does not get them what they want.

Example: If you lie to me that you used drugs and your Probation Officer
(PO) catches that in random drug testing, I cannot advocate for you.  If we
work together and you make a mistake and use, but are willing to change
your treatment plan in a positive direction, I can explain to your PO that you are still in treatment and compliant with court orders.

Example: If you keep breaking your curfew, how can I help get your parents off your back and from getting mad at you?  Do you still want me to help you with that?  Or have you changed your mind and actually want them mad at you? You don’t need my help with that.


It’s easy to be judgmental about people who relapse or repeat self-defeating, counterproductive behavior.  Of course those people have no excuse.  When we do it, we have good reasons we think any reasonable person would understand. This justifies our repetitive, self-defeating behavior.

Tell that to the Highway Patrol officer who pulls you over for going 84 miles per hour in a 65 mph highway zone. I mean, tell that to the officer who pulled me over. “Officer, it’s a new car that I’m just getting used to.  My old car was a ten year old VW; this is brand spanking new and I’m still adjusting. I’m a physician and racing to get to my destination….”

So in January 2006, my invitation at the end of a SOUL section on my then recent speeding fine was: (note- a similar speed in a similar highway speed zone)
àWant to join me in the “go slow” recovery path?
If you want to read my excuses and justifications in my last speeding ticket, here’s the link:

On this Mothers’ Day I got the speeding ticket and fell off the wagon. I relapsed after four years in the “go slow, no-speeding recovery path”.  Well, actually I was caught speeding after four years when I got caught the last time.  I wasn’t actually in “go slow” recovery so it wasn’t a relapse.  It’s sort of like people who drink and drive anywhere from 300-2,000 times before actually getting a Driving Under the Influence (DUI) arrest. I wasn’t not speeding and I wasn’t in recovery. I just hadn’t gotten caught.

But after this 2nd speeding ticket in 5 years, I am really going into “go slow” recovery. In Motivational Interviewing and Stages of Change work it’s good to declare to people around you that you’re serious about taking Action for change.  They are then able to support you in the tough work of “walking the talk”.  Or in this case “driving the talk”.

Besides all the ‘trivial’ reasons not to speed, ( like it’s dangerous and the “speed that thrills is the speed that kills”; you could die and in the process kill other people), I tell myself other reasons not to speed: (like it’s stressful to be forever watching the rear view mirror for flashing highway patrol officer cars; speeding burns up gas; it’s bad for the environment; it wastes money because it’s unnecessary wear and tear on the car and it wastes my energy because my stress level is taxed.)

So I am declaring…..I am not speeding anymore….except where it might be dangerous if I don’t keep up with the flow of other traffic all going over the speed limit as well; and when I might be late for an appointment that inconveniences others if I am not there on time; and if I am rushing a pregnant woman to the emergency room……

No actually I really am not going to speed anymore.

(Comment from the editor- who happens to share the same last name as the SOUL author:  WE’LL SEE. I wish Dr. Mee-Lee all the best in his recovery!!!)


Last month I requested that if “you are already doing some effective innovations e-mail a brief description of what you are doing and how the innovation operates and in what way it is effective.”  Here are responses to share with you.

Note:  Inclusion of this feedback does not mean I am endorsing or recommending the content or the agency represented.

1.  “One innovation involves phone inquiries. It is company policy when someone calls and says, “Tell me about your program,” that we ask, “First, tell me about the issue.” We explain that, while we have an outpatient facility, it is our mission to help people find programs that are right for them. We explain that every person has specific needs and that our program may or may not be right for them.

We recommend an Addiction Severity Index assessment, using ASAM Patient Placement Criteria and DSM IV dependence and abuse criteria. We assure each caller that we will find a program that is right for them. This means that the majority of potential clients that call do not enroll in our program.

However, it provides a resource for our community that helps people navigate the complex treatment environment, taking into consideration treatment needs, financial constraints, medical and mental health needs, and expectations with regard to program philosophy.”

Dale White
Assessment, Training & Research Associates Central California Recovery, Inc.
1100 W Shaw, Ste 122
Fresno, CA  93711
(559) 681-1947

2.  “I always enjoy reading your TNTs, but I thought this one was exceptional. It’s a great summary where the field is headed and hopefully will push others in that direction. We’ve been using Vivitrol (injectable, extended release naltrexone for alcoholism relapse prevention) at Tarzana Treatment Centers for nearly two years now, with some very positive results.”

Ken Bachrach, Ph.D.
Clinical Director
Tarzana Treatment Centers, California

3. “I don’t know if what I am doing is “innovative,” but it is a different approach to addressing alcohol/drug addiction.  With 26 years in the addictions field, I’ve seen a lot of “silver bullet” ideas about addiction come and go.  I work primarily as a vocational rehabilitation counselor and use my addiction experience as a ministry through my church.

Presently, what seems to be making a difference is a combination of education, Cognitive Behavioral Therapy (CBT), Life Skills, Relapse Prevention and Motivational Interviewing (MI)  with an equal measure of Scriptural teachings about God’s unconditional acceptance of us no matter who or what we have done.   The guilt and shame are at the heart of the problem and if not specifically addressed, will return an addict to using in short order.  Since we are spiritual beings, this component of the “whole person,” in my opinion, is often overlooked or nominally touched upon.”

Mike Mikulski, M.Ed., CRC, LAC

4.  “I have worked at Providence St. Vincent’s in Portland OR and have been reading and enjoying your newsletter for years.  My innovative approach is using SoulCollage® with the clients in chemical dependency treatment and in the General Psych program.  The heart of this strategy is externalizing the “voice” of the part of them that enjoys drinking and doesn’t connect choices to consequences.  Some people call this the “conman” or “the connoisseur” or “the fun loving party gal”.  Others call it the “sophisticate”.

Using recycled magazine images, the client collages a small 5 x 8 representation of this part of them.  And they ask this image to speak in first person about their point of view, motivations, agendas etc.  It’s kind of fun, and they develop an observing ego without realizing it.  They go on to make many other cards representing the wise self, the happy self etc.  As they build motivation for change and move through the stages, they eventually create the recovery self who has goals and motivation to sustain recovery.”

“I’ve attached a little article on the subject.” (If you want this article, contact Suzie Wolfer directly.)

Suzie Wolfer, LCSW
Counseling Services of Portland

Until Next Time

Please join us again in late June.

David Mee-Lee, M.D.

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