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May 2013

Headline news; Do no harm; DOs and DON’Ts in Myanmar


A small proportion of Tips and Topics readers receive the American Medical Association News. When reading some recent editions, two headlines caught my attention. I’ll share them with you and address the implications for addiction and mental health clinicians and services.

Our overseas readers will, I expect, find the first headline less relevant unless you are curious (amused?) by how the USA still struggles to provide universal health care to its citizens. Where you live, you likely have solved this years ago.

Despite the fact that we spend more per person on healthcare than you do, we have poorer quality results. The Institute of Medicine (IOM) reports that the “the panel analyzed US health conditions against 16 nations: Australia, Austria, Canada, Denmark, Finland, France, Germany, Italy, Japan, Norway, Portugal, Spain, Sweden, Switzerland, the Netherlands and the UK.” The report explains: the “disadvantage exists even though the US spends more per capita on health care than any other nation, partly because of a large uninsured population and inaccessible or unaffordable medical care.”)


­Volume, not quality, still decides most doctor pay

This was a headline in the April 22, 2013 edition of American Medical News, page 5.

While this talks about how doctors get paid for their services, it’s also true for how just about every other counselor, clinician and behavioral health program and agency is paid – the more patients and clients you serve, the more money and funding you get.

–> The more services you provide – (individual and group sessions, family therapy, medications and recreational therapy etc.) – the more you can charge (unless you are funded with a fixed case rate.) That is why it has been said the USA has a sick-care system not a health-care system. The incentives are to fill beds or treatment slots with sick people. If the population is well and don’t need you, you’re out of business.

Why is this important if you live and work in the USA?   The Affordable Care Act (ACA) is coming into full force in just over 7 months. The shift in how you will be paid for services will continue to change and pick up pace. It has already started. Hospitals are already being penalized for quality issues like readmission of patients within 30 days. For patients, it was bad if they were quickly released from hospital, became destabilized and then needed to return for readmission. But….it was not bad for hospitals. That kept hospitals’ censuses up, helped pay their bills, maybe even increased their profits.

–> Everyone says they are interested in quality outcomes and excellence. But you have to follow the money. Check with your institution’s budget and finance person. Ask how much your program spends on measuring and tracking outcomes. Then check how much is spent on marketing and expanding services to increase the volume of new clients and increase revenues. My guess is that the budget for the first is a fraction of the budget for the second.

–> I’m not saying marketing and expansion is “bad”. It’s just that the shift in healthcare has already started where quality outcomes will increasingly determine your funding, referrals and revenues than just volume.


Top 10 ways to improve patient safety NOW!

This was a headline in the April 22, 2013 edition of American Medical News, page 12.

The article talked about newly-released evidence on the best areas to prevent harm to patients – things hospitals should be doing to prevent harm. In that setting, this involved things like:

  • Improved hand hygiene compliance – to prevent health-care associated infections.
  • Use of barrier precautions to stop the spread of infections – by wearing gowns and gloves when providing care.
  • Employing pre-operative checklists to reduce surgical complications – the checklist prompts communication among members of the surgical team.   

So I asked myself:

What are the equivalent areas to prevent harm in behavioral health treatment?

A few came to mind, drawing from the first 5 of 13 research-based Principles of Effective Addiction Treatment from the National Institute on Drug Abuse (NIDA):

Principle 1.

“Addiction is a complex but treatable disease that affects brain function and behavior.” – “Drugs of abuse alter the brain’s function, resulting in changes that persist long after drug use has ceased. This may explain why drug abusers are at risk for relapse even after long periods of abstinence…”

In relation to this principle, how do we prevent harm to our clients?

  • We design and deliver chronic disease management of addiction.
    When you “graduate” people from treatment and talk of “treatment completion,” it sounds like you don’t believe addiction is a chronic disease. It creates potential harm if the client and others believe they are “cured” and done with treatment altogether. Patients don’t complete treatment and “graduate” from diabetes, bipolar disorder or asthma care.

Principle 2.
“No single treatment is appropriate for everyone.” – “Matching treatment settings, interventions, and services to an individual’s particular problems and needs is critical…”

In relation to this principle, how do we prevent harm to our clients?

  • We “walk the talk” about true individualized and person-centered services.
    No longer will it make sense to answer, “How long do I have to be here?” with a number of weeks, months or sessions. Then perhaps we can avoid potential harm when the client spends more time focused on their treatment plan, rather than the calendar/ treatment time!

Principle 3.
“Treatment needs to be readily available.” – “Potential patients can be lost if treatment is not immediately available or readily accessible. As with other chronic diseases, the earlier treatment is offered in the disease process, the greater the likelihood of positive outcomes.”

In relation to this principle, how do we prevent harm to our clients?

  • We work to eliminate waiting lists and any barriers to access to care.
    Other areas of healthcare are streets ahead of behavioral health in screening, early intervention and immediate access to care.  Certainly they do not have it all resolved; however we could learn from approaches like “no appointment necessary” experiments, telemedicine and in-home consultations etc. When clients are not moved flexibly through seamless continuums of care (often due to long fixed lengths of stay and lack of community resources for housing and care management), what happens?  Waiting lists lengthen, access diminishes and harm increases.

Principle 4.

“Effective treatment attends to multiple needs of the individual, not just his or her drug abuse.” – “To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems….”

In relation to this principle, how do we prevent harm to our clients?

  • We provide assessment-driven services rather than program-driven care. Using the structure of multidimensional assessment like the 6 ASAM Criteria dimensions, the individualized service plan covers all client needs.

(See January 2011 for more on the 6 ASAM dimensions 

Treatment is not about compliance with a certain program model. It is the development of services to match each person’s unique multidimensional needs. It would be harmful for every patient to get the same medication dose for withdrawal management, diabetes treatment; the same type and intensity of therapy for trauma work; the same vocational counseling regardless of assessed needs. Worse still, outcomes are poorer if housing needs are unaddressed; family and significant other treatment is ignored; and trauma and co-occurring disorders are not detected. It is much more than “don’t drink or drug.”

Principle 5.
“Remaining in treatment for an adequate period of time is critical.” – “The appropriate duration for an individual depends on the type and degree of his or her problems and needs. Research indicates that most addicted individuals need at least 3 months in treatment to significantly reduce or stop their drug use and that the best outcomes occur with longer durations of treatment….As with other chronic illnesses, relapses to drug abuse can occur and should signal a need for treatment to be reinstated or adjusted. Because individuals often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment.”

In relation to this principle, how do we prevent harm to our clients?

  • We engage and attract people into recovery.  We use the whole continuum of care to increase access to, and lengths of, treatment.  Treat relapse, don’t discharge for relapse.

People with addiction rarely seek treatment spontaneously without any external family, work, school or legal pressure.  Typical readiness to change issues, slips and recurrences of addictive behavior will always show up. We need to assess them, not harmfully exclude and discharge from treatment.  How can we call addiction a disease and then exclude people from treatment for recurrences of their signs and symptoms? 

That’s my two cents’ worth. So it’s your turn now. What’s on your Top 10 list of ways to improve patient safety and behavioral health care NOW!? Send me one or two of your Top 10, especially if you have any supporting evidence or data.  


1. Institute of Medicine: U.S. Health in International Perspective- Shorter Live, Poorer Health. Report Brief, January 2013.

2. National Institute on Drug Abuse: Principles of drug addiction treatment: a research-based guide (NIH Publ No 09-4180). Rockville, MD: National Institute on Drug Abuse, 2009


This month, two major publications will affect addiction and mental health treatment providers and programs:

  1. The Fifth edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, DSM-5. (DSM-5 is now released.)
  2. A new edition of The ASAM Criteria.

(The ASAM Criteria will be released in October, 2013) (See SHARING SOLUTIONS for how to Preorder the new edition.)

For most clinicians and programs in the USA, you will need to use DSM-5 to get paid.

The ASAM Criteria will not only help you provide and manage care which prevents harm to your clients and patients, but also get you ready for healthcare reform, if you truly implement the spirit and content of The ASAM Criteria.


Compare how the new edition of The ASAM Criteria addresses all the issues in SAVVY above and more – the goal being to “do no harm”.

Ways to improve patient safety and care How The ASAM Criteria helps design/deliver services  
  Design and deliver chronic disease management of addiction. Current & Continuing New & Additional
The Criteria have always had multiple levels of care to promote a seamless continuum. The new edition expands Level 1 It emphasizes outpatient services for ongoing disease management and recovery monitoring. Level 1 isn’t just a treatment level at the beginning of recovery.
“Walk the talk” about true individualized and person-centered services. Since first published, The ASAM Criteria has advocated for a shift from program-driven services to person-centered, individualized care.   The new edition has a brand new layout. There is a logical sequence from assessment to service planning to level of care placement and continuing care. It will guide you better to the Dimensional Admission Criteria for each level of care.
Work to eliminate waiting lists and any barriers to access to care. It has always been the spirit of The ASAM Criteria, to increase access to care. Clients move flexibly through the levels of care, receiving whatever length of treatment they need. This helps eliminate waiting lists if coupled with more Dimension 6, Recovery Environment community support services.   There is a new section on working effectively with managed care and healthcare reform. This will also help everyone manage care to be good stewards of resources and increase access to care.
Provide assessment-driven services rather than program-driven care. Use the structure of multidimensional assessment (6 ASAM Criteria dimensions) to cover all client needs. The six assessment dimensions of The ASAM Criteria provide the common language of holistic assessment. The new edition expands the discussion of co-occurring disorders. Integration with general health treatment is highlighted for the first time in this edition. Across all health systems, the six dimensions are a common language of behavioral health assessment.
Engage and attract people into recovery. Use the whole continuum of care to increase access to, and lengths of, treatment. Dimension 4, Readiness to Change:
Assessing stage of change is as important   as assessing withdrawal and mental health needs.

Dimension 5, Relapse, Continued Use, or Continued Problem Potential:
This is used to treat recurrences, not used as a discharge policy.
There is an expanded section on Dimension 5. This will guide programs on dealing with relapse as a treatment issue.   If we fund and use the full continuum of care in The ASAM Criteria, we’ll realize the vision of: Increasing access to care Stretching resources to give people longer lengths of stay in the continuum of services Improving engagement, ongoing monitoring and outcomes.


If you think there are a lot of changes coming to healthcare you haven’t seen anything about changing systems until you see what’s happening in places like Myanmar (Burma). Well I haven’t seen it yet either, but I will….and very soon.

By the time you read this edition of TNT, I will be in Myanmar for an up-close and personal look at astounding scenery, temples, cultural transition and sights, sounds and smells so new to me. I’m going for a week of touristing – a new experience for Marcia and me as we meet up with Taylor, our son, for his last week traveling in SE Asia.

Our travel agent sent us a list of DOs and DON’Ts. It’s a quick lesson in cultural competence. Here are some off the list that fascinated me. I’ll add my comments in italics:

Typical Character

  • Friendly, helpful, honest, but proud.
  • Treat everyone with respect and you will be respected. (That’s good advice in any country)   


  • When addressing people, don’t leave out U (which stand for Mr) or Daw (which stand for Ms/Mrs)
  • Speak slowly and clearly. (But will they understand an Australian-Chinese-39 years in the USA accent?!)   


  • Not always necessary to shake hands.
  • Don’t hug or kiss in public. (No PDAs = Public Displays of Affection)
  • Don’t touch any adult on the head. (I’m not one of those TV preacher healers and can’t think when I would touch anyone on the head in the USA, so that shouldn’t be hard)
  • Don’t step over any part of a person, as it is considered rude. (Imagination runs wild thinking about what that situation would be like)
  • Accept or give things with your right hand.
  • In Myanmar, unlike the Indian continent, nodding mean YES, and shaking head means NO. (Phew, that’s familiar)   


  • Let the oldest be served first. (That’s good, since I’ll be the oldest)
  • Myanmar food is often complained about as ‘oily’.   


  • Beware of cheats, swindlers, imposters. (I’m glad we don’t have any people like this in the USA!!)   


  • Stay away from narcotic drugs. (Now that’s good advice for a lot of people worldwide)
  • Health insurance is not available. (Just like the 45 to 50 million people in the USA)   


  • Accept that facilities may not be the best. (Serenity Prayer time)
  • Carry toilet paper in your bag. (Serenity Prayer time)     


  • At religious places, remove footwear, but to remove headwear is not necessary.
  • Avoid shouting or laughing. (No loud Americans here please)
  • Tread Buddha images with respect.
  • Tuck away your feet. Don’t point it toward the pagoda or a monk.
  • Don’t play loud music in these areas. Note that Buddhist monks are not allowed to listen to music. (No booming, thumping music coming from the car beside you. Maybe this should be a rule in the USA)
  • Do not put Buddha statues or images on the floor or somewhere inappropriate.
  • Don’t touch sacred objects with disrespect. Hold them in your right- hand, or with both hands.
  • Leave a donation when possible. (At least the need for money is worldwide)
  • Show respect to monks, nuns, and novices (even if they are children). (“Even if they are children” – Now that’s different)
  • Don’t offer your hand to shake hands with a monk.
  • Sit lower than a monk and elders. (Don’t make your patients and clients do this with your treatment sessions)
  • Don’t offer food to a monk, nun, or a novice after noon time.
  • A woman should not touch a monk. (No women’s lib here)

This is going to be some experience. Can’t wait.

sharing solutions

There’s still time for the special 10th anniversary celebration. The Tips and Topics book for $10 total (shipping and handling free) – that’s $1 for each year. After May 31, it will revert to regular pricing of $19.95 plus shipping.  

TNT book cover

Get selected relevant clinical and systems tips from the years of Tips and Topics all in one place.

“Tips and Topics: Opening the Toolbox for Transforming Services and Systems” by David Mee-Lee, MD with Jennifer E. Harrison, MSW. (158 pages; usually sells for $19.95 plus shipping but through May 31, $10 all-inclusive, except for international orders)

You can buy in two ways:

1. Go to and buy online;

2. Call The Change Companies at (888) 889-8866 and ask for the anniversary deal for the Tips and Topics book.

The special runs through May 31, 2013.

Preorder The ASAM Criteria and get more than the book

The new edition of The ASAM Criteria is coming in October.

If you preorder now, you receive 3 months of free access to the enhanced, web-based version when it releases.  Find out more and preorder at    

  • See video clips where I explain what’s new and what’s coming in the new edition.
  • Opt-in and sign up there to be kept in the loop on the new edition even before it releases in October.
  • See FAQs on The ASAM Criteria.
  • We’ll keep adding more at for all things ASAM criteria.
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