In the July 2011 edition, the focus was on Amy Winehouse, the 27 year old singer-songwriter who had just died. She was famous for having won a Grammy award for her “Rehab” song (“They tried to make me go to rehab but I said ‘no, no, no”). Because of her very public and tragic addiction illness, it was assumed that she died of an overdose. On October 26, 2011, the official ruling on her death was released – “death by misadventure,” Amy Winehouse “died from consuming an extreme amount of alcohol.”
Here were a few more facts about Amy’s medical care:

Amy Winehouse’s doctor, Dr. Christina Romete, said Amy had resumed drinking in the days before her death, falling off the wagon after a period of sobriety.

Dr. Romete saw Winehouse the night before her death, and revealed the singer was “tipsy but calm.” Last month, Amy’s father, Mitch, had speculated that she died from alcohol withdrawal and possibly overdosed on Librium, a drug used to treat her addiction.

While Dr. Romete confirmed that Winehouse had been taking Librium, the coroner’s report suggests the drug played no role in the singer’s death.

(http://www.spinner.com/2011/10/26/amy-winehouse-cause-of-death)

And now, Michael Jackson…….

On November 23, 2011 prosecutors asked a judge to sentence Michael Jackson’s former doctor, Dr. Conrad Murray, to the maximum four years in prison for his involuntary manslaughter conviction in the singer’s 2009 death. Michael Jackson was found lifeless at his mansion on June 25, 2009, about three weeks before he was due to begin a series of comeback concerts in London.

Dr. Murray was at the singer’s house and had given him the powerful anesthetic, propofol, as a sleep aid, which medical examiners said was the chief cause of his death.


“Instead of utilizing his medical knowledge and training to provide Mr. Jackson with proper medical care, the defendant acted as an employee and as a drug dealer and completely corrupted the trust necessary in a proper doctor-patient relationship,” prosecutors stated.

(http://www.reuters.com/article/2011/11/24/us-michaeljackson-idUSTRE7AN00B20111124)

TIP 1
Steps to assess and identify leverage and significant others to promote recovery

I don’t know anything about these celebrity doctors, their famous singer-songwriter patients, or the treatment they provided – except what the press has published. But what I do know is that many doctors and other healthcare professionals have had little training and experience to know what to do about addiction, especially when their patients are “in denial” and not ready to start on the road to recovery.
The celebrity doctor has an even harder time, because the rich and famous can usually reject and replace anyone who tells them the truth about their addiction illness and tries to set a limit on their alcohol and other drug use to save their life.
It is a repeated tragedy that seems so avoidable when a doctor, family member, an employer or supervisor or any significant other has a patient, client or loved one who does not see that they have a substance use problem. We don’t have to wait until a person “hits bottom” or progresses so far in their addiction that it makes it harder to recover. So here is a flow chart on how to assess resistant behavior and create incentives for change in a person who shows up for an appointment but does not think they have a problem. Just maybe, if the celebrity doctors had tried this process perhaps Amy and Michael might still be alive.

Waiting for a person to “hit bottom” may never happen. By the time someone fully appreciates the severity of their substance use or addiction, it may be too late to achieve a good remission and quality of sobriety. Here is more detail on the flow chart in SAVVY to assist in “raising the bottom” – creating incentives for change and recovery.

TIP 1
Use any meaningful leverage to align incentives for change

Step 1: To engage a person in a therapeutic alliance, a good place to start is with “What is the most important thing you want or made you decide to call or come in for help right now? What is most important to you that you would like help with right now?” – This requires actually being interested in what is most important to that person and in helping them get that, if ethical and possible. If you are just interested in telling them what to do, then don’t even ask what they want.

Step 2: It is usual and expected that many people who come to treatment settings do so because of some external pressure e.g., impending loss of a job, a relationship, money or housing – anything of value to that person. If the answer to No. 2 is No (i.e. they are coming in pain and ready to change) then you have someone who presents ready for recovery and wants to change their life. They have already started to recover and you can keep that process moving.

If the answer to No. 2 is Yes (meaning the main reason they present to treatment is to avoid a negative consequence) then the next step 3 is important – to attract a person into recovery by working with incentives, which are of real value to the person.

Step 3: There has usually been some event or person who has gotten the client’s attention sufficiently and this has prompted them to call or show up for an assessment. Explore what that leverage was. Can it be consistently sustained to promote “discovery” and recovery work? Was there a job problem that threatens the person’s career or livelihood? Is there a health or relationship problem that the person wants to improve? These are all leverage points that can all be incentives for change.

If the answer to No. 3 is No, then this is the immediate task: to work with family or significant others, employers, care managers, justice services or school to identify what would attract a person into recovery and create incentives of real value to this person. Would retaining custody of her children be most important? Keeping a relationship or job? Keeping freedom and autonomy by staying out of prison or getting off probation? Feeling healthy and strong again? This is not about punishment or empty threats. All involved must be committed, courageous and caring enough to consistently set limits and/or maintain incentives for change.

Step 4: Even though there may have been a person or event, which got the attention of the client, some people are not always fully aware of the impact of their behavior and attitudes on others. They may not realize how they may be “shooting themselves in the foot”. Does the client really self-identify they have a substance use or mental health problem, which stops them from having a full, successful life? Is there evidence of “change talk”, or is your client more interested in changing other people, places and things than themselves?
If the answer to No. 4 is No (which indicates that the person does not appreciate the impact of their behavior on others) then continue your work with family, significant others, employers, care managers, justice services or school. Again the task is to keep setting consistent limits. Find whatever incentives can be used to engage the client in “discovery”, motivational enhancement. This motivational individual or group work meets the client at their stage of readiness and interest, respectfully moving at a pace that matches their progress and outcomes in treatment.

Step 5: Just because a person is fully aware of the impact of their behavior and attitudes on others, we cannot assume this automatically means they are interested in actually changing. Remember- we do not want to hear the right answer about change; or what others want the person to do or change. You are interested in what the client honestly wants to change or not. Then you can match interventions, which have the best chance of attracting them into recovery.

If the answer to No. 5 is No (meaning that the person does not want to abstain or cut down their substance use nor improve their health) then continue work with family or significant others to sustain any limits set. Continue with incentives that promote “discovery”, motivational enhancement. This motivational individual or group work seeks to raise the client’s consciousness to move towards “change talk”.

Step 6: A person who shows up for an assessment or treatment is motivated to get what they want (Step 1). Before doing your own assessment and recommending your own strategies, first fully explore the client’s assessment and strategies. Many people have specific ideas on what they think would work e.g., “Just tell them to leave me alone”; “Help them see that they are over-reacting or misjudging me”; Find me an apartment”; “Get me disability payments”; “Tell me what to do to be healthy and well and happy”. Or “I don’t want to go to AA meetings, or groups, or residential treatment”; “I don’t want to take medication or that medication”; “I just want medication not therapy”.

When you share with them your concern that their plan may not work, a client often insists on their plan (if you honestly give them the respect and right to make their own decisions). Unless the client is in imminent danger, you will need to start with their “treatment plan” to help them discover whether they can be successful or not.

If the answer to No. 6 is No, this means that the person is open to your strategies and treatment plan. This assumes that you have genuinely given the client every opportunity to question and disagree with your recommendations. Now they are ready for recovery and relapse prevention work.

Step 7: In this step you are observing the outcomes of the client’s “treatment plan”. Did it achieve periods of abstinence or improvement? By starting with the client’s strategies, you build the therapeutic alliance and develop client “buy-in” to the therapeutic process. Besides, since you don’t know everything about everyone, the client might actually be successful -with your help- using his/her skills, strengths and resources. If there are any periods of success, then Step 8 is next – to specifically identify and explore what skills, strengths and resources worked.

If the answer to No. 7 is No (i.e. the client’s own ideas and strategies did not work) then now is the time to have the client try more of your recommendations to achieve any improved progress and outcomes. This will involve pacing your motivational enhancement to match their readiness to give up on their “treatment plan” and strongly-held perspective and strategies.

Step 8: If there are any periods of success, even if only for a short time, you want to support self-efficacy (the optimism and confidence to know that change is possible). Explore and specifically identify what skills, strengths and resources worked. How did the person change their thinking and behavior; who did they work and play with; what did they do for leisure or fun; who did they turn to for comfort and support; what did they tell themselves about who they are and where they are heading? If something worked even for a short time, it can work for longer if they commit to use those skills, strengths and resources again.

If the answer to No. 8 is No (meaning there was no ongoing success) then keep working with the person to try more of your recommendations to improve outcomes. Again, this will involve pacing your motivational enhancement to match their readiness to give up on their “treatment plan” and perspectives and strategies.

Step 9: Continue to encourage and support the client to keep their success going by using their skills, strengths and resources. Caution them that continued success takes maintaining what has worked. It is easy to slip back, which is why it is important to keep tracking progress and outcomes and shifting strategies if a person’s stage and readiness changes. If all is going well, continue the Recovery and Relapse Prevention strategies.

Step 10: Since success is not always an ever onward and upward march towards perfection, “Progress, not Perfection” is the usual path. Whenever there is lack of progress, a crisis, a slip or relapse, a reoccurrence of signs and symptoms, that is a mandate for reassessment. What is the treatment contract and what does the client still want? What is their continuing stage and readiness and interest in changing? What does the client’s multidimensional assessment indicate is working well and what is not effective? With that re-assessment completed, the plan and if necessary, the level of care, can be changed.

I take a lot of plane trips, especially traveling to Australia two or three times a year. On this latest trip in United Airlines Economy Plus (wow, five inches of extra leg room!) the woman behind me kept using my seat back as a pull-up handrail. I think she thought it was OK to jerk me out of my sleep every time she wanted to get up out of her seat. Of course, when she returned to her seat, she again grabbed the back of my seat jerking it while she lowered herself down.

Bathrooms equipped for older adults and those physically challenged do have sturdy, well-anchored, pull-up steel railings to grab onto. An airline seat back is not so sturdy.

Now for the passenger in the seat in front of me.

When he returned to his seat, he plonked into it with such force that it seemed like someone dropping into a bean bag chair six feet below. The whole seat in front of me shook. Then he kept pushing on his seat back coming dangerously close to crushing my laptop computer on the tray table.

You can imagine my reactions to being shaken and wakened by my fellow passengers fore and aft. You see, because I travel so much, I try to be aware of this phenomenon and return to my seat without plonking down or grabbing the seat back. It’s the right thing to do for the person behind and in front of me.

But then I got to thinking why can I do that and they can’t? After I cycled through the judgmental reasons, I realized that unlike my co-passengers, I was not obese and had good balance. It was relatively easy for me to gently lower myself hands-free – no grabbing seat backs; no heavy plonking.

Then the message of Thanksgiving started the flow of the milk of human kindness. Thanks for not being overweight with all those extra pounds to carry that affects agility, balance and maneuverability. Thanks for being able to fly to see family and friends. Thanks for those extra five inches or my computer would certainly be crushed by now.

Thanks.

Thanks for reading. Join us again in late December.

David