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September 2006 – Tips & Topics

Volume 4, No.5
September 2006

In this issue
– Until Next Time

Welcome to the September issue of TIPS and TOPICS. If you are receiving this in October, it is because we have been playing catch-up all month. Hopefully you will actually receive the October issue in October!


I was listening to the BBC on National Public Radio when they had a program on government regulations. They were discussing ways to decrease the burden of government oversight and bureaucracy. My mind drifted to parallels with accreditation and quality audits in the behavioral health field. A panel member suggested that too much time and effort was placed on compliance with regulations, rather than the outcome the regulation is aiming for. That rang a bell – good advice to our field also.


    • In clinical work and administrative and quality audits, focus on the outcome to be achieved rather than on compliance with program rules, administrative regulations or accreditation standards.

Clinical work

In documentation, Progress Notes are often too general – focused on attendance and compliance, rather than on the client’s clinical progress and outcome of the strategies in the treatment plan.

Examples of general Progress Notes: “More willing to follow rules and compliant with treatment activities”; “Compliant participation in group”; “Attended and participated in all scheduled groups”; “Plan: Continue to monitor”

The goal of treatment is not to get patients and clients to jump through the hoops, to be good boys and girls who do what they are told in the program. When counselors and therapists focus on compliance, clients often seem resistant and frustrating. When administrators and accreditors focus on compliance, clinicians often seem resistant to change.

A client might be trying to deal with cravings through a combination of relaxation techniques, reaching out to others, recovery group attendance and anti- addiction medication. The Progress Note should state whether the cravings are improving with these treatments or not. The important point is whether the cravings are improving, not whether the person is atttending all treatment groups. Now the “continue to

Administrative or quality audits
Too much emphasis is placed on compliance with the administrative rule or quality standard. A better emphasis would be on whether the program is actually achieving what the standard is meant to safeguard.

Here are examples of well-intended standards and audit procedures designed to assure quality and safety:

1. All clients will be informed of the benefits and risks of their medication. Compliance with this standard will be monitored by percentage of all medical records which have signed consent forms present and up to date.
2. All clients will have an individualized treatment plan based on their goals, preferences and stage of change. Compliance with this standard will be monitored by review of ten charts at random. The quality audit will review the degree of individualized Problem statements, Goals and Objectives, Interventions and Progress Notes.


An agency might achieve 100% compliance with signed consent forms or beautifully-written individualized treatment plans. But the real question is this:
–>Do clients really know about their medication?
–>Do they even know what their treatment plan says and what they are working on?

These questions suggest an alternate way to audit quality and safety:
–>Interview ten clients at random. Measure what percentage can describe the medication they are taking, why, and what the benefits and risks are.
–>Interview ten clients at random. See if they can tell you about their treatment plan, and if it is helping them.

I travel a lot and many of the hotels I stay in provide a welcome letter and at the end of the stay, another reminder. Their main focus is on the outcome of my stay. The letters say something to the effect that if there is anything that would prevent me from giving them the highest rating of satisfaction, they want to know about it at the time, so they can fix it. They also want to know if my complaints were satisfactorily responded to.

Probably they have supervisors who check that the rooms are cleaned, refurbished to certain quality standards; they likely audit workers to ensure that they comply with all rules and standards. But 100% compliance is secondary; it takes second place to whether the customer had a pleasant stay and would return and recommend the hotel to others.

Perhaps it’s time!

With the degree of stress, time, energy and resources that go into paperwork as well as administrative, accreditation and quality audits, perhaps it’s time to shift the emphasis with clients, documentation, CARF and JCAHO surveys, and administrative review.


While online the other day, a pop-up screen blared “Things that don’t make sense” — I didn’t even pursue what they were selling. However it became the inspiration for this month’s Skills section.


    • Things That Don’t Make Sense – a list of a few things (in no particular order) and a little bit on what to do about it.

Things that don’t make sense- No.1
Agencies recognize that 50% of the client population has co-occurring disorders, yet only one or two clinicians on the treatment team is skilled or competent in the other disorder.

It is not unusual for me to ask a mental health program how many of their clients have co-occurring mental or substance use disorders. Most estimate 40% to 50% or even more. Then I ask who on the staff is a certified addiction counselor. Again it is not unusual to hear silence or: “I think Joe used to work in a detox once. He’s here on weekends.” And the same is in the reverse on addiction programs: “I think Joe used to work on a psychiatric unit once. He’s here on weekends.”

What to do about it
If there are not resources to hire more people, make sure that the next staff member who leaves is replaced with whatever expertise is needed: someone with addiction or mental health competency. Or start trading staff to co-lead a group; or spend a week at the other program.

Things that don’t make sense- No.2
Agencies that believe that addiction is a chronic, relapsing illness but then, on intake, tell a client that if he uses alcohol or some other drug, that he should not show up for group that day. Or if he does show up for group, the policy is to send him away.

I have never heard of a program or clinician telling clients, on intake, about a policy like this: If you should get depressed or suicidal, manic or psychotic, panicky or anxious, do not come to treatment that day. I could not imagine a program turning someone away because they showed up to a session with the very problem for which they are getting help. As William White puts it, programs/clinicians “punitively discharge clients for becoming symptomatic.” (White, W (2005): “Recovery Management: What If We Really Believed that Addiction was a Chronic Disorder?” Great Lakes ATTC.

What to do about it
First decide whether you really believe that addiction is often a chronic, relapsing illness just as that can be true for schizophrenic disorder, bipolar disorder, major depressive disorder and panic disorder. Examine whether we still hold some of the stigma and attitudes of the lay public. They view addiction as willful misconduct with a need for consequences. It is hard to treat co-occurring disorders, if we have such different attitudes about mental disorders versus substance use disorders.

Things that don’t make sense- No.3
Clinicians excluding an addiction client from group treatment when she shows with alcohol on her breath. There’s a fear she might trigger other group members. In contrast, they are quite comfortable with a mental health client talking about domestic violence or sexual abuse even though that talk may trigger others in the group.

I have never heard of a therapist asking someone to leave group because their sobbing or severe anxiety disturbed another group member and made them feel uncomfortable or even angry. Yes we need to keep the treatment milieu safe and therapeutic.

**Do not misunderstand:
I am not saying that if a person is severely intoxicated – slurred speech, cognitively unable to participate- that we continue to do group or psychotherapy with them. These are urgent needs that must be addressed. You would do the same with an acutely suicidal and impulsive person where establishing safety is also the top priority. Nor am I saying that if the client is intent on using substances and trying to get others to use with them that we just ignore that and continue treatment as usual. But if a person is wanting help, what better place to be triggered! Triggered in a therapy group with trained therapists, right there to help both the client who relapsed and any others who could identify with the same struggles and loss of control.

What to do about it:
Make it clear to all clients that recurrence of use is a treatment alert. Similarly recurrence of psychosis, mania, depression or suicidal thoughts and behavior are also significant events that need professional assistance. If a client is willing to reassess their treatment and change their plan in a positive direction, then treatment continues.

Things that don’t make sense- No. 4
Clinicians who have assessed a client as being quite out of control, severe and a chronic relapser who needs residential treatment. But then the client is placed on a waiting list for anything from days to weeks.

I have never heard of a patient who needs the intensive care unit being placed on a waiting list. I cannot imagine a pregnant mother who is in labor and coping with increasing labor pains being told to come back later when a bed is available. By the Patient Placement Criteria of the American Society of Addiction Medicine (ASAM) a client who needs residential treatment has one or more dimensions that are of such severity that the client would be in imminent danger if not in a 24 hour setting. How such a person can now be placed on a waiting list is one of those things that don’t make sense.

What to do about it:
Use residential treatment and 24 hour care for those who are truly in imminent danger. This frees up beds that allows timely admission of people who really need a residential level of care. If someone is safe enough to be on a waiting list, then by definition, they don’t need residential treatment. These clients still need services, but can be started immediately through a combination of outpatient, intensive outpatient, or partial hospital care and structure; coupled with supportive living.

I realize that I may be stamping all over your sacred cows or core beliefs. Accept whatever stage of readiness to change you select. My goal is not to step on your toes, but to have you think about what you or our agency does—and to ponder Things That Don’t Make Sense.


Early this month, Steve Irwin, the “Crocodile Hunter” died. He was doing what he loved most, interacting with wild animals he respected and protected. I watched the final tributes to this unique individual. It was sad to realize that the contagious enthusiasm and committed passion he exuded would only be seen now in time-warped reruns.
I mention Steve not just because he was a fellow Aussie from my hometown region in Queensland, Australia. (There is a level of pride and admiration that a down-to-earth, authentic, engaging man from way Down Under could influence world opinion and millions of viewers.) I mention Steve because he demonstrated so well what just one person can do to “change the world.” His passion and pure joy in what he believed shone through. Yes, there was probably some savvy marketing and skillful production thrown in. But Steve Irwin’s unbridled energy and total commitment to his mission attracted many to hear and embrace his message.

This writer, this Aussie guy from Queensland, Australia, will never reflect the same level of raw authenticity and risk-taking adventures as the “Crocodile Hunter”. But Steve Irwin’s life and death inspires me (and millions of others) to stay focused and enthusiastic about what we believe and to convey that in a way that attracts and engages people. Advocacy for the thousands of just causes and world-saving priorities is increasingly becoming strident, divisive, adversarial and polarizing. Unfortunately few political campaigns will actually survive unless someone airs the first negative and often vicious TV or radio ad.

Watching the sheer joy of Steve as he raises our consciousness about endangered species and other causes dear to his heart, is in stark contrast to the mean and angry ways of many advocacy efforts. The “Crocodile Hunter” has shot his last piece of video. Yet he still looms larger than life with his smiling face and signature exclamation of “Crikey!”. It is hard not to smile along with him and wish for a world where standing up for what you believe doesn’t have to mean cutting down whomever disagrees. Thanks Steve, the world will miss you.


Here is a success story that addresses how to engage physicians on your team:

“Getting physicians to agree to provide psychiatric care for persons with co-occurring disorders( COD), particularly if they are still actively using substances, can be a challenge. Whether it is starting or continuing psychotropics regardless of use, being cautious or developing discontinuation plans for benzodiazepines or other addiction medications, or prescribing medications to manage cravings or detox itself, clinicians can often see doctors as a barrier, rather than a member of the team. This can create lots of frustration on the part of clinicians, and a sense that “we cannot move forward in effective treatment because our doctors won’t support our efforts.”

Although every medical staff includes doctors from a variety of perspectives, our medical staff tends to be highly concerned about liability risk, and conservative in prescribing practices, especially with persons with substance use disorders. As a result, we seemed to have lots of people with COD either not getting any medication until they were “30 days clean” (which they could never achieve of course without treatment for their mental health disorder), or on massive doses of PRN Ativan or Klonopin because they had told the doctor they “couldn’t sleep, were anxious, and had racing thoughts.” Although these symptoms could very well have been accurate, it didn’t seem to the rest of the team that using benzodiazepines was the best way to deal with it, and then when the clients began abusing the addictive medications by taking more than prescribed, getting prescriptions from multiple doctors, or buying or selling their medication, our doctors would cut them off entirely after applying the “drug-seeking” label, which was painful even to watch.

Over a good period of time, we tried several unsuccessful measures to address this issue. We would argue with the doctors, and increase their resistance. We would try to get more “COD friendly” doctors, who quickly became overwhelmed with complex clients without a team to support them. We would despair—always a helpful strategy.

Then one day, after developing an educational tool for clients called a Benzodiazepine Client Agreement, which our medical director bought into and even recommended some fine-tuning to, I mentioned that one of our agency teams was undergoing an Integrated Dual Disorders Treatment (IDDT) fidelity visit. I happened to mention that there were psychopharmacology practices that were measured and scored. The doctor asked how the scoring worked, and I explained that it was a 1-5 scale, 5 being the most fidelitous to the practice.

He then said, “so, what does it take to get an A?” I almost missed that, because I am so focused on representing the fidelity process as a clinical quality improvement tool, not a score or audit, until I saw his eyes light up when he asked the question. Our medical director, like many psychiatrists, is very educated, very bright, and very focused on achievement.

So, instead of correcting him, I explained what an A would mean:

Prescribing medications to treat a psychiatric illness you are reasonably sure exists regardless of substance use; actively minimizing addictive medication usage; and prescribing medications to manage the addictive disorder. I also added that the whole team was charged with supporting a doctor in their treatment, and that issues such as screening, eligibility, client directed care, and stage-wise interventions were also “graded.” That was music to his ears, and not only did he fully support applying those practices himself and educating and advocating for the same practice with other physicians in the medical staff, he also asked to pilot screening measures (the DALI-14) to be used for all clients coming to the medication clinic, so the doctors would know which clients were more likely to have an SUD, so they could be aware of this in their treatment.

“I had never thought that getting a good grade would be what moved our medical staff along in their readiness to change, but it seems to be working.”

A Michigan Clinician, 2006

Until Next Time

Thanks for reading. See you in the next edition of TNT.


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