TIPS and TOPICS from David Mee-Lee, M.D.
Volume 8, No. 4
July-August 2010

In this issue
SAVVY Aging by the numbers; and tips on eldercare
SKILLS Facing your fears, saying good-bye, and planning the future
SOUL What is Your Legacy?
SHAMELESS SELLING The new Tips n Topics book just released! Plus a freebie
Until Next Time

Welcome to a combined July-August edition of TIPS and TOPICS.
With summer vacation on our mind (here in the northern hemisphere at least), I took it easy these two months. But what I include in this edition is not light summer reading. It is, in fact, a topic I have not addressed before in any detail partly because it can be a sad and depressing focus for discussion. I’m speaking of aging, elder care, dying and death. Still want to read on?

SAVVY
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What’s on my mind these past two months is obviously influenced by my 95 year old mother’s fall (her broken and repaired hip), her slow convalescence and changed level of function and independence.

TIP 1
Statistics on why aging, ailing parents and end-of-life issues will increasingly be on your mind.

Source:2007 Study released from American Association of Retired Persons (AARP)

> It’s estimated that 34 million Americans serve as unpaid caregivers for other adults, usually elderly relatives, and that they spend an average 21 hours a week helping out. Millions more grown children are calling regularly, flying into town every few weeks or months or just stopping by to take Mom or Dad to the doctor.

> AARP estimates that the economic impact of this “free” care was about $350 billion in 2006. That’s more than the U.S. government spent on Medicare in 2005. It exceeded the size of the federal budget deficit in 2006.

> Reference: http://www.usatoday.com/money/perfi/eldercare/2007-06-24-elder-care-cover_N.htm

Source: SeniorJournal.com / October 19, 2005

Scope of Survey
>A survey of 815 baby boomers (born 1946-1960; spanning age 64 to age 50 yr. olds) and elderly parents (aged 60-90) examined how both groups interact when the senior parents are ill.

Findings & Conclusions
>13 million baby boomers are caregivers of sick parents and are deeply involved in every facet of their parents’ care, according to a 2005 survey.

>56% of the boomers and their parents surveyed agreed that elders received assistance at least once a week. 25% of those boomers and 22% of those elders agreed that the care was daily.

>Baby Boomers have much more trouble discussing sensitive matters about financial planning, medical care and end-of-life issues with their senior citizen parents than do these parents who are now in their ’70s.

>Reference:http://seniorjournal.com/NEWS/Boomers/5-10-19 BoomersCare4Parents.htm

Source: 2009 Survey by AARP and the National Alliance for Caregiving

Thrust of Survey
> To look at facts on care giving

Findings & Conclusions
>Nearly 11 million people take care of the 5.3 million Americans with Alzheimer’s, a number that’s expected to grow to almost 16 million by 2050, according to the Alzheimer’s Association.

>The survey found that caregivers (most commonly middle-aged women caring for a parent) give more than 20 hours of their time per week.  Most say it interferes with work, and the longer someone is a caregiver, the more likely her own health is to suffer.

>Reference: Los Angeles Times:http://www.latimes.com/news/health/la-he-alzheimers-caregivers-20100726,0,2361716.story

Source: Study from the University of Southern California’s Leonard Davis School of Gerontology

Scope of Survey
> This research is one of a set of studies looking at attitudes and behaviors toward caring for aging parents using the USC Longitudinal Study of Generations, which followed individuals from 333 families over two generations.

> For this study, Gans and co-author Merril Silverstein, professors of gerontology and sociology at USC, examined expected behaviors of adult children towards their aging parents over the 15-year period from 1985 through 2000.

Findings & Conclusions
> The study found that the generation born in the 1950’s and 60’s are more committed to caring for their aging parents than their own parents were.

> The findings, published in the December 2006 Journal of Marriage and Family, run contrary to the popular notion that the institution of the family is in decline.

> Among their findings, an adult child’s desire to care for an aging parent peaks at the age of 51 when individuals are most likely to be called upon to provide parental support. Women consistently express stronger familial obligations towards their parents than men.

>The study also showed that the oldest respondents, presumably those most in need of care, valued the care the least. The researchers say this illustrates that as parents get closer to death, they become more altruistic toward their children – that is, they make fewer demands of them in spite of their growing needs and increasing dependence.

>”Very old adults give priority to their adult children and grandchildren and want to see them thrive, even if it means getting less care then they may actually need,” said Silverstein.

> Reference: http://www.medicalnewstoday.com/articles/58056.php

TIP 2
Tips for Baby Boomers Taking Care of Their Parents

The following tips are excerpts from the May & June 2005 AARP Magazine. They put into words a number of issues which have confronted my brother, sister and me.

·         Face Your Fears
Parents’ demands can trigger elemental fears-the looming specter of one’s own mortality, the scary knowledge that a parent’s decline brings us all a step closer to our own old age. However only by facing fears can we defuse them and put ourselves back in control.

·         Say No-but Gently
It’s not easy-especially when we’re faced with a request we’re not prepared to argue against.  It can even take practice.  Enlist a spouse or friend to act out a scenario in which your parents make an unreasonable demand.  Write dialogue out in advance, supplying your helper with a list of your parents’ usual defenses. Formulate responses to all their potential harangues.

·         Separate Needs From Wants
There’s a chasm of difference between a crucial need elderly parents may have (food, clothing, shelter, and basic kindness) and something they want (two-hour visits every day, your kids to be quiet at the table, a bigger condo in Boca Raton).

·         Make Fun a Priority
Many people mistake quantity for quality when it comes to spending time with their parents. I would argue that it’s better to spend less time with them and make sure those hours are truly satisfying. Plan activities that will bring you together as human beings. If possible, hire caregivers for routine chores; save your own time and energy for more meaningful interactions. Join a book club with your mom, escort your father to an exhibit of Civil War memorabilia. If they are not able to get up and about, find audio books you can listen to together.

·         Do Your Share of the Work
Family dynamics tend to build to a fever pitch when the care of an aging parent is involved. While it’s true that some siblings may be more suited to the task than you, don’t assume they are okay with the situation.  Ask them periodically how they feel about it. And remember, there is plenty you can do from afar-researching a medical procedure on the Internet, subsidizing home care, and sending care packages.

Reference:  You can read more on this at:

http://seniorjournal.com/NEWS/Boomers/5-10-19BoomersCare4Parents.htm

SAVVY
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Our clients – Increasingly the people we serve will themselves either (1) be older adults moving quickly to a time when they will need eldercare, or (2) be the children of such elderly parents, where they’ll struggle to cope with the practical demands of physical care and emotional support.

Ourselves – Though professionally we are clinicians and providers, as human individuals we are all aging and will inevitably face these issues someday.  Because I have been blessed so far with good health, it has been easy to fend off facing issues of aging, sickness, death and dying. I feel nowhere near my age.

These past two months have forced me to confront issues easy to ignore until now. I invite you to do a little inward-looking also.  This will be useful to you and your family, and positively spill over to your clients (and their families) as well.

TIP 1
1. Reflect on these: Stop this Train and Facing your Fears

John Mayer is one of those musical artists who not only entertains, but makes you think. His song “Stop this Train” speaks to his fears that life is moving on quickly (he’s only 32 now); he would like to get off the speeding train and slow things down. I can identify with the earlier statement: “Parents’ demands can trigger elemental fears-the looming specter of their mortality, the scary knowledge that a parent’s decline brings us a step closer to our own old age.”

This is how John Mayer expressed it in some excerpts from his song:

“Stop this train I want to get off and go home again
I can’t take the speed it’s moving in
I know I can’t
But honestly, won’t someone stop this train

Don’t know how else to say it, don’t want to see my parents go
One generation’s length away
From fighting life out on my own

So scared of getting older
I’m only good at being young
So I play the numbers game to find a way to say that life has just begun
Had a talk with my old man
Said help me understand
He said turn 68, you’ll renegotiate
Don’t stop this train
Don’t for a minute change the place you’re in
Don’t think I couldn’t ever understand
I tried my hand
John, honestly we’ll never stop this train.”

TIP 2
Practice these:  Be present; Set boundaries; Have fun; Say good-bye

My sister is geographically and emotionally close to my mother.  My brother and I live thousands of miles away – oceans apart from her.  It is easy to be present and devoted, to set boundaries for a week at a time, for a couple of times a year. But for my sister who is just as devoted to her nuclear and extended family, it is not so easy.

Practice being Present
>How does someone strike the balance – between attending to the increasing physical and emotional needs of a frail parent and the daily demands of the rest of the important family relationships which need ongoing nurturing?

>How do you determine what you should do- i.e. to meet an older adult’s needs without infantilizing them and inadvertently stifling their confidence and independent functioning?

e.g.  Do I rush to take over the task of setting the table as my mother starts placing out the silverware and plates?  Or is it better to let her feel she is still capable of providing for her children and is not an invalid?

e.g.  Do I ask her to wait at the door while I drive the car right to her?  Or would it be better to assist her to walk to where the car is parked 30 feet away so she can get the exercise and stay as mobile as she can?

It’s tricky to be caring without being over-protective and stifling her sense of competence.

Set Boundaries
What are the most effective ways to attend to the crucial needs of parents and older adults (food, clothing, shelter, and basic kindness) and yet set limits on something they might want which may be unrealistic or unachievable (two-hour visits every day, your kids to be quiet at the table)?

Have Fun
> The challenge: How do you plan activities that will bring you together as human beings especially if you have short visits a couple of times a year? How upsetting is it to be fully present with your parent for a few days or a week or two, and then leave them high and dry? My mother says she has to “steel herself” every time I go away, and that is from a woman who is very stoical, supportive and philosophical about where I live and work.

> If you don’t live right near your aging loved ones, it is comforting to reflect on the tip above: “Many people mistake quantity for quality when it comes to spending time with their parents. I would argue that it’s better to spend less time with them and make sure those hours are truly satisfying.”

Saying good-bye
I never had the chance to say good-bye to my father. He got suddenly sick and was in intensive care before I could fly to Sydney all the way from Boston. I doubt he knew who we were by the time all the siblings arrived to see him. I certainly didn’t get to converse and have a meaningful and heart-felt exchange. That is not the case with my mother. At 95 heading to 96, she is still quite cognitively clear. In a few weeks, I want to start saying good-bye. I don’t want her to go, but she is tired and would just as soon “go to sleep”. And who knows when that will be, but here is the opportunity to do what I could not do with my father.

Just as it takes some deliberation and attention in the termination phase of a psychotherapy relationship, this is even more profound.

TIP 3
Plan for the future; Share the Decisions and Share the Work

Planning for the Future
Advance Directives; End-of-life decisions about “Do not resuscitate” orders, Power of Attorney, Wills and Executor of Will; Funerals- what kind? Cremation or burial?; Long-term Care Insurance; Assisted living environments, Nursing home or living with family members; and the list goes on……

Then there is planning for the sunset years (or whatever is the current palatable term): retirement accounts? If and when to retire? When to downsize and move into the condo or the retirement village? Preserving resources in case of long life or severe illness requiring those savings? Or decisions to travel, to gift family, to gift charities, to spend one’s money versus preserving resources for a possible future problem?

Sharing the Decisions
Here are other important issues to consider for your family and in those of the clients we work with:

Because “family dynamics tend to build to a fever pitch when the care of an aging parent is involved”, it is never too late to compare values and opinions of the older adult and the reactions and opinions of family members about such issues as:

·         How do you feel about being in an institution like a nursing home versus living with your children or other family members?
·         In your heart of heart, do you feel your children owe it to you to take care of you in your old age; or would you want to avoid the “burden”, cost and interference to their families?
·         Have you made plans for end-of-life, extended care insurance? Or are you relying on the government or your family to take care of any needs you may have for long-term care?
·         If you find yourself needing 24 hour care, would you rather die than have all medical and surgical procedures be done to keep you alive? Is your answer different depending upon whether you are cognitively clear or not?
·         If you reach a level of function where you don’t feel like eating, walking or socializing (and medical and psychiatric illnesses have been excluded) would you want loved ones to urge and encourage you to improve functioning? Or would you rather they respect your wishes to fade away?

Sharing the Work
This is one I know from personal experience. Due to geography, personality, gender and a host of other factors one of your siblings may be more suited to the task of eldercare than you are. While being sensitive to this, don’t assume the ‘designated” sibling is always okay with the situation.

·         Ask the “designated” sibling periodically how they feel about it. What can I do to help you? (Who cares for the carer?)
·         Again there is plenty you can do from afar-researching a medical procedure on the Internet, subsidizing home care, calling your parent frequently so that emotional support is not the sole responsibility of your ‘carer’ sibling.
·         Visit in person as frequently as you can. Take over duties to give your sibling a break: arrange doctor appointments when you are there; do the food shopping; do the fun trips/ fun activities to allow your sibling to be “off duty.”

Overwhelmed yet? But it is time to start the conversation.

SOUL
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Forty US billionaires have taken up the challenge from Berkshire Hathaway CEO, Warren Buffett, and Microsoft founder, Bill Gates, to pledge a majority of their wealth to charity. This is not just about having so much money you don’t know what to do with it. It is about giving back to society and leaving the world a better place.  This is what you think about when you become older and realize you aren’t going to live forever – especially if you are way past the survival level of existence.  Billionaires tend not to think about how they’re going to get food and the rent money.

Getting older can put you in a reflective mood, wondering what you have contributed to make the world a better place and what will you be remembered for. Not that I have done much reflecting yet because I am still “in denial” that I am all that old. Then I read about poor old George Ferris.  Actually it was poor young George Ferris because he died penniless and unheralded in 1896 at the age of just 37.

I love going to the California State Fair each year!  Every August about now, in Brisbane, my hometown in Australia, they are holding the equivalent to the State Fair: it’s called the Royal Queensland Show at the Brisbane Exhibition Ground, affectionately known as the “Ekka”.  As a kid, each year I couldn’t wait to go to the Ekka organized by the Royal National Agricultural and Industrial Association of Queensland.

That is where George Ferris comes in. You guessed it! You can’t go to a state fair or an amusement park without seeing a Ferris Wheel or two or three. George, an up and coming engineer, created America’s answer to the Eiffel Tower for the Chicago World Expo of 1893.  Sadly he died not knowing that in 1904, his great invention was advertised for sale as scrap metal.  None of Ferris’s paper or plans survived and no one knows where his remains are buried. Yet his name lives on and his invention continues to bring excitement and joy to millions every year.

So who knows what your legacy will be?

Preoccupation with our legacy shouldn’t be the driving force of what we do every day anyway.  But I will make this promise right here and now….that when I become a billionaire, I pledge to give a majority away to charity.  You heard it here and you can hold me to that!

SHAMELESS SELLING
__________________________________________________

Just released…..

I am excited to announce the publication of……

“Tips and Topics: Opening the Toolbox for Transforming Services and Systems”
by David Mee-Lee, MD with Jennifer E. Harrison, MSW.  (158 pages; Sells for $19.95)

I invite you to read it and use the material to translate theory into practice; concepts into clinical services; and be a change agent for people, programs, payers and policy makers.

FYI- Here is a preview of the chapter headings:

Chapter 1: Changing a System of Care is not for the Weak
Chapter 2: Attracting People into Recovery, Even When You Don’t Feel Like It
Chapter 3: Screening and Assessment: Finding Your Audience
Chapter 4: Level of Care…or now you’ve got them…what’s next?
Chapter 5: Turning Paperwork into Peoplework
Chapter 6: Let’s Make Sure That’s What We’re Actually Doing
Chapter 7: Consolidating Systems’ Change: Celebrating Successes, Grieving Loss and Resolving Conflicts

Special Offer !
For the first 800 buyers, I will include a second book, Dynamic Health, for free!

Dynamic Health is a 142 page book of interviews with expert health practitioners, featuring prominent ones such as Bernie Siegel, MD (Patient Empowerment) , Dr. Earl Mindell (Nutritionist & author of the Vitamin Bible), Dr. Norman Rosenthal (best known for describing Seasonal Affective Disorder.)  I was invited to contribute to Dynamic Health, and was interviewed about Co-Occurring Mental and Substance-Related Disorders.

How to buy

Call The Change Companies at (888) 889-8866.
Ask for the Tips and Topics book and the free Dynamic Health book offer.
or
Go online and get started on ordering at www.changecompanies.net/tips-and-topics.php It sells for $19.95.

As always, the TNT monthly newsletters are free and online at www.changecompanies.net.

UNTIL NEXT TIME
__________________________________________________

Thanks for reading.  See you in September.

David

David Mee-Lee, M.D.

TIPS and TOPICS from David Mee-Lee, M.D.
Volume 8, No. 3
June 2010

In this issue
SAVVY and SKILLS Better working relationship with clients
SOUL Families are people too!
Until Next Time

Welcome to the June edition of TIPS and TOPICS.  Like you, I am inundated with information pouring daily into my e-mail inbox.  I save interesting bits and pieces in my “research news” folder. This edition you have the chance to take a peek at some of those.

SAVVY & SKILLS (combined this month)
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Research done in other health fields can spark innovations and application to our own behavioral health work.  In this TNT there are 10 SAVVY tips; I have written the implications for our field at the bottom of each number. These are the SKILLS “tips” for this issue.

1. Patients want to know the truth about their prognosis, nurse writes.

In the New York Times (5/12) “Well” blog, Theresa Brown, RN, wrote, “It’s easy for doctors and nurses to be bold when the news is good; more difficult when it’s not.” Brown noted, “It’s not easy to deliver or receive the news that you or someone you love has run out of options; that there is no hope. But people want the truth. In fact, they crave it.” She concluded, “It may be just as important to tell someone they are dying as to tell them that they aren’t.”
Reference

Implication:
You want your client to be an informed consumer.  Be sure to clearly and completely explain to them your evaluation, diagnosis and their treatment options.

2. Researchers examine some patients’ decision not to undergo lung cancer surgery.

The New York Times (6/22, D6, Rabin) reports that, in order to determine why some lung cancer patients refuse to undergo an operation which could prolong their lives, “researchers asked 386 new lung cancer patients who were eligible for the operation, called resection, to fill out detailed questionnaires about their backgrounds and access to health care.” They found that “patients who reported feeling that they did not communicate well with their doctors were less likely to have the operation, as were those who thought they would not necessarily be better off a year later if they had surgery.”
Reference

Implication:
Communicating with clients is not: just telling them what their problem is and to comply with treatment.
Communicating with clients is: collaborating with them about their options for treatment plus your recommendations.  It also involves inspiring in them a sense of hope and optimism for recovery.

3. Patient’s gender may determine how they feel about their physician.

In the New York Times (5/6) Doctor and Patient column, Pauline W. Chen, MD, wrote, “For two decades, spurred on by the rising number of women going to medical school…researchers have been studying the influence of gender on physician style.” Recent research has revealed that “the patient’s gender determines how patients feel about their doctors, as much if not more than the physician’s.” In fact, one study conducted by Swiss and American researchers showed that “patients, depending on their gender, evaluated their male and female physicians’ displays of concern for their patients differently.” A separate study appearing in the Journal of Women’s Health showed that “women patients were more likely to have discussions with doctors that focused on their illness experience and personal factors, regardless of the physician’s gender.”

Reference

Implication:
Whether you are a male or female clinician, you may experience that women clients may naturally offer more about their needs and treatment.  However you may need to be deliberate with male clients: Invite them to speak up and often; keep asking them about their needs and wants, and encouraging them to voice those.

4. Patients not taking medicine as directed is a national problem.

The Boston Globe (5/10, Smith) reports that “a common conundrum” is “patients who do not take their medication as directed.” Part of the issue can be economic. A study found “that a $5 increase in copayments for cholesterol-controlling statin drugs significantly reduced the likelihood prescriptions would be filled by veterans in Philadelphia. Still, that same study discovered that even when veterans were exempt from copayments, there was far from universal use of prescribed drugs.”

Reference

Implication:
Just creating a goal in your client’s treatment plan- “Medication Compliance”- can be meaningless…..unless they are actively involved in the decision to take medication…unless they actually agree to take their meds…..and unless they are consistently monitored to check if they are adhering to the plan.

5. Medication non-adherence costs over $170 billion in the US annually.

Pauline W. Chen, MD writes in the New York Times (5/21) Doctor and Patient column, “Like politics, religion and sex, medication non-adherence, or noncompliance, remains a topic of conversation that most of us try to avoid. While anyone who has ever tried to complete a full course of antibiotics can understand how easy it is to skip, cut down or forget one’s medications altogether, bringing the topic up in the exam room feels more like a confession or inquisition than a rational discussion.” In fact, “few of us want to talk about medication non-adherence, much less admit to it.” Data show that medication non-adherence costs “more than $170 billion annually in the United States alone.”

Reference

Implication:
Ask your client: “Are you even interested in taking medication?  If you are, can you anticipate what obstacles to taking it might arise? What situations in your daily life might prevent you from taking the medication faithfully?”

6. Small study indicates patient beliefs may affect medication adherence in bipolar disorder.

MedWire (1/5, Davenport) reports that, according to a study published online Dec. 14 in the journal European Psychiatry, “the treatment and illness beliefs of patients with bipolar disorder predict medication adherence and may represent a potential target for modification.” In a study of 35 patients with bipolar disorder, UK researchers found that “patients who were non-adherent were significantly younger than adherent patients…were prescribed significantly more psychiatric medications,” and “were significantly more likely to believe that their illness would have negative effects on their life, and would have a longer-term impact.” Finally, “age and beliefs about whether medications are overprescribed were significant predictors of non-adherence to medication.”

Reference

European Psychiatry
Volume 25, Issue 4, May 2010, Pages 216-219

Implication:
We should never dismiss or underestimate our clients’ belief about their illness and the effect on their lives.  This does affect their adherence to treatment.  Be proactive and elicit what your client understands and believes about their signs and symptoms; and how it does, and will continue to, affect their lives. What do you know about your diagnosis? The prognosis? How do you feel about this? Do you see yourself getting well? Or just living with it?

7.  Even severely-ill patients adhere better if they help choose their own treatment.

Even people with severe mental illness are more likely to adhere to their medication if they are given a voice in choosing it. Duke University psychiatrists found a 27% increase in medications prescribed and a significant improvement in adherence over 12 months among severely ill patients given the opportunity to create an advance directive for their own care.

Reference

“Medication Preferences and Adherence Among Individuals With Severe Mental Illness and Psychiatric Advance Directives”
Christine M. Wilder, M.D., Eric B. Elbogen, Ph.D., Lorna L. Moser, Ph.D., Jeffrey W. Swanson, Ph.D. and Marvin S. Swartz, M.D.

Psychiatric Services 2010, 61: 380-385

Implication:
Severely mentally-ill clients can be seen as hopeless to improve, and therefore are offered just stabilization and maintenance treatment. A recovery-oriented perspective expects and offers more: What does recovery for this person look like? Upgrade your conversation with them. Discuss and discover what is important to them: What do you want in how and where you live? How do you want to spend your time in doing something productive? In having fun?  Who are your friends? And what do you enjoy doing with them?

8. Researchers Identify Factors Predicting Non-adherence To Bipolar Disorder Treatments.

Med Wire (4/6, Czyzewski) reports that, according to a study published in the Journal of Clinical Psychiatry, “poor treatment adherence in bipolar disorder is associated with a number of socio-demographic and clinical factors.” After examining “data from the Systematic Treatment Enhancement Program for Bipolar Disorder,” researchers found that “several socio-demographic features were significantly associated with poor adherence” to treatment, “including younger age (odds ratio [OR]=0.89 per 10-year age increase), Hispanic race (OR=1.48), and having a household income less then $50,000 per year (OR=1.45).” Other “features associated with poor adherence included rapid cycling (OR=1.40), suicide attempts (OR=1.32), earlier onset of illness age (OR=0.77 per 10-year age increase), current anxiety disorders, (OR=1.47), and alcohol use disorders (OR=1.68).”

Reference

Implication:
Not all clients are the same.  Age, race, illness onset, other psychiatric conditions and more help sharpen the “profile” of who might be at greater risk for non-adherence to treatment.  When the odds are stacked against your client, be proactive and vigilant to track and engage that client. Think about more frequent check-in visits; or more social supports like a peer run drop-in center or club; closer case management. Sometimes an ounce of proactive prevention is worth a pound of cure and treatment.

9. Experts propose small financial incentives to help ensure medication adherence.

The New York Times (6/14, A1, Belluck) reports on its front page, “One-third to one-half of all patients do not take medication as prescribed, and up to one-quarter never fill prescriptions at all, experts say. Such lapses fuel more than $100 billion dollars in health costs annually because those patients often get sicker.” But “now, a controversial, and seemingly counterintuitive, effort to tackle the problem is gaining ground: paying people money to take medicine or to comply with prescribed treatment. The idea, which is being embraced by doctors, pharmacy companies, insurers and researchers, is that paying modest financial incentives up front can save much larger costs of hospitalization.” One physician noted that “although ‘economically irrational’…small sums might work better than bigger ones.”

Reference

Implication:
Incentives for negative drug urine tests, attendance at treatment and meeting treatment goals in addiction treatment has been studied for decades.  There is a case to be made for broadening its application in behavioral health.
“Contingency management (CM) – the systematic reinforcement of desired behaviors and the withholding of reinforcement or punishment of undesired behaviors- is an effective strategy in the treatment of alcohol and other drug (AOD) use disorders.” (Stephen T. Higgins, Ph.D., and Nancy M. Petry, Ph.D. “Contingency Management – Incentives for Sobriety” Alcohol Research & Health, Vol. 23, No. 2, 1999, pp. 122-127

10. Placebo treatments may have actual biological effect in the body.

The  AP (2/19, Cheng) reports that, according to a review published online Feb. 19 in The Lancet, “there is increasing evidence that fake treatments, or placebos, have an actual biological effect in the body.” In a “review of previous research on placebos,” researchers found that “the doctor-patient relationship, plus the expectation of recovery, may sometimes be enough to change a patient’s brain, body, and behavior.” The review’s authors specifically cited studies in which patients with Parkinson’s disease who were given a placebo still experienced a dopamine release in the brain, as well as other brain-activity changes.

Damien G Finniss, Ted J Kaptchuk,  Franklin Miller, Fabrizio Benedetti (2010):
“Biological, clinical, and ethical advances of placebo effects”
The Lancet, Volume 375, Issue 9715, Pages 686 – 695, 20 Feb. 2010

Reference

Implication:
This research points to the power that exists when a client expects hope and recovery.  When a clinician (1) establishes a positive therapeutic relationship and (2) engenders this hope in the client, treatment succeeds.  These 2 factors are much more powerful indicators of effective outcomes than the evidence-based practice of a specific technique and model.  General health is just now discovering this to be true; however we in behavioral health have forgotten four decades of psychotherapy research which overwhelmingly proves this.

SOUL
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Consider these three vignettes:

1. A 95 year old, relatively-healthy, widowed woman falls and breaks her left hip.  Her three children, well-educated and respectful, are worried.  They want the best available orthopedic surgeon to pin and plate the fracture; they are willing to pay whatever it takes, but have great difficulty finding out ahead of time what he will charge.  Nurses make the arrangement for the operation.  The surgeon talks to the worried family neither before nor after the surgery, even briefly, to inform the family pre-operatively or reassure them after.

Before you dismiss this as “a surgeon being a surgeon” and that behavioral health clinicians in would never be like that, read vignettes #2 and 3.

2. A clinician evaluates a mother of a two year old. The mother is seeking residential addiction treatment.  Her partner, and father of their child, has threatened to seek custody because of her out-of-control drug use. I ask the assessor: Is it true that the frustrated father would actually do that? Or is the father just so worried and frustrated that it could be an empty threat?  The clinician tells me he didn’t speak to the father.  I wonder: Who will empathize with, and support, this distressed father?  Or does he have to wait for family group which takes place- next week?!

3. A drug addicted woman shows up for admission at a large hospital which has addiction services. She is willing, but strung out; distressed and needs the support of her brother who has accompanied her to assist however he can.  As they both start walking into the admissions office, the staff person says: “Oh no, you can’t come in…just the patient.” The woman says she needs her brother’s support and is OK about confidentiality. The brother is still excluded.

The first vignette is about my mother in Australia who fell last week.  I’m on my way to see her and so far she is doing well.  If I happen to see her surgeon………!!

The second vignette occurred many years ago. I hope my supervision of this clinician paid off and has changed how he engages and empathizes with family members now.

The third vignette
Some years ago, I heard of this case in a presentation from, as I recall,  NIATx.*
The woman was the Vice President of Clinical Services of the hospital posing as the patient; and the “brother” was the Medical Director of the addiction service also posing as the family member. Since it was a large hospital, they were not immediately recognized. It was a real eye-opener to them on how their hospital treated family members.

*(NIATx helps behavioral health providers improve access to and retention in treatment for all of their clients. We do this primarily by helping treatment providers use process improvement methods. www.niatx.net).

I hope these are isolated and rare examples of how families are excluded, unsupported and left to deal with their stress of living with an addicted or mentally-ill loved one; or left to worry and wonder about the well-being of their mother.

I fear this still happens all too often.

Until Next Time
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Thanks for reading.  See you in late July.

David

David Mee-Lee, M.D.

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.

SAVVY

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.

Tips:

*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). http://www.emergencymedicaled.com/Definitions/Signs%20and%20Symptoms.htm
• 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)
•

SKILLS
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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.

Tip

*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: http://www.changecompanies.net/blog/?m=200405

·         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.

SOUL
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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: http://www.changecompanies.net/blog/?m=200601

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!!!)

SHARING SOLUTIONS
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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
http://www.centralvalleyshops.com/content/5117/atr-as

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
MMikulski@mt.gov

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
503-224-3318
suzie@suziewolfer.com
www.suziewolfer.com

Until Next Time
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Please join us again in late June.

David

David Mee-Lee, M.D.