Vol. #15, No. 8

Welcome to the November edition of Tips & Topics (TNT). To all of you in North America, I hope you had a great Happy Thanksgiving. Wikipedia says that Thanksgiving is also celebrated by some of the Caribbean islands, and Liberia. But I don’t have any Tips & Topics readers there.

Senior Vice President

of The Change Companies®

SAVVY, SKILLS & STUMP THE SHRINK

I frequently receive questions from readers that I answer under a section we call “Stump the Shrink”. Of course I only put in the questions I know the answers to. This month I’m combining Savvy, Skills and Stump the Shrink to include some of the recent questions you may be interested in.
TIP 1
Address client complaints in a person-centered, not counselor-centered manner
Question:
Dr. Mee-Lee, I have a question regarding changing counselors in a residential treatment setting. A person receiving services has stated that she feels that her counselor hates her. She talked with the supervisor and requested another counselor. It was denied. The counselor then gave the person receiving services a book regarding resistant clients in treatment. How would you suggest that a situation like this be handled in a more person-centered manner? Thank you for your time in this matter.
Jan, Minnesota
My response:
Hi Jan:
Thanks for your question. Here are some thoughts:
1. You said the person spoke to the supervisor, but did the person first speak directly to the counselor to share their concern? In any conflict between clients and counselor or staff member to staff member, it is best to have the person talk first at the lowest level of involvement. Then pull in the next level up of authority if the conflict is not resolved. So the client would be encouraged to first talk to the counselor before the supervisor gets involved.
2. If the person said, “I already tried talking to the counselor and it didn’t go well, which is why I am coming you”, the supervisor, then the next step is for the client, counselor and supervisor to meet together so the supervisor can observe how the counselor responds. The supervisor may see that the request for a change is appropriate or if not, they can all discuss why a change would not be helpful and how to work on the conflict in future sessions.
3. If the counselor gave the person a book regarding “resistant clients”, as in this case, that signals to me that the counselor puts all the blame on the client, which would concern me about the counselor’s competence (and maybe even that of the supervisor) though I would need to hear all sides of the decision-making. The 2013 edition of Motivational Interviewing doesn’t even use “resistance” any more because clinicians should be looking as much at their contribution to so-called “resistance” as blaming the client.
Here’s a quote from page 197: “…our discomfort with the concept of resistance has continued to grow, particularly because it seems to place the locus and responsibility for the phenomenon within the client. It is as though one were blaming the client for “being difficult.” Even if it is not seen as intentional, but rather as arising from unconscious defenses, the concept of resistance nevertheless focuses on client pathology, under-emphasizing interpersonal determinants.”
(Miller, William R; Rollnick, Stephen (2013): “Motivational Interviewing – Helping People Change” Third Edition, New York, NY. Guilford Press.)
Hope this helps, but let me know if not.
Thanks.
David
In the February 2007 edition of Tips & Topics, I wrote about conflict and a conflict resolution policy. If you don’t have such a policy where you work, here is one to consider:
 
 
TIP 2
Engaging youth in treatment and using ASAM Criteria levels of care
Question:
Good Morning!
I took a refresher course in ASAM Criteria this past weekend. I was compelled to reach out. Strange how my 10 years in the field has added a “reality” lens to my use of the Criteria. Dealing with insurance companies and limited availability of resources has surely effected my clinical impressions.
 
Working in Portland, Oregon you would think we have great resources, we do – for adults. However, for insured adolescents there is almost nothing. I work with these families. I have a few clients in my outpatient practice who could use Level I (ASAM Criteria Outpatient Services) or Level 2.1 (ASAM Criteria Intensive Outpatient Services) levels of care. It turns out, I am their ONLY source of treatment. I carry my CADCII as well as an LCSW, but I CANNOT meet the needs for clients who need a higher level of care.
 
Any thoughts?
 
Also, what is my responsibility (ethically) working with teens who have no interest in decreasing their use? I am engaging in Motivational Enhancement Therapy (MET) with these folks but I feel a bit stuck.
 
Thanks for your guidance,
Beth Rossi, LCSW, CADCII
Hillsboro, Oregon
My response:
Hi Beth:
Thanks for staying up on The ASAM Criteria and sounds like you are doing some good work with adolescents and their families. While you may not have a lot of access to residential levels, from an ASAM Criteria perspective, clients only need 24 hour treatment in residential if they are in imminent danger* and life threatening risk to self or others or of running behavior with severe consequences like fire setting or prostitution etc. Unless a client is in imminent danger, residential levels should not be used to “break through denial” or just get them away from their environment. Such treatment ends up focusing on behavior control for a young person not interested in learning about prosocial behavior change and recovery. The focus of behavior control treatment is on adolescent rule breaking and loss of privileges and setbacks in the phases of the program rather than on treatment and recovery.
So one question I would have for you is what are the clinical reasons you think your adolescent clients need a more intensive level of care than you can provide?
As regards working with teens not interested in decreasing their use, that is normal for most clients who are motivated more for getting people off their back or avoiding some consequence they don’t like e.g., limiting their curfew, being sent to a foster home or juvenile hall. So the focus of treatment you do is “discovery, dropout prevention” not “recovery, relapse prevention”** using as you are doing MET and Motivational Interviewing. You help the teen discover, at a pace that makes sense to them, a connection between drug use and the consequences they don’t want. Also you want to keep them engaged to not drop out. It is hard to help someone if they are not there!
Here is an example of “discovery” motivational work for a teen who doesn’t think he has a drug problem because “I can stop any time I want”; and certainly doesn’t see anything wrong with hanging with his drug using friends:
Treatment Plan Strategies:
1. Jordan will gather all the data he can from school, family, legal history to prove he doesn’t have an addiction problem.
2. Jordan will demonstrate he doesn’t have a substance use problem by just stopping all use; and continue hanging with his friends to see how well he does with abstinence as measured by random urine drug screens.
So long as the teen is willing to try these “discovery plans” and is adhering to them, you keep working with them. If a client doesn’t show up or doesn’t follow through on a treatment plan you collaboratively agreed upon, then you could be “enabling” the client. By that I mean, that if outcomes are not going well, and the teen keeps getting into trouble with their substance use or behaviors, the next step is to assess what is not working and change the treatment plan in a positive direction. It is “enabling” If the client is not held accountable to change the treatment plan in a positive direction and you just continue to see the client. The client gets the message that there is no real expectation to change or take responsibility for treatment.
Any changes to the treatment plan can be a small incremental step e.g., “OK I will stay away from Harry who is the hardest person I have trouble saying “no” to. But I’m not giving up all my friends.” That is a change in the client’s treatment plan in a positive direction so treatment should continue. That is progress and you keep going. But if the client does not see anything s/he will do in a positive direction, then just keeping the person in treatment is enabling. The client has the right to choose no further treatment and then you let the consequence happen.
Hope this helps, but let me know if not.
Thanks.
David
* Imminent Danger (The ASAM Criteria 2013, pp. 65-58) – Three components:
1. A strong probability that certain behaviors (such as continued alcohol or other drug use or addictive behavior relapse) will occur.
2. The likelihood that such behaviors will present a significant risk of serious adverse consequences to the individual and/or others (as in reckless driving while intoxicated, or neglect of a child).
3. The likelihood that such adverse events will occur in the very near future, within hours and days, rather than weeks or months.
  
** I first wrote about “discovery, dropout prevention” and “recovery, relapse prevention” plans in just the third edition of the first year of publication of Tips & Topics – June 2003. If you’d like to read more on that, here’s the link:

Beth’s response:
Dr. Mee-Lee:
I really appreciate your feedback. You have given me numerous points to consider. What is my role for these clients? Therapist or addiction counselor, usually BOTH roles apply.
 
I guess for some reason I am fearful that parents/guardians will have expectations that I can decrease/prevent substance abuse in their teen. Having worked in residential facilities in the past and knowing that parents sometimes think treatment = abstinence. Now that I am processing it, I realize I am placing some high expectations on MYSELF!
 
I am currently working with a family whose daughter was in imminent danger and I could not get her treatment until she made a suicide attempt (after running away with drug use and prostitution). Now she is in treatment in another state and we are engaging in weekly sessions via telephone. Her progress is limited.
 
I feel that some of my adolescent clients need 2.1 level of care and I do not have the time in my schedule to provide this amount of client contact/treatment.
 
Maybe I am looking at the ASAM Criteria too literally? I do not need to place someone AT a facility just to place them using the Criteria. I need to be more flexible in my thinking! 😉
 
Thanks again!
Beth
 
 
My second response:
Yes, Beth, with your training you are actually able to do integrated co-occurring disorders work, which is what a lot of clients need but can’t obtain very well.  For most youth, motivational work is going to be where to start- once any imminent danger situations have been stabilized.  I wonder if your client ,who is in residential treatment, is actually receiving motivational work; or whether she is expected to be interested in sobriety and recovery when she might not be.  That might be contributing to what you said is happening: “progress is limited.”
You are in a good position to do that motivational work once any imminent danger activities are stable.
All the best,
David
 
References:
1. Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies.
2. Miller, William R; Rollnick, Stephen (2013): “Motivational Interviewing – Helping People Change” Third Edition, New York, NY. Guilford Press.

SOUL

As I write this, I am on a plane en route to India to conduct three days of ASAM Criteria training. Making this training happen has been a labor of love for both the organization in Pune, (not far from Mumbai or previously, Bombay) and for me as well. They have very limited resources, yet the Executive Director has been passionate and single-minded about introducing The ASAM Criteria to India.  I couldn’t let her commitment over the past two years go unsupported.
When they finally found enough resources to conduct the training, it was a rush to match my limited availability with their window of dates too. That made getting an Indian entry visa a time-pressured, tense process: completing a complicated visa application (three times to get errors correct); photos; several approval processes, some requiring

more documentation, explanatory phone calls, waiting…….more waiting, more documents and explanation – all of this to just enter the country for a week to do an ASAM Criteria training to physicians.

Once all the documents were declared accurate and the complete, the tension shifted to the Embassy’s processing the application. Would the visa come on time to make the trip? Why did the tracking update information on their website stay stuck for days on “Under Process at Embassy”? All I want is to do a 3-day training in India, I am not wanting to immigrate; or steal any resources; or terrorize the country.
In the process, I expanded my empathy for the millions applying for a visa to enter the USA. Getting an Indian visa was not life and death. The worst that could happen is the training got postponed.  However for many seeking asylum and safety in the USA, it is literally life and death. And they are not waiting just for a few days or weeks. The wait is often years, maybe decades!
I am so grateful to hold a passport to two wonderful countries – my country of birth, Australia; and my country of choice, the USA.  Coming and going so freely with passports many would die for trying to get them, is easy to take for granted.
My Indian visa experience reminds me that freedom to come and go is to be treasured.

Until next time

Thanks for joining us this month. See you in late December.

David