TIPS & TOPICS
March 2006
 Vol 3. No.10

– SAVVY
– SKILLS
– SUCCESS STORIES
– STUMP THE SHRINK
– SOUL
– Until Next Time

Welcome to TIPS and TOPICS, especially the many new readers who have joined us recently. This month’s edition follows-up the February edition which focused on paperwork and the search for more meaningful and efficient ways to address the universal paperwork frustrations. The comments, questions, suggestions and success stories generated by last month’s topic prompted me to extend this paperwork focus for the March edition.

SAVVY

Here’s what a friend and colleague suggested: “As always, I enjoyed reading the current issue of Tips &Topics and I agree with all of your suggestions for reorienting paperwork, recommending the same in my training and consulting. I would like to add one more:

Tips:

  • If you don’t use the information you collect, don’t collect it—–or stop collecting it!

In my experience, I have seen situations in which at some point a regulatory body required the reporting of some specific information. Later on, they stopped requiring it, but it is still being collected.

A second example is collecting information that has little or no relevance to the treatment plan or treatment. There are records in which there is a listing of every first and second degree relative with a substance use disorder and the type. How does that help? If you want to know whether the patient lives with someone who has an active substance use disorder, that is different, but if the patient’s grandmother was alcoholic, how does that help?

My suggestion is when you place all your forms and data collection instruments on the floor (to identify and highlight where there is duplication of data), also look for information that we collect but don’t use.”

Jerry Shulman

Shulman &Associates, Training & Consulting in Behavioral Health
8648 Rolling Brook Lane, Jacksonville, FL 32256
Ph: (904) 363-0667
Fax: (904) 363-0668
E-mail: GDShulman@aolcom
Website: www.ShulmanSolutions.com

  • Check NIATx website for more ideas on paperwork.

“Great issue of Tips and Topics. I would add a visit to the NIATx website, The Network for the Improvement of Addiction Treatment, http://www.niatx.org) to your list of suggestions. There, frustrated counselors and others will find practical ideas to reduce unnecessary paperwork and to increase access and retention in treatment. There are many states involved in this quality improvement process and state directors, including myself, are conducting walk-through visits that open our eyes to the service delivery system from the client’s/patient’s/family’s point of view. Positive changes are being made, and CSAT currently has funding available for states (through a competitive process) to assist with this effort.”

Janet Wood, M.B.A., M.Ed.
ADAD Director
Colorado Dept of Human Services
Denver, CO
303-866-7486 (ph)
janet.wood@state.co.us (email)

Here is an excerpt from a website.  Go to “Key Paths to Recovery”, then to “Paperwork.”

“Paperwork (including regulatory requirements): The challenges associated with medical and administrative records and reports are significant. Information requested should maximize the therapeutic and administrative return as well as minimize burden on staff, patients and families. This is complicated by the need to shift patients between levels of care (sometimes between organizations) as well as by the requirements of different payers and regulators. It is important that regulatory data collection is integrated into an organization’s value-added work rather than layered on top of it (an expensive and demoralizing approach). Key ingredients to managing this problem include: 1) elimination of duplication, 2) forms design, 3) efficient processing, transmission and storage of information through methods such as electronic records, smart fax and OCR.”

SKILLS

I have often suggested that programs for people with substance use disorders have both “discovery” services as well as “recovery” services. Not every client comes to treatment seeking serenity, sobriety and abstinence one day at a time. To attract them into recovery we may need to start at whatever stage of change they present, rather than to start treatment at the stage of change we want them to be at.

This however can be tricky if you work with referral sources or in a setting where total abstinence is required whether the client is ready for that or not. This is how I responded to a clinician in an Army addiction treatment setting where the pressure is on them to achieve abstinence as soon as possible.

Tips:

  • Write Problem Statements in the Treatment Plan that allow the client and you to know how and when progress is being made. Avoid problem statements that are solely a piece of history information.

Here is what the clinician said:

“I’ve been thinking seriously about how we can adapt your treatment planning into our module which requires abstinence. As an example, the Problem List may be:

1. Alcohol related Assault Charges.
2. Command considering Chapter Actions.
3. Marital Problems from Alcohol Abuse. Soldier wants to salvage career and marriage.

What would you suggest for a Treatment Plan beginning? Thanks for your support.”

Here are the suggestions I gave on how to re-fashion the Problem Statements:

1.Alcohol related Assault Charges

I’d suggest you try to avoid having problems that are just history information. It makes it hard to create a goal and individualized strategies, to know what progress is made and what the outcome is. You can’t measure treatment change in an historical fact. Also the goal of problems stated as such often then becomes “To complete the program” or a generic “To develop alcohol free lifestyle” or “To comply with all program expectations” or some equivalent.

Perhaps a better problem statement would be to see where this particular client is at regarding the assault charges: write that down as the Problem Statement. What are his feelings, attitudes, thoughts or ideas about the assault charge?

Problem:
Assault charges but feels it was a one time mistake and not alcohol dependence. (Now we can focus on discovering with the client whether it was a one time mistake, or whether there is more of a problem than he thinks. This will lead to a relevant Goal statement.)
Goal:
To review previous experience with alcohol and identify if there is an alcohol problem or not. This then leads to—
Specific strategies:
1. Review legal, vocational, relationship and health history and see if it is all squeaky clean with no evidence of an alcohol problem.
2. Share his assault events in group and get feedback on what others think; or maybe what an old-timer in recovery at AA thinks and report back to group next week.

2. Command considering Chapter Actions (“Chapter Actions” refers to procedures that could lead to dismissal from the Army)

Ask “What Made Me Say That?” What made me want to say and write the Problem Statement as Command considering Chapter Actions? What is the client doing that concerns his superiors so much? Command considering Chapter Actions is just a piece of the current history and situation, but not specific enough for this client. Nor do we obtain a sense of where the client is at regarding the charges. It is better if we can focus more on what this particular client is doing, and what are this particular client’s feelings, attitudes,thoughts or ideas about this. If the answer is that he sleeps or drinks when on guard duty, then check out whether the client agrees with these concerns or not. Ascertain whether he wants to do anything about it. For example:

Problem:
Realizes he shouldn’t drink on guard duty, but thinks he can just stop without needing any recovery work. Or to word that more succinctly: “I can just stop drinking and don’t need treatment” This could be a more individualized problem statement to start with. The goals and interventions fall into place better and are measurable.
Goal:
To identify how hard or easy it is to just stop without doing recovery work and lifestyle change.
Strategies:
1. Try not drinking for one month and monitor once per week with counselor.
2. Meet with or talk to family, significant others and work to check on how hard or easy it was for client to not drink, as well as to monitor functioning at home and work.
3. Random breathalyzer tests.

In settings that want you to produce abstinence as soon as possible, these strategies may strike you as incompatible. Unless we move to this kind of treatment planning, we only perpetuate treatment compliance and “doing time” in treatment. Treatment should provide an opportunity for the client to do the research on their theories of change. The time for clients to make mistakes is while they are in the structure of treatment where there is the external leverage and mandates present to support the clinician’s assessment as well as the client’s treatment adherence as a condition of continued employment.

3. Marital Problems from Alcohol Abuse. Soldier wants to salvage career and marriage.

This problem statement is more specific. It isn’t a problem statement noting just a piece of history. The client wants to save his career and marriage, and this will drive the treatment plan. You could start with this as the Problem Statement. Or you could also start with a Problem Statement that captures what he wants to work on first. Is the problem this? “I really don’t want to drink and lose everything, but just can’t relax without drinking,” or is it this? “I get cravings to use, especially after an argument, and don’t know what to do”.

The ASAM multidimensional assessment can assist by identifying the priorities to work on to keep his marriage and job. Is it a Dimension 5, Relapse/Continued Use, Continued Problem issue? Does he need help to learn non-drinking relaxation methods? Or does he need help to deal with frustrations and arguments? Is it a Dimension 6, Recovery Environment issue? Are there marital problems that require couples counseling? Or does his spouse need education about addiction and Al- Anon?

Note: If you want more Tips on treatment planning, check these previous editions of Tips & Topics:

. June 2003
. July 2003
. February 2005
. March 2005
. July-August 2005
. February 2006

SUCCESS STORIES

It’s nice to hear from readers about what works for them in their daily work.

Here is how one clinician-reader builds on the theme of engaging people as “customers” when he explains treatment, treatment planning and discharge criteria.

Dr. Mee-Lee:

Just finished reading the latest Tips and Topics. Certainly made a lot of sense. I also wanted to comment on the language usage of “non-compliance” versus “non-adherence.” That also made so much sense to me. I personally started to use that language now in my clinical practice. I use the metaphor of our customers coming into treatment as “shopping in the store” as being no different if I were to go shopping at Wal-Mart, except my store sells services for drug and alcohol use issues. I find my customers really buy into this approach. When I have a customer come in and expect me to just tell them what to do I counter with this phrase, “Have you ever walked into Wal-Mart and asked the girl behind the cash register what you should buy at the store?” Usually I get that look that says “NOOO” and when I present it that I’m like that girl behind the register, the customer has to determine what they want to buy.

I’m here to help you find or show you how to use the products in my store (unless of course they’re looking for something in my store that I don’t carry- I may have to refer them to another “store”). When length of stay comes up, I simply ask “How do you know when it’s time to check out from Wal- Mart?” Usual response: “When I get everything on my shopping list!” Exactly. The Treatment Plan is the “shopping list” for the customer.

It’s amazing how this helps completely change a customer’s perspective of treatment (but also places responsibility and accountability on the customer). Of course, I also have a sign that says “No Loitering-Loiterers will be asked to leave.” When I explain loitering (not shopping for what you say you’re shopping for, breaking the store rules, etc) it sets clear expectations. I guess my point in this is how we present things and language we use is important. Thanks for your time.

Michael Blume, BS, LBSW
Prairie Ridge Addiction Treatment Services
Mason City, Iowa

STUMP THE SHRINK

The following comments continue last month’s focus on paperwork and forms.

Here’s one reader’s email in full, followed by my thoughts on certain excerpts.

“Hi Dr. Mee-Lee:
The issue raised in the February Tips and Topics is an important one. Just to play devil’s advocate, here are some thoughts to consider.

There are several problems with the “rainbow” idea. (Note: The “rainbow” idea refers to different colored forms for substance use history, medical history, social history etc.) First it assumes that every assessor is equally skilled at eliciting the history and second that every patient will feel equally comfortable answering questions for any interviewer.

Then there is the strength that a multidisciplinary approach brings to every aspect of treatment. There is value in having a substance abuse history obtained from both a physician and a counselor. Given the difference in training and experience, the two ask and listen differently. The two probe unclear answers differently.

When the assessor is also the provider (medical or counseling), it is especially important for both providers to have an addiction history interview with the person seeking treatment. The interviewer gets so much more than the words that are on the paper. There is a whole flavor of the person and the disease and the way the two interact and the person’s response. The better we understand people’s journey, the better the care we can provide.

There is value in looking over whatever history is available prior to meeting a patient, provided this can be done and an open mind maintained. It is reassuring to a person to know that the person interviewing is not completely clueless about the basics (“I am here because of methamphetamine for example.”) and is interested in understanding better, in a personal way. There is a fine line here. Acknowledging that the patient’s history has been explored before without parroting that history back again…when a history is parroted back it may more accurately reflect the biases and conclusions of the other interviewer than the story the patient has to tell or has told.

The other advantage of more than one assessment covering the same topic is the opportunity for both interviewers to get together and put the story and the pieces of the puzzle together, each benefiting from all of the other’s expertise and ultimately allowing the person seeking treatment to have both providers have a clearer and hopefully less biased picture. When the stories are contradictory, this too is helpful. Now there is exploration to be done. Is the person ambivalent? Having difficulty remembering, so inventing? Trying to conceal? Each of these possibilities will impact the provider’s approach to the patient.

On a personal note, when I am seeking help, I prefer to repeat the most important part of my need to each person involved. I need assurance that it is heard and understood by the all of the key players.

Here’s to peace and trust and ongoing refinement of the process.”

Reader
California

I appreciate that people take the time to comment and I try to respond to as many as I can. My responses below elaborate further on what I was meaning. Don’t misunderstand me as though I think that “rainbow” forms are the greatest invention since sliced bread. When I suggested the “rainbow” forms last month, this was just one of a number of suggestions on better ways to make paperwork less painful for clients and us. Can we brainstorm ways to make the client chart and medical record more user-friendly, and a living document that helps, not hinders, treatment?

Excerpt:
“There are several problems with the “rainbow” idea. First it assumes that every assessor is equally skilled at eliciting the history and second that every patient will feel equally comfortable answering questions for any interviewer.”

Response:
The “rainbow” forms do not require there be multiple assessors. They could be used with only one assessor. If one clinician uses the rainbow forms, there would naturally be one level of skill in eliciting the history. The information however would be easier to track and easier to update. All relevant information for each section of the assessment is in the same accessible area. It’s true that if multiple assessors use the rainbow forms, there could be variations in the skill of the clinician, and the patient’s comfort with the different interviewers. But not necessarily. The rainbow forms still have the advantages of relevant information being easily tracked and updated.

If more then one assessor gathers information on the same assessment area, they could document any corrections, updates or modifications on the same rainbow form. You could track and see the discrepancies and updates all in the one location in the chart.

Excerpt:
“Then there is the strength that a multidisciplinary approach brings to every aspect of treatment. There is value in having a substance abuse history obtained from both a physician and a counselor. Given the difference in training and experience, the two ask and listen differently. The two probe unclear answers differently.”

Response:
Your program may have the luxury of multiple assessors, with clients who do not feel harassed by several interviewers asking questions about the same assessment area. The rainbow forms, as mentioned above, would allow for each clinician to build on or check the quality and comprehensiveness of the data. In general, I do not see the need for multiple assessors except in areas where a counselor, for example, would be outside of their scope of practice to assess detox. needs or medical status etc.

Excerpt:
“When the assessor is also the provider (medical or counseling), it is especially important for both providers to have an addiction history interview with the person seeking treatment. The interviewer gets so much more than the words that are on the paper. There is a whole flavor of the person and the disease and the way the two interact and the person’s response. The better we understand people’s journey, the better the care we can provide.”

Response:
If I understand your point here, I agree that data gathering is more than words, and that body language, nuance, pauses and hesitations and other subtle signals can speak volumes. Even if you use a computer to obtain client information, it’s important for the clinician to review that information “live” and interactionally with the client.

Excerpt:
“There is value in looking over whatever history is available prior to meeting a patient, provided this can be done and an open mind maintained. It is reassuring to a person to know that the person interviewing is not completely clueless about the basics (“I am here because of methamphetamine for example.”) and is interested in understanding better, in a personal way. There is a fine line here. Acknowledging that the patient’s history has been explored before without parroting that history back again…when a history is parroted back it may more accurately reflect the biases and conclusions of the other interviewer than the story the patient has to tell or has told.”

Response:
I agree with looking over the history prior to meeting the client. Use of something like the “rainbow” forms would allow more efficient access to each area of the biopsychosocial data, and to the corrections, discrepancies and updates from previous clinicians.

Excerpt:
“The other advantage of more than one assessment covering the same topic is the opportunity for both interviewers to get together and put the story and the pieces of the puzzle together, each benefiting from all of the other’s expertise and ultimately allowing the person seeking treatment to have both providers have a clearer and hopefully less biased picture. When the stories are contradictory, this too is helpful. Now there is exploration to be done. Is the person ambivalent? Having difficulty remembering, so inventing? Trying to conceal? Each of these possibilities will impact the provider’s approach to the patient. “

Response:
Again, if you have the luxury of multiple assessors who work well together in an interdisciplinary team fashion, and if it can be done in a way that is experienced by the client as caring and engaging, then it has the advantages you speak of. However, I have seen too often that it is an inefficient formality where the client is shunted from one discipline to the next. Each team member of a different discipline fills out a separate form in a different format, and their form is placed in a different section of the chart. The result is that the client gets asked many of the same questions in a perfunctory way to get the assessment done. A team member would need to be quite conscientious to read each discipline’s assessment, and compare and contrast the data.

SOUL

I was watching James Lipton’s interview of Dave Chappelle on Inside the Actor’s Studio. Dave Chappelle is a wildly popular African American comedian. I find some of his material incredibly intelligent, insightful and funny. My kids find him deliciously irreverent and hilariously funny; they can lip sync many of his comedy routines—must be a college student phenomenon. Listening to how he got started in comedy, it was interesting to hear how he learned from others’ successes and failures—and his own.
Dave’s mother gave him a TIME magazine with Bill Cosby’s photo on the cover plus a story about his life and work. Dave determined then to be a comedian. He would go to comedy clubs on Saturday night and watch what worked for the successful comedians. On Tuesday’s “open mike” nights when wannabe comedians ventured on stage, Dave was there to watch for what did not work and what got those budding comedians booed off the stage. He learnt a lot, prepared himself, and tried his hand at comedy at age 14. And the audience loved him from the start.

Within a year, Dave was invited to perform at the famed Apollo Theater in Harlem, New York. Feeling confident, he made his debut appearance—and was booed off the stage. It had all come so easy for him to that point: he was stunned. But this was a tremendous help to him because he experienced how badly that felt; he determined to learn how to avoid that happening again.

It’s cliché to talk about learning from our mistakes, making lemonade out of the “lemons’ you are served up in life. But we hate it when bad things happen to us. We sometimes drive ourselves and others crazy trying to be perfect. Marci Bauman-Bork, M.D., then at Menninger Outpatient, Topeka, Kansas, said: “Every time I try to be perfect, I am trying to be someone else. Being “perfect” means I am freer to be fully myself. After all, I am better at being me than anyone else could ever be.”

Parents and clinicians can easily want their children or clients to be perfect. (In fact, many addiction treatment programs and mandated referral sources want people with addiction problems to be perfectly abstinent. If the client cannot perfectly control their substance use, slips or relapses, he/she is kicked out of treatment, perhaps loses freedom, children or job.) Dave Chappelle talked about how, as a youngster, he watched hours and hours of TV and used marijuana to cope with problems. He joked that before he could tell time by the clock, he could tell time by which TV program was on. If this show is on, it must be 7:30 PM on a Tuesday. This would rattle any concerned parent—and his parents were no ordinary parents. His father was a college professor and his mother a Unitarian minister.

I will always strive for excellence for the people we serve in our work, for my family and for myself. But I hope I will be kind enough to our clients, my family and myself to realize there are many paths to success. And for the times when the path is not so perfect, the richness of the lessons to be learned cannot be measured in dollars and cents.

Until Next Time

Thanks for joining us this month. Hope you found something you can use in your daily work. See you in April.
David