TIPS & TOPICSĀ 
Volume 4, No.4
July/August 2006

In this issue
– SAVVY
– SKILLS
– SOUL
– STUMP THE SHRINK
– Until Next Time

Welcome to the summer edition of TIPS and TOPICS. (For the Southern Hemisphere readers, it’s the winter edition). August has been a month of stimulating international travel. The rich cultural experience and still vivid images makes writing about clinical behavioral health issues an anticlimax. So this edition of TNT is going to be a version of “What I did on my summer holidays.”

SAVVY

A twelve day trip to India is far too short. But here are some views of this vast and fascinating country and culture with perspectives provoked by our travels.

Tips:

  • Be open to new ideas and find ways to get exposure to alternate perspectives.

At a conference many years ago I was startled when the plenary speaker picked up a full glass of water and started pouring into it from another full jug of water. Of course it was only moments before the overflow was splashing noisily and messily on the stage floor. His point being :(which I will always remember, was easy to grasp, but would never have occurred to me to illustrate it in quite that way)– If you think you know everything, are so satisfied and full of your own knowledge, you will never benefit from new knowledge that will wash over you. It will fall on deaf ears and go to waste.

Nietzsche said it another way in words to this effect: “Convictions are greater enemies of the truth than lies.” Being full of our certainty on how the world turns; what treatment approaches are best; and what I know is the right way to do recovery etc. are all convictions which block openness to new findings. Lies can be exposed for their invalidity. However convictions and ideology are much more embedded in us. People fight, kill and die for their convictions, and see attacks as even more justification to be closed to any alternate perspectives.

Our Indian exposure to a wide variety of socioeconomic groups, rural and urban settings, and such ranges of work duties and human roles – even in a brief stay- made thinking outside of our American ‘cultural box’ a necessity, not a choice. Our first stop was in Bangalore, a southern Indian city throbbing with 7 million people. Roughly 600 new drivers’ licenses are approved every day. 900 newly-registered vehicles hit their already- clogged roads each morning (mostly two and three- wheeled motorcycles-come-taxis.) Never mind the media scrutiny that Britney Spears got for driving her car with her infant on her lap and not in a car seat! Bangalore’s roads were choked with every mode of transportation- jammed with motorcycles carrying dad, mom and junior, all without helmets. Dad talked on the mobile phone while mother shielded the baby- squashed in between them- from the monsoon rains.

Last stop -*Mumbai (Bombay). We were told that 5,000 people move into this vast city daily, villagers pouring in for housing and work. In this metropolis, rather than the countryside, they can at least have a chance at work. Their highway-lined shanties and living conditions sat in stark contrast to the well- appointed, floor-to-ceiling marble/granite designer apartment of the friend of a friend who picked us up at the airport. These folks have the exclusive contract for all advertising and promotion of Bollywood movies and music on the SKY TV satellite network in India. Not many of us have on the payroll a fulltime driver at our disposal. It just seemed obvious to me that people living in those shanty conditions must be sad, frustrated and/or angry. On the contrary, they ‘voted’ with their feet by relocating; our host explained that generally many newcomers feel privileged and relieved that they now have some hope for a better life.

* From Wikipedia, the free encyclopedia / Mumbai is the 5th most populous city on the planet/~18 million

  • Looking at the world through another’s eyes is an illuminating experience.

We received our touring recommendations for Mumbai from “Joanna”! She was taking our May service call from California to Capital One Bank, from her phone in Mumbai (Bombay). Joanna suggested we should visit a meditation center in Pune, three hours drive from Mumbai. So we booked one night there. Our friend arranged for a driver to take us; wait for us and stay overnight; then return us to Mumbai the next day. Eventually when we arrived late in the day, it was clear one night would not be enough. We sheepishly informed our driver we wanted to stay 2 days instead of 1. Would he agree to stay longer and wait for us?

Here was a man who moved from Kolkata (Calcutta) to Mumbai to work as a driver so he could support his wife and three children back home. Mahesh works seven days a week. He sees his family once a year. He is perpetually on call. One month’s pay for him almost equals what three friends paid for cocktails on Saturday night at one of Mumbai’s hot nightspots (where the closest our driver will ever get to such a place is waiting outside.) Back to Pune: Mahesh gladly waited 2 days for us, especially when we tripled the daily allowance his boss typically gives him, so he could lodge at a better hotel and eat more generously.

I cannot imagine working under those conditions. And yet he remained personable, friendly, enjoying sharing his perspectives on family, work, marriage and children- to the extent he understood our questions, and we his responses. If only we could speak his language as well as he understood and bravely ventured into English. I could have learned so much more about cultural differences in attitudes, values and priorities in life.

In the late 1970’s just after China was opening itself up, our Chinese guide shared that he worked in one city while his wife lived and worked in another faraway city. At that time, the government assigned people to their work positions; people willingly accepted. That was amazing to me. I remember asking how he could stand to be told where to live and what job to do, especially separated such a distance from his wife. He looked at me and asked how I could stand to live in a country where I didn’t know if I had a job for sure, nor a place to live!

SKILLS

The clinical applications of such rich international travel go far beyond traditional admonitions about cultural consciousness, competency and proficiency. There are implications for all clinical work.

Tips:

  • Enter individual counseling and family therapy as you would enter another’s country and culture.

Perhaps it is because caseloads and the demand for services are high; or because it is easy for any work to become routine and predictable–but when we enter into the world of clients and their families, it should be with the same respect, curiosity and novelty as a trip to India, China or any other travel destination.

How does this client see the world? What is this client’s view of relationships, family interaction, vocational and living situations, and socioeconomic values? How can I best communicate with this family? Do I speak their same language; or am I using jargon as if speaking a whole different dialect and vocabulary? What is important to this client and his/her family?

Imagine entering another’s country and confronting people for thinking differently from what you value. Could you conceive of seeing a vastly different world view, living and working environment, and being more interested in telling the citizens what they should do to change VERSUS being genuinely curious about how they got there, how they experience their environment and conditions? Could we enter the client’s world with the same openness to new experiences, new perspectives and with the same sense of being lost in unfamiliar territory as when we pass through passport control and step out into a new country and culture? There are a multitude of rich discoveries that open up not only ourselves, but also clients and families to see the world from a different angle.

When the therapist (the “foreigner”) and the client (the “local”) relate in an open and curious way, when there is enthusiasm for one another’s perspective, when there is an attitude of wide-eyed exploration of the other’s “world”, it’s easy to empathize and engage clients.

  • Leave your comfort zone and stretch into territory that leads to new skills and knowledge.

It doesn’t have to be international travel or globe- trotting which stretches you beyond familiar tried and true set of values, perspectives and belief systems. Travel certainly is a faster way to literally and figuratively put oneself in a whole new world, when you sit in a plane for 20 hours and disembark in an India or China. But find some way – if not through travel- to take those figurative ‘cataracts’ that may cloud your viewpoint and vision and replace then with a new set of lenses or glasses.

Are there some team members whose ideas and skills you find hard to identify with? Could you make a renewed effort to reach out and approach them as you would a local citizen in a foreign land? With a new mindset, you could seek to understand; you might compare and contrast your experiences with them; you may decide to be willing to value perspectives different from yours, even those perspectives you never imagined you would ever change.

Perhaps you work with clients and families who, despite your good intentions and hard work, still do not seem to “get it”? To what degree are you willing to start with them in a new place exploring different, unfamiliar approaches which broaden your toolkit of therapeutic interventions?

SOUL

On the last day of our Indian vacation, the front page of the Sunday edition “Times of India” featured three stories which underlined this country of vast contrasts. Within the previous few days, thousands of people had flocked to Mahim creek to wash away their sins in the “miraculous” water that had turned sweet overnight. Some drank the water; others brought sick relatives to dip in the water to cure their illness; and many brought infants in the belief that a wash would keep them healthy for life. Some entrepreneurs even bottled the water and sold it.
The creek flows into one of the most polluted beaches in Mumbai. Government agencies tested the water and declared it “unfit” for drinking. Others elaborated that heavy monsoon rains always dilute the water at this time of year, and that water samples show very low levels of salt. This could explain why normally salty water tasted “sweet”.

On that same page was a photo of an attractive Bollywood actress, Amisha Patel. An Air India employee claimed the actress and her friend got verbally abusive and threatening while flying to the USA. The two women allegedly were so foul- mouthed that other passengers were provoked into summoning the security guards. Amisha countered that she was shocked to hear about the complaint, that in fact, she was planning to file her own complaint against the airline for their rude behavior. “We kept telling the ground staff about a drunken fat man who was misbehaving with us, but they did not pay any heed to our complaint. Even the lady at the counter was rude to us.”

The third article reported that Mumbai was cruising towards its second airport. It would be brand new and built by a consortium of state government, Airports Authority of India and a private investor group. The need for a second airport reflected the tremendous growth and opportunity in Mumbai and India in general.

It’s not so unusual for a newspaper’s front page to report contrasting stories which point to the clash between issues of faith and science, the secular world of pop culture, and the unrelenting push for new development and construction. But I had not witnessed quite this clash since our trip to China in the late 1970’s. It was then that people were beginning to talk more openly against some of the excesses of Mao Tse Tung, their revered leader of 27 years. We saw one of Beijing’s very first commercial billboards advertising cosmetics, when all other billboards to that point sported political slogans. Of course China is a whole different story today.

So I ponder how we view our own families and cultures. How do we deal with the contrasts even between siblings and within extended “families”? I wonder how we approach others whose culture and background are even more removed from our understanding and experience. What we don’t understand provides such a rich opportunity for new knowledge so long as we can get our “convictions” out of the way and keep our glass half full, ready and able to receive more.

STUMP THE SHRINK

Here’s a question to do with placing people in programs versus designing services to match needs and level of function.

Question:

We have a residential treatment center with three beds earmarked by the state for dual diagnosis clients who are severely and persistently mentally ill with substance use problems. In your opinion, and the ASAM opinion, does the borderline personality disordered client fit the criteria for this population i.e. dual diagnosed enhanced treatment?

There is a split decision at our facility on whether they fit the criteria or if they should just be in a straight alcohol and drug treatment center with dual diagnosis capable features.

Please give us your thoughts on this.

Truly
Counselor, Oregon

My response:

My perspective on your question is not to focus on the diagnosis, but more on the function and severity that needs treatment right now. There would be times that a person affected by Borderline Personality Disorder issues might need a DDE (Dual Diagnosis Enhanced) service e.g., suicidal and intoxicated; or self mutilating and impulsive or some psychotic symptoms or dissociation along with substance use.

There are other times that the dual issues need to be addressed but can be handled in a DDC (Dual Diagnosis Capable) service e.g., some suicidal ideation, but not impulsive. However the person is using substance and also needs addiction focused treatment.

States and counties often define severe and persistent as people with major Axis I DSM diagnoses, and not a focus on function and needed services. I can understand the need to have funding distinctions, but it would be better to focus on function and need, not diagnoses. There could be times that a stable schizophrenic-disordered substance user could be well served in a DDC program in an addiction setting.

The ASAM PPC-2R criteria give you guidelines on function-oriented criteria for DDC and DDE. (Readers, if you need information on DDC versus DDE, see the last issue of TNT in June 2006. Thanks,
David

Follow-up Question:

I would like to expand on the questions that I asked you about the borderline personality disordered clients and where they fit into the picture for alcohol and drug treatment, or maybe it doesn’t have to do with it at all.

We do have these 3 beds for the Severe and persistent mental illness (SPMI) persons for residential alcohol and drug dual diagnosis treatment. If there is a client who has had many treatment experiences and has not been able to stop drinking, chronic late stage, would it be appropriate to place them in the dual diagnosis bed? It seems to me that if mainstream alcohol and drug treatment has not been successful with them, we should try a different avenue (DDE). They are not necessarily actively suicidal when not under the influence, but obviously have difficulties with poor impulse control. Once again I would like your feedback on treating the clients who have been unable to remain abstinent, have lost everything.
Thank you.

My response:

With people who continue to use or relapse despite many treatment experiences, it is true that you need to try something different. Why a person keeps using or relapsing, however, is an assessment question that can involve a variety of factors. If you have ASAM PPC-2R (2001) you will see in Appendix C that there are many factors that should be assessed to understand relapse for a particular individual.

(Readers: See Volume 2, No. 6 October 2004 for more detail on these relapse factors.)

The reasons for relapsing can involve any one or more of the ASAM assessment dimensions. A person may continue to use because of a Dimension 4, Readiness to Change issue where s/he is not even sure that they have a drug problem or are very ambivalent. Or they may really know they have a problem, but have poor refusal skills to overcome peer pressure; or have intense cravings for which they have few skills to resist. Or they may live in a toxic environment with poor housing, little money and few positive significant others to support recovery (Dimension 6, Recovery Environment). Or indeed there may be a co-occurring mental disorder that is poorly controlled or stable, which contributes to repeated continued use or relapse.

If the services needed require staff who are skilled in mental health and addiction treatment; and both the mental health and addiction problems are unstable and need to be concurrently addressed, then a Dual Diagnosis Enhanced (DDE) program is appropriate regardless of the specific diagnoses. Again, to me, it is a focus on level of function and current severity needing services that determines the type and intensity of the level of care and program needed. Eligibility for an SPMI DDE bed should be based on the current function and service needs that can only safely and effectively be delivered and provided in that kind of setting and program.

Repeated use and relapse might just as effectively be treated by addressing the Dimension 4, 5 and 6 issues if it is determined in the assessment that those areas explain most of the relapse behavior. These service needs may not need to be done in an SPMI DDE bed. Case management, Assertive Community Treatment team, housing, financial and vocational help and motivational enhancement work may be what is needed. Those services could be delivered by an SPMI program, but also be delivered without a special program as well.

David

Until Next Time

See you in late September for the next edition of TNT.
David