TIPS & TOPICS
Volume 6, No.5

September 2008

In this issue
— SAVVY
— SKILLS
— SOUL
— SUCCESS STORY
— SHAMELESS SELLING
— Until Next Time

Welcome to all our new subscribers and to everyone after the summer (or winter) break.

This month in the USA, it has been National Alcohol and Drug Addiction Recovery Month. Even though we are at the very end of September, I will continue this focus in this edition of TIPS and TOPICS.

SAVVY

In the behavioral health field these days there’s a lot of talk about recovery. In my opinion that is a good thing. It puts an emphasis on helping individuals change their lives, not their circumstances (people, places or things). Addiction professionals in the USA usually embrace a 12 Step Alcoholics Anonymous philosophy; moreover they have been emphasizing recovery for years longer than their mental health colleagues. It is interesting that although they often “talk the talk”, they may not always “walk the walk”.

    • Traditional addiction treatment, 12 Step and other Recovery Groups address common client attitudes and behaviors differently. Take note.

See if you agree with the comparisons I charted below.

The first column describes common client attitudes and behavior.
The second column refers to common AA and other recovery groups’ sayings and approaches to that behavior.
The third column addresses how I see traditional addiction treatment attitude and practice.

Inconsistencies in Attitudes and Practice

Person’s Attitudes & Behavior Recovery Process in 12 Step Programs & Other Recovery Groups Traditional Addiction Treatment Attitudes & Practice
1. Ambivalent about abstinence and recovery 1. “Keep coming back” – do the research; you don’t have to get the program; it will get you; stages of change and cognitive behavioral approach (SMART Recovery) 1. Client must agree to abstinence as a precondition of admission into treatment; or “come back when you are ready”
2. Reluctant to attend recovery meetings and groups 2. Outreach with 12-Step calls; offer to be a sponsor; assist with transportation; welcoming and “attraction not promotion” 2. Access to care is difficult; long waiting lists; recorded messages and complicated intake procedures
3. Shows up to a meeting after a few drinks 3. “Keep coming back” – “There but for the grace of God go I”; a good “remember when” 3. Leave and come back when you are sober. Sign a contract that you will not come to treatment if you have used
4. Feels willpower will fix addiction and trouble accepting suggestions 4. “Powerlessness” and helping people understand the paradox of surrender and power; unmanageability and making amends 4. Counselors act as if powerful and able to confront; “break through denial” and coerce a person into recovery; work harder for recovery than the client
5. Involves family and significant others in a web of pain and loss 5. “Detachment” – Al-Anon, Alateen; Naranon; help the family develop serenity and their personal recovery 5. Act as if we will stop addiction; work as hard as the family did to stop addiction; compassion fatigue and staff burnout
     
  • Traditional addiction treatment addresses common client attitudes and behaviors differently from how the physical and mental health do.

Again the third column states how I observe traditional addiction treatment attitude and practice differing from physical and mental health.

Contrasting Physical and Mental Health Approaches to Clinical Dilemmas

Person’s Attitudes & Behavior Physical & Mental Health Recovery Approach Addiction Treatment Recovery Approach
1. Relapse or re-occurrence of signs and symptoms of disorder 1. Viewed as a poor outcome or crisis requiring a timely response; assessment and treatment plan change 1. Viewed as willful misconduct with exclusion from treatment that day and possible discharge from treatment. “Punitively discharge clients for becoming symptomatic” (W.White, 2005)
2. Psychosocial crisis; treatment adherence problems; acute exacerbation of the disorder 2. Discussed as lack of progress and a poor outcome requiring a change in treatment strategies e.g., individual, group, family therapy, pharmacotherapy, case management 2. Discussed as the need for “consequences”, sanctions and possible discharge or transfer to another treatment team and setting
3. Persistent treatment adherence problems 3. Variety of proactive strategies – Assertive Community Treatment (ACT teams); Intensive Case Management (ICM); supported housing and employment; variety of “wet”, “damp” and “dry” shelters; mental health crisis teams to enhance natural and community supports 3. Blacklist client from readmission to the facility; discharge and send notice of case closed; refer to extended residential and inpatient care away from the person’s community with poor continuing care and reintegration into the community; invoke legal sanctions and remove from treatment
4. Severe and chronic illness 4. Utilize levels of care including acute hospitalization; day treatment; outpatient and community-based services; group and independent housing options. No fixed length of stay. Illness, disease and recovery management model. 4. Utilize predominantly fixed length of stay residential programs for those who can pay. Utilize predominantly low intensity outpatient services in the public sector. “Serial episodes of self-contained, unlinked intervention—Relegate post-treatment continuing care services to an afterthought” (W.White, 2005) Repeated episodes of acute care for detoxification; stabilization; discrete fixed program stay; “treatment completion”; “graduation”
5. Poor outcomes 5. Viewed as the need for more intensive case and care management and community outreach 5. Blame the client for denial and “stinking thinking”; non-compliance; stubbornness to take suggestions
     

References and Resources

McLellan A.T., McKay J.R., Forman R., Cacciola J., Kemp J. (2005) Reconsidering the evaluation of addiction treatment: from retrospective follow-up to concurrent recovery monitoring. Addiction 100:447-458. (http://www.tresearch.org/resources/pubs/ConcurrentRecoveryMonitoring.pdf)

McLellan AT, Lewis DC, O’Brien CP, Kleber HD (2000): “Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation.” JAMA. 2000 Oct 4;284(13):1689-95.

Mueser KT, Noordsy DL, Drake RE, Fox L (2003): “Integrated Treatment for Dual Disorders – A Guide to Effective Practice” The Guilford Press, NY.

White, W. & Kurtz, E. (2006). “Recovery – Linking Addiction Treatment and Communities of Recovery: A Primer for Addiction Counselors and Recovery Coaches” Northeast Addiction Technology Transfer Center. Obtain copies from (866) 246-5344. Also www.ireta.org for PowerPoint slides.

White, W (2005): “Recovery Management: What If We Really Believed that Addiction was a Chronic Disorder?” Great Lakes ATTC. www.glattc.org.

SKILLS

Even if you don’t agree with how I have characterized “traditional” addiction treatment, there are still implications worth discussing. These encompass the following areas: client ambivalence, relapse, family work, non-adherence and poor outcomes. This time I’ve changed the third column to reflect how 21st century addiction treatment might operate.

    • Check out your program or treatment team’s attitudes, policies and procedures. How closely do they line up with this vision for addiction treatment?

Vision for New Attitudes and Practice

Person’s Attitudes & Behavior Recovery Process in 12 Step Programs & Other Recovery Groups Traditional Addiction Treatment Attitudes & Practice
1. Ambivalent about abstinence and recovery 1. “Keep coming back” – do the research; you don’t have to get the program; it will get you; stages of change and cognitive behavioral approach (SMART Recovery) 1. Motivational interviewing; stages of change work to focus on ambivalence; “Discovery” plans rather than “Recovery” plans e.g., trying the “just cut back using” plan if not yet ready to embrace abstinence
2. Reluctant to attend recovery meetings and groups 2. Outreach with 12-Step calls; offer to be a sponsor; assist with transportation; welcoming and “attraction not promotion” 2. Process improvement to increase access to care and retention rates e.g., Network for the Improvement of Addiction Treatment (NIATx); work on “drop-out prevention” not relapse prevention
3. Shows up to a meeting after a few drinks 3. “Keep coming back” – “There but for the grace of God go I”; a good “remember when” 3. Assess for immediate safety needs e.g., detox or medical or psychiatric stability. If no acute danger, relapsing client to process in group what went wrong and modify the treatment plan in a positive direction
4. Feels willpower will fix addiction and trouble accepting suggestions 4. “Powerlessness” and helping people understand the paradox of surrender and power; unmanageability and making amends 4. Motivational Interviewing and Roll with Resistance e.g., try the “strong willpower; no AA meeting” treatment plan and track how it is working or not; raise consciousness by “doing the research” in a “Discovery” plan
5. Involves family and significant others in a web of pain and loss 5. “Detachment” – Al-Anon, Alateen; Naranon; help the family develop serenity and their personal recovery 5. Work actively with family and significant others to begin their personal recovery and thus change the family system dynamic
     
  • 21st century addiction attitudes and practices parallel those of the physical and mental health fields.

My vision for 21st century treatment is that we view addiction illness no differently from many other physical and mental disorders- especially regarding relapse possibilities, clients’ common non-adherence with their treatment, the chronic nature of many illnesses and frequent poor outcomes.

–> Whatever the illness, if a patient or client relapses, the first task is to make sure there are no immediate acute needs that are life-threatening. Assess what went wrong; and then what the new and improved, modified plan will be.

You wouldn’t want your physician to discharge you for your elevated blood pressure or blood sugar level; or your mental health professional to dismiss you from a treatment session for getting more depressed.

–> Whatever the illness, if a client does not stick to the collaborative treatment plan, outcomes will be poor most likely. This is an urgent situation. The goal is to re-engage the client and assess what can be done to retain them in treatment.

You wouldn’t want your physician to blacklist you from his clinical practice for your fourth diabetic coma or emphysema crisis, even if you were careless with your insulin or having trouble not smoking. You wouldn’t want your mental health clinic to ban you from their center because you became psychotic after not taking your medication.

–> Whatever the illness, if an individual is getting worse, this simply means that a broader array of services may be necessary. The system of care is designed to encourage illness management in an ongoing continuum of care.

You wouldn’t want your physician to blame you for your worsening hypertension or diabetes; or to simply re-admit you for diabetic coma without managing your diabetes in a long-term fashion. You wouldn’t want your mental health therapist to blame you for getting obsessive-compulsive, or simply stabilize an acute crisis and neglect planning a long term strategy with you.

We can all share and learn from each other, no matter our fields.

The general public still largely views addiction as a self-inflicted problem. There is less tolerance for supporting treatment when compared with physical illness, and even for many mental disorders. What is even worse still is when addiction treatment also embraces policies which appear to view addiction relapse as willful misconduct, needing consequences and possible discharge.

SOUL

How do you decide who to choose for President of the United States of America? That’s easy if you always vote Republican, Democrat, or your favorite third party. But what if you could block out all the marketing messages of the media frenzy; all the ducking and weaving of the spinmeisters; all the conventional wisdom of the cable commentators? What if you could actually decide in the quiet of your own thoughts who would be the best person for this enormous job? What are your criteria? And how would you really know if Barack or John meet those indicators?

Around the world there’s a lot of interest in this decision. Australians get almost as much news about the US Presidential race as they would about their own elections. But then again, the Presidential race is a marathon ten times over; and it is hard to ignore something that goes on for so long. Some counselors from Lebanon visiting the Cape Cod Symposium on Addictive Disorders earlier this month reported there’s a lot of interest in that country as well.

The answer is obvious: Choose whose plans, policies and promises you most agree with. However there is such interplay between the Presidential Executive branch of government and the Congressional Legislative branch that I don’t hold my breath on any candidates’ promises of what they will do when elected President. This is, after all, a democracy not a dictatorship. On top of that, you never know what new crisis is just around the corner (like a 9/11; or the failure of so many Wall Street institutions). The best laid plans and promises can disappear in disarray in a moment.

So how will I make my decision?

I remembered something about intelligence being the ability to use past experience and information to solve new problems. Knowing how circumstances and crises are constantly changing, I figured I would want a President who is nimble and smart enough to solve new problems in this unpredictable world. So I opened Webster’s Dictionary to check out if my understanding of “intelligent” was correct. And sure enough, there it was: “Intelligent stresses success in coping with new situations and solving problems.”

So now you know who I will vote for.

Well not exactly.

It depends on who you think I think is intelligent. We’ll see if millions agree with me in about five weeks. Let the voting begin.

SUCCESS STORY

Here is the success story from a participant at a recent workshop on Co-occurring Disorders. Judy structures it nicely in what she got out of the training: Things to say; things to think; and things to do. In the workshop, we were talking about how to approach “resistant” clients and engage them. Judy sent me a message saying how much she got from the workshop and I asked her to share more specifics of what was helpful with us all.

Here’s what Judy wrote:

“I am always satisfied with a training if I come out with one thing I can use right away. At your training yesterday, I got things to say, things to think and things to do right away that seem likely to help me do a better job right away.

This morning (right away), I met with one of my counselors who had also attended the training. We discussed a case that had been frustrating us because the client had clear priorities that we had thought were unhealthy and self-defeating. Although her solutions had the veneer of recovery, we had decided she was being dishonest, just manipulating to get out of treatment and resume her addicted lifestyle. Nobody was moving and we were all stuck.

Because of your training, we decided to ask her what she wanted (things to say), presume she was being honest (things to think) and help her implement her plan (things to do), provided it was safe for her child and pointed her toward a future she wanted. The first and immediate benefit was that the counselor and I both felt a burden lifted even before we met with the client. It turns out being smug and resentful is fatiguing. The second benefit was that the client obviously and visibly felt the same relief and just as quickly. Realizing that we were no longer “resistant” to her treatment plan, the client stopped defending herself and decided she didn’t really want to leave. Apparently, her talk of leaving treatment was her only way of feeling her own power. The client may yet change her mind and leave, but she now feels her own strength, and knows she has partners and not adversaries as she shapes her life.

Thank you, David. What a difference a day makes.”

Judy

Judith Gorman LCSW, LCDCS
Clinical Supervisor
Sstarbirth
80 East Street
Cranston, RI 02920
401-463-6001

SHAMELESS SELLING

This is not exactly “selling”. But I do want to let you know about a couple of exciting website resources you should check out. One is www.SoberBulldog.com,- the voice of the recovery community. This is a provocative new interactive home for the recovery community.

The other is its companion website for the professional community.

C4 Recovery Solutions is dedicated to improving the effectiveness of substance use disorder prevention and recovery services by:

Coordinating-Designing, implementing, facilitating, and/or monitoring projects and programs to improve outcomes-based prevention and recovery services for substance use disorders;

Conferencing-Providing platforms for the dissemination of effective practices;

Collaborating-Bringing together purchasers, payers, providers, and policy makers to improve collaboration in the implementation of outcomes-informed strategies;

Convening-Initiating constructive dialogues for the professional community OR those interested in recovery to grow and disseminate knowledge and build the effectiveness of all interested groups.

Check out my blog on “What is Recovery?”

Until Next Time

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

David