TIPS & TOPICS
Volume 7, No.1
April 2009

In this issue
— SAVVY
— SKILLS
— SOUL
— STUMP THE SHRINK
— SUCCESS STORIES
— SHAMELESS SELLING
— Until Next Time

Time flies when you are having fun. This month’s edition begins year seven of TIPS and TOPICS (TNT). A special welcome to those of you who have been here from the beginning with our first edition in April 2003. If you are a new subscriber, welcome too.

SAVVY

At the beginning of a “new year” for TIPS and TOPICS, I wanted to remember and reprise some favorite themes of past editions. I have drawn on some of the material from previous editions and added new content which supports and confirms the SAVVY and SKILLS of earlier years.

Commonly Used Phrases

In June 2008, I focused on some phrases commonly used in client assessments and progress notes which suggest attitudes we have towards clients. http://changecompanies.net/tips-and-topics/2008/06

1. “More willing to follow rules and be compliant with treatment activities.”

2. “Client admitted that alcohol and marijuana use sometimes interferes with her school grades.”

3. “Client minimizes the extent of his methamphetamine use.”

4. “Client denied any previous addiction or mental health treatment.”

Additions to Commonly Used Phrases

Recently as I was reading a comprehensive addiction evaluation, I noticed a few more phrases; here they are.

** “He claims current daily usage is 5 – 7 beers on weekdays and up to 12 beers/day on the weekends.”

Like the phrase “client minimizes the extent of his methamphetamine use”, the verb “claims” suggests that the clinician believes, and knows, the client is lying about how much alcohol he is using. “Claims” translates into:

“I know you are drinking much more than you are willing to admit, so although you claim to be drinking only 5-7 beers on weekdays and more on weekends, we all know that you are lying.”

Now you may not mean any ill-will in writing “claims” and you most likely didn’t verbalize the dialogue above. However it is possible to create a person-centered environment of acceptance so a client has no reason to shave the truth about how much he is drinking. When you approach the client with an attitude that assumes he is lying, it comes across – whether you say it directly or not.

Imagine your supervisor listening to you describe the hours you spent doing paperwork and then they document this in your personnel file: “The counselor claims she spent three hours doing paperwork and wants me to consider decreasing her caseload.” Would you consider that unsupportive and even be suspicious whether your supervisor trusts you?

  • Alternative Assessment language: “He describes his current daily usage as 5 – 7 beers on weekdays and up to 12 beers/day on the weekends.”

This doesn’t mean you are naive. We know people with addiction (this is a stigmatized illness) can lie about their substance usage. However evidence from collateral sources may inform you that your client is using more than he says. So your assessment summary will document the discrepancy – between what the client describes and what collateral evidence shows. You are more likely to attract a person into recovery if you appraoch them with acceptance. Trust, but verify, President Ronald Reagan said.

** “He is not willing to admit that he is alcoholic in spite of previous treatment with successful outcome (18 months abstinence.)”

“Not willing to admit” suggests that the client knows good and well that he has an alcohol problem but is just being stubborn and “not willing to admit” the truth. From the client’s perspective he does not have an alcohol problem no matter how obvious it may be to you and others around him. When you use person-centered language (rather than clinician-centered or diagnosis-centered language) you look at the world through the client’s eyes. This is what the principle in Motivational Interviewing, “Express Empathy”, means.

“Admit” implies the client is refusing to tell the truth; that somehow the clinician has to get the person to finally admit they know they’re an alcoholic and are willing to confess that. While it is true that a client can lie and hide information, there is no need for him/her to do that if you’ve created an accepting environment which invites openness. There is nothing for a client to defend and admit to – if you’re willing to start wherever the client is at. We are not trying to get the client to say the right answer. We want to know honestly what they think, believe and feel.

  • Alternative Assessment Note: “Client does not believe that he is alcoholic in spite of previous treatment with successful outcome (18 months abstinence).”

Imagine you are telling your supervisor how your large caseload makes it difficult to get all the paperwork done in a timely fashion. Then you read the supervisor’s documentation in your personnel file: “Counselor is not willing to admit her time management problems and how inefficient she is in documentation.” How likely would you confide in your supervisor next time and come to him or her for support?

SKILLS

In the December 2006 TNT edition, I shared some skills tips on what to say in various counseling situations. Here is another.

Tips:

1. When clients are ambivalent, don’t always argue for the healthy choice: “You can hangout with those friends if you want to. Why not continue going to parties with them?”

People are often of two minds on what to do. If you always express/ recommend the healthy side of the ambivalence, it almost invariably evokes from them a defense of the unhealthy or counterproductive side of the argument.

Therapist: “If you keep hanging out with those friends, you’re only going to get into more trouble. They’re the ones you party with and got arrested with. They’re not good for you. You should make new friends who will be more supportive.”

Client: “Well they’re not all bad. They’re not always getting into trouble. I’ve had some of those friends all my life and they care about me”

Therapist: “Yes, but they all use drugs and have criminal records.”

Client: “But they aren’t using all the time. Some of them haven’t used or gotten arrested for six months now.”
Don’t argue for “doing the right thing.” Don’t list all the reasons to give up those friends. If the client wants to stay out of detention, employ the Motivational Interviewing principle – Rolling with Resistance. It could sound like this:

Therapist: “So why not keep hanging out with them? Don’t get me wrong, I think the best plan would be to make new friends. But you want to hang out with them, so go ahead. Why not keep partying with them and staying in the gang. “

Client: “Yes, but what if I get arrested again, I could be sanctioned and go back to juvenile hall.”

Therapist: “Yes, I know, that what I was thinking. But go ahead and keep hanging with them and partying with them.”

Client: “Yeah, but what if I get a dirty urine and get into trouble. I don’t want to go back to detention.”

Therapist: “Yeah, I know. That’s what I was thinking. But keep partying with them if you really want to.”

Client: “I don’t know, maybe I should think about this a bit.”

If a client is in imminent danger of harm to himself or others, then we would need to override his will for the time it takes to stabilize his safety. However, if his ambivalence is not posing an immediate safety threat, then focus on dialogue that encourages client “change talk” and self-motivational statements. Rolling with Resistance is more effective in helping people change than your litany of reasons to change.

Reference:

Miller, William R; Rollnick, Stephen (2002): “Motivational Interviewing – Preparing People for Change ” Second Edition. New York, NY., Guilford Press.

SOUL

My mother in Australia turned 94 in January. Every day she walks over to the nursing home section of the elder retirement village to visit her 96 year old sister and help her eat breakfast. Fortunately my mother lives independently in her own apartment across the hall from another sister who is in her own apartment. On my last visit with my mother, she complained that her bed-ridden and cognitively-compromised sister sometimes “refuses” to eat. When breakfast comes promptly at 8 AM, my mother tries to cajole, urge, encourage and almost force her to eat, concerned for her well being.

I asked my mother what time she likes to eat breakfast herself. She said usually about 9:30 AM or 10 AM, but sometimes when she’s not hungry, she will eat later. We had a laugh together when I pointed out that when she is not hungry and likes to eat later on, it is just that she is not hungry and would like to eat later. But when it is her sister, lying helpless in a nursing home, not hungry at 8AM, she is “refusing” to eat.

I asked my mother how she would feel if she was told to eat at 8 AM, 12 Noon and 4 PM whether she was hungry or not, with little choice of what was on the menu. She is still quite mentally sharp and laughed insightfully. She realized that her preferences on what and when to eat are just her preferences. But somehow when it is her institutionalized sister, we label it “refusal to eat”.

Consider other versions of this same phenomenon:

My resoluteness is your stubbornness.
My spontaneity is your flightiness.
My attention to detail is your micromanaging.
My honesty is your insensitivity.
My leadership is your bossiness.

And my different perspective and difference of opinion is your denial and resistance.

STUMP THE SHRINK

Kathy’s Question:

Dr. Mee-Lee,
We are having a disagreement with our local probation departments about what information we share with them and are trying to gather information from the field about “best practice” or standard practice.

Specifically, our local probation departments (both juvenile and adult) want us to share any information we have from client sessions about client substance use or illegal behaviors. This is despite the fact that they are drug testing the youth and young adults. We have resisted sharing, with the rationale that we believe that clients will not be as truthful with us and consequently we won’t have as much rich content to work on in sessions.

It seems to continue to be a problem that we are not sharing the information that they want and so I’m trying to understand what others are doing and if there is any research to assist in this decision.

I appreciate any direction you might send me or if you have any thoughts or resources.

Kathy Davis, ACSW, LMSW, CAAC, CCS
Family Services Division Director
Child & Family Services, Capital Area
4287 Five Oaks Drive
Lansing, MI 48911
kathy@childandfamily.org

My Response:

Kathy:

This is an important issue. Most conditions of probation or parole are that the offender agree to treatment and comply with treatment. Once the person is in a treatment program, it is the duty of the treatment provider to “do treatment”, not to have the client “do time”. Treatment is not the right arm of the criminal justice system and probation officers are not the treatment providers. Treatment has the obligation to inform probation that the client is doing treatment responsibly and in good faith and not skating through treatment “doing time”.

But details of treatment should be confidential so as to increase the chance for honesty and creating lasting change, which both criminal justice and treatment have as a goal. It is not about a person just sitting in a treatment slot until they “graduate” or “complete fixed treatment”. Take a look at the November 2007 edition of my e-newsletter, TIPS and TOPICS for more on this. And you can also go to my website, www.davidmeelee.com and do a search of six years of archived editions to see where I have written more on this.

The responsibility also falls on treatment providers however, to actually hold clients accountable to treatment, and not just let a person sit in a program in a compliance mode. If a client does not show up for even a second appointment, the treatment provider should consider informing the Probation Officer that the client may be out of compliance with agreement to do treatment. Or if the client is missing treatment sessions or getting positive drug screens and is not continuously making adjustments to the treatment plan in a positive direction, then the provider should raise the issue of sanctions with probation. Such sanctions would not be due to a positive drug test, but because the client was not willing to add an AA meeting; or stay away from a using friend to improve the treatment plan in a positive direction. This would be a sign that the client was not doing treatment and that fact should be reported to the probation department for possible graduated sanctions.

If the client is in fact willing to change their treatment plan in a positive direction, then he/she is doing treatment. The client is making progress in good faith, even if not perfect, and the report to probation would be that the client is compliant with court conditions and is in treatment. The details of treatment are confidential. If we report every positive drug screen or mistake in their treatment, this compels the client to be secretive and lie about continued use or lapses. To be honest would be self defeating to get what they want (to get off probation). But in fact, it would be us as treatment providers who created an environment of conning and dishonesty. Our job is to focus on assessment and treatment rather than sanctioning a person for recurrence of their addiction illness.

Hope this makes sense,

David

SUCCESS STORIES

“Dr. Mee-Lee, I recently attended your conference in Gaylord, Michigan. I thought your approach to treatment planning was innovative and practical. I was especially impressed with the shift in perception to view and treat the substance using client as truly a person with a disease.

This was particularly radical to me because I am in recovery. I was shocked to learn how I was punishing intoxicated clients who arrived for treatment. My reaction was to find them transportation and send them home.

I have seen a need for new ideas in substance abuse treatment both as a client and as a clinician.
Thank-you for your work.”

Julie Van Dusen, MA, LLPC
Gaylord, Michigan.

P.S. “In my very small way, I try to contribute to the undoing of the stigma attached to the word “addict.” I would be honored to have my identity attached to the message (especially the “recovering addict” portion of my life).”

SHAMELESS SELLING

“Helping People Change” – A Five Part Series Workshop – Live and Uncut”

These five, approximately 30 minute DVDs, are part of a day-long workshop filmed in Los Angeles, California. It is “live” in front of real workshop participants and not a hand-picked studio audience. I cover the Therapeutic Alliance, Stages of Change, Motivating ‘resistant’ clients, and …. I encourage you to purchase the entire set. If however you have a particular section of interest, I have made it possible for you to purchase any DVD individually. I hope you will use these DVDs to help integrate these ideas and skills into your daily practice.

The Therapeutic Alliance – Pre-Test Questions and a discussion of answers; Enhancing Self-Change and Forging the Alliance
Disc 1 of a Five Part Series Workshop

Understanding and Assessing Stages of Change – Discussion of Compliance versus Adherence; Explanation of Stages of Change Models (12-Step model; Transtheoretical Model of Change; Miller and Rollnick)
Disc 2 of a Five Part Series Workshop

Motivational Interviewing and Ambivalence – Principles of Motivational Interviewing; Spirit of Motivational Interviewing; Working with Ambivalence
Disc 3 of a Five Part Series Workshop

Establishing the Treatment Contract; Role Play – What, Why, How, Where and When to establish the Treatment Contract; and a role play with a “17 year old young man” to illustrate this technique
Disc 4 of a Five Part Series Workshop

Stages of Change; Implications for Treatment Planning – Stage of Change and the Therapist’s Tasks; discussion of Relapse Policies; Using Treatment Tracks to match Stage of Change; discussion of Mandated Clients and relationship to the criminal justice system
Disc 5 of a Five Part Series Workshop

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In the near future, you will be able to purchase these items in an online shopping cart.

BUT for now, click here for instructions on how to buy any or all of these DVDs!

Until Next Time

Thanks for joining us. See you in late May.

David
DML Training & Consulting