TIPS & TOPICS
Volume 7, No. 5
August 2009

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

Thanks for reading the August edition of TIPS and TOPICS. Welcome to all our new readers.

SAVVY

I don’t know if children returning to school are still asked to write an essay on “What I did on my summer vacation”, but I thought I’d do my version of that perennial assignment. A long plane ride from Australia is a good time to catch up on the movies you intended to see, but couldn’t find time in your schedule. So when The Soloist was on the list to be shown, I just had to catch it this time.

Tip:

  • Movies are for entertainment, but sometimes entertainment is also educational and enlightening.

If you haven’t heard about The Soloist, here is a brief description: The Soloist is a 2009 drama film directed by Joe Wright, and starring Jamie Foxx and Robert Downey Jr. The screenplay by Susannah Grant is based on the book, The Soloist by Steve Lopez. The film is based on a true story of Nathaniel Ayers, a musician who becomes schizophrenic and homeless.

Foxx portrays Ayers, who is considered a cello prodigy, and Downey portrays Lopez, a Los Angeles Times columnist who discovers Ayers and writes about him in the newspaper. The film was released in theatres on 24 April 2009. The Soloist is based on the true story of Nathaniel Ayers (Jamie Foxx), a musical prodigy who develops schizophrenia during his second year at the Juilliard School in New York City. Ayers become homeless in the streets of downtown Los Angeles, while still playing the violin and the cello.

If you have seen the film, see if you agree with the issues and lessons I learned from watching and thinking about it. If you haven’t seen the film, I hope this doesn’t pre-empt your enjoyment of it. Here are ten observations I made from the perspective of behavioral health:

1. Understanding the client experience of auditory hallucinations and the beginning experience of a person’s first psychotic break evidenced by increasing isolation and limitation in function.

2. Empathizing with the anxieties and fears of the family as they witness and experience the sad transformation of their loved one troubled by mental illness. Nathaniel’s sister responds to a phone call inquiring about her brother; she suspects the worst: “Is he dead?”

3. Appreciating the person-centeredness of the worker at Lamp Community, a Los Angeles-based nonprofit organization with a mission to permanently end homelessness, improve health, and build self-sufficiency among men and women living with severe mental illness. The worker said: “We don’t pay attention to diagnoses that much”. How I heard that was that people are not the walking embodiment of their DSM diagnosis, but rather people who need to be heard and understood.

4. Recognizing the impulse- well-meaning and well-intended – to force treatment and medication in hopes of restoring Nathaniel’s talent to his fullest potential.

5. Seeing how alienating it was to Nathaniel to attempt to have him committed to treatment and the mistrust and fracturing which that engendered.

6. Sensing the panic and paranoid fear when personal space and boundaries were invaded. A gentle touch on Nathaniel’s shoulder engendered violent panic.

7.
Identifying the magnitude of homelessness (90,000 homeless in the greater Los Angeles area), but additionally recognizing also that many homeless may not have the same values about a home as middle class America. Some view the obligation to pay rent or a mortgage every month as a repetitive limitation rather than reassuring security of a place to live. Or the stability of one place to live as a stifling restriction to roam free.

8. Experiencing the anguish and frustration of those who help people with severe mental illness. The person’s mental illness can clash with what seems perfectly reasonable expectations e.g., Nathaniel wanted to keep an expensive cello but keep living on the street, oblivious to the potential that the cello could be stolen, broken and ruined. He resisted storing the cello at Lamp and also refused safe, clean housing where he could live and take cello lessons.

9. Witnessing the transformative power of friendship, acceptance and meeting a person where they are at, instead of trying to force change no matter how logical, well-intended and valid from the greater society’s point of view.

10. Appreciating the resourcefulness of mentally-ill, homeless people. Nathaniel knew how to survive in conditions that would overwhelm me; protected his only possessions with the vigilance of a loving parent.

Not only does “The Soloist” remind us of the lessons of “A Beautiful Mind”, but it also shows the restorative power of beautiful music. The film was a nice ray of sunshine in my summer vacation.

References:

1. The Soloist – http://en.wikipedia.org/wiki/The_Soloist

2. Lamp Community – http://lampcommunity.org/about_lamp.php

SKILLS

Most of us have been trained to see only pathology and problems. It can be a tough transition to a strength-based, recovery perspective.

Tip:

  • Consider these steps to reframe “pathological” views into recovery and strength-based universal human needs.

1. Look for the feelings, needs and values behind your pathological (and sometimes judgmental) view of the client’s goals.

  • e.g. “He just wants to get his benefits so he can get more drugs to get high.” Who among us does not want to feel good and has the need for pleasure?
  • e.g., “He is so unrealistic wanting to get a job when he can’t even take his medication as prescribed.” Who doesn’t feel good when productive so you can get financial freedom and security?
  • e.g., “She is just here to get her kids back and not really interested in abstinence.” Who doesn’t feel frightened when threatened with losing loved ones and needs love and family togetherness?

2. Reframe to yourself and the client what you are hearing in his or her request or goal to further assess what the real needs are.

  • e.g., “So when you use run out of your disability money and use it to buy drugs, are you still getting a good high from the drugs? Or are you needing drugs to get rid of withdrawal problems and don’t get much of a high anymore?                                                                                                                                versus: “See how drug addicted you are that you are spending all your money and don’t even have enough for food for the month?”
  • e.g., “So when you say you want a job, what do you see the job will do for you? Do you want something to do to occupy your time? Or are you wanting more money and frustrated that you have a representative payee who is controlling all your money?                                                                         versus: “How do you think you can get a job when you can’t even get to your doctor appointments on time and don’t take you medication regularly”
  • e.g., “So when you say you’re here otherwise you won’t get you kids back, are you missing them so much that you’ll do whatever it takes to be with them again? Or is it really hard to make it financially without the child support payments? Or is it both, which I can totally understand too?               versus: “You have to comply with the program and be abstinent if you want a good report for child protective services”

3. Address the universal human and recovery need of the client, not just your assessed treatment plan.

  • e.g., “So let’s find a way so you feel better and don’t have to be so uncomfortable and worried about withdrawal.” – the need for comfort; avoidance of pain
  • e.g., “Let’s see what would have to happen for you to regain control of your money –the need for autonomy and financial security
  • e.g., “Let’s figure out together how to reunite your family; and what people are seeing that makes them think that you are not safe to be with your children – the need for love and connection

SOUL

The death of Senator Edward Kennedy has generated a lot of radio and TV coverage. Not as much as when Michael Jackson died. I guess that says we are more fascinated by entertainment, eccentricity, intrigue and innuendo than in public service, elder statesmen and end-of-life sunsets. Although Ted Kennedy has had his share of intrigue and innuendo in his life too.

Listening to the myriad of eulogies and testimonials about the virtues, vitality and acumen of the second longest sitting senator in American history, I was interested by one observation explaining Ted Kennedy’s success in political battles.

“He wasn’t afraid to lose; and that’s why he won.”

This is one of those paradoxes like Alcoholics Anonymous’ embracing powerlessness to empower recovery, or “letting go and letting God”. Or the biblical “dying daily to live”. Then there’s “what you resist, persists” and another version of that: “absence is presence.” (“Absence makes the heart grow fonder”)

It can take some brain power to get your mind fully around these. That’s what a paradox is: a truth stood on its head so you don’t recognize it. But the common theme of all these phrases, which by the way are not original with me, is this:

When you are obsessed with winning, being powerful, in control, avoiding death or loss, or being perfect there is a lot of wasted time and energy. And you are much less likely to get what you want anyway.

When you are at peace to lose, to give up power and control, ready to die, then that’s when life can really begin and thrive. A more mundane example for those of you dating is that when you are desperate for a relationship, you exude neediness. Nothing kills attraction better than the air of desperation.

In our results-oriented society, it’s good sometimes to relax into the journey and let go of the destination. And you might just get there—–or not.

STUMP THE SHRINK

Dear David:

I hope you can give me some direction.

I’m having a difficult time explaining my understanding of individualized treatment to our contracted provider. They use the Matrix program, which I have no problem with. The hitch is that they require everyone to participate in each and every exercise because “that is part of the program”. I view this as program-driven services, rather than individualized treatment.

My understanding is that to apply an exercise from a treatment curriculum there should be an identified problem that the patient has and a treatment plan connected to that problem.

Please, if I’m missing the point tell me. If I’m on point do you have any suggestions how I might frame it so they can better hear what I’m trying to convey.

Don Lupien, Ph.D.
Substance Abuse Treatment Coordinator
Island County Human Services
Coupeville, WA
D.Lupien@co.island.wa.us

My response

Hi Don:
You are correct from my point of view and this is a common issue as people struggle to balance so called evidence based practices (EBP) and individualized treatment.

You can say that EBPs are to be used to engage people in a therapeutic alliance (that equals agreement on goals and strategies in the context of a therapeutic bond with the client). The Matrix Model and other EBPs don’t stand alone apart from where the client is at. In fact, studies have shown the Matrix Model was better than Treatment as Usual (TAU) in retaining people in treatment and decreased methamphetamine use. But by discharge after 18 months of treatment, and at 6 months’ follow-up, there was no difference in substance use and functioning outcomes between the Matrix Model and TAU.

Encourage your provider to focus on a collaborative individualized treatment plan and use the Matrix Model and other EBPs to build an alliance and check outcomes in real time. You can also do a search of six years of my e-newsletter, TIPS and TOPICS at www.davidmeelee.com. Enter keywords of evidence-based practices, or treatment planning, or alliance and you should get more information.

Hope this helps.
David

Reference:

Rawson, RA, Marinelli-Casey, P, Anglin, MD et al: (2004): “A multi-site comparison of psychococial approaches for the treatment of methamphetamine dependence” Addiction:Volume 99(6)June 2004 pp 708-717.

http://csam-asam.org/pdf/misc/MultisiteMethTrialRawson.pdf

SHAMELESS SELLING

There are major conferences coming up in September and October that are outstanding (and not just because I am one of the speakers). Take a look at the 22nd Cape Cod Symposium on Addictive Disorders, September 10-13, 2009 in Hyannis, Cape Cod, Massachusetts.

http://www.ccsad.com

The other conference on the opposite coast, but at an equally attractive beach site is the Southwest Regional Integrated Behavioral Health Conference, September 16-17, 2009 in
San Diego, California.

http://www.regonline.com/builder/site/default.aspx?EventID=741586

On October 26-28, 2009, the Northeast Conference on Behavioral Health and Addictive Disorders will be in Philadelphia, Pennsylvania.

http://www.usjt.com/behpa/

Until Next Time

Please join us in September.

David