TIPS & TOPICS
Volume 7, No. 8
November 2009

In this issue

— SAVVY   Pros & Cons of the Medical Model

— SKILLS   Retaining what’s good about the Medical Model

— SOUL Obama, Change, Empathy

— STUMP THE SHRINK Changing how you use Stages of Change

— Until Next Time

Thanks for joining us this month. Welcome to the beginning of the holiday season.

SAVVY

Some feel the Medical Model is incompatible with a strengths-based, empowerment recovery approach to helping people.  As a physician, when I am asked about that, the answer is ‘yes’ and ‘no’.

TIP

* Decide what you mean by the Medical Model before lauding or lambasting it

Here’s what I found when I asked “Dr. Google” about the Medical Model.

Definitions of Medical Model on the Web:

*Medical model is the term cited by psychiatrist Ronald D. Laing in his “The Politics of the Family and Other Essays” for the “set of procedures in which all doctors are trained.”

http://en.wikipedia.org/wiki/Medical_model

*The view that abnormal behavior results from a physical/biological cause and should be treated medically.

www.mindcontrolforums.com/didglossary.htm

*The view that behavioral and emotional problems are analogous to physical diseases. www.socialpolicy.ca/m.htm

*A theory of drug abuse or addiction in which the addiction is seen as a medical, rather than as a social problem.

www.addiction-rehabilitation.com/glossary.html

*Health services based mainly on providing health care once people are ill, rather than focusing on a more preventative and holistic approach.

www.tameside.gov.uk/la21/glossary

It is clear there are all kinds of ways to look at the MM; they all hold elements of what is appreciated and criticized about the MM.

Next I address the elements I view as counterproductive in the MM if recovery and wellness are important goals.  Additionally I address what I see as productive in the MM for promoting wellness and change. As a physician, I have been raised and trained in the MM as I understand it, and have retained, as well as rejected, elements of the MM.

Productive Elements of the Medical Model

—-> If you are diagnosed with cancer, heart disease or diabetes, most of us would want to see a physician who based his/her recommendations for treatment on science and evidence-based best practices.  You wouldn’t want a doctor who avoided reading the latest research findings, who placed more value on his/her intuition and “gut impressions”, and didn’t change what they’ve done for the past 30 years.  The MM requires a level of rigor and evidence-base from which to individualize treatment. It is focused on effective outcomes even if that necessitates totally changing traditions and previous practices (think blood-letting, non-sterile surgical procedures).

—-> In mental health and addiction treatment, it is more effective to start with a view that abnormal behavior and out-of-control substance use are treatable illnesses rather than a person’s moral weakness to be punished or ostracized.  Some individuals suffer from severe and ongoing illness best viewed as chronic illness not unlike diabetes, asthma and hypertension.  This allows for ongoing support and care rather than completion of a program and graduation.

—-> Medications and medical procedures arise from a MM which constantly searches how to develop the least intrusive and detrimental strategies, pharmacotherapy and procedures that will have an equal or superior outcome.  New generations of medications increasingly target specific neurotransmitters so as to minimize side effects. Older medications affected all sites indiscriminately. Electroconvulsive therapy (ECT) has been refined to minimize memory loss. Surgical procedures used to require opening wide sections of the abdomen or totally exposing a knee joint. Now these are executed via a tiny incision in the abdominal wall or skin.  Surgeries routinely performed in inpatient settings followed by days of recuperation in an infection-prone hospital environment are now being completed in outpatient clinics, with brief post-operative recovery before returning home the very same day.

—-> The MM has been evolving over the past decade or more. The US Health care system has been re-engineering itself to address the need for quality improvement. It is being actively reshaped by the expectations of consumers where all stakeholders increasingly demand active collaboration with the health care system.

(Kizer, KW (2001): “Establishing Health Care Performance Standards in an Era of Consumerism” JAMA 286:1213-1217)

—-> New chronic disease paradigms highlight the patient-professional partnership, involving collaborative care and self-management education. Programs teaching self-management skills are being found to be more effective in improving clinical outcomes than information-only patient education . Self-management education for chronic illness is increasingly becoming an integral part of high-quality primary care.

(Bodenheimer T, Lorig K, Holman H, Grumbach K (2002): “Patient Self-management of Chronic Disease in Primary Care”  JAMA 288:2469-2475)

Attitudes and practices change slowly.  Therefore not everyone raised in the MM, and working in healthcare where the MM predominates, is ready to move to a recovery, strength-based approach.  This is where criticism of the MM finds fruitful ammunition.

Counterproductive Elements of the Medical Model

—-> Some clinicians apply the MM to mean diagnosing a patient’s illness, assessing the severity, then prescribing a medication or procedure with which the patient should comply.  There is little involvement of the patient’s goals and a cursory explanation of alternatives.  The patient is often left with many unanswered questions they were too overwhelmed to ask about in a rushed encounter (before the next patient from a crowded waiting room was ushered in.)  Admittedly, this is not inherent in the MM.  You could just put this down to poor customer service.  But it is inherent in the older aspects of the MM which has put people in a one-down position as patients who should just do what they are told by the physician or healthcare provider, the one who knows best about the patient’s illness. (Incidentally, mental health and addiction clinicians can also treat people the same way.  The MM has tended to perpetuate the authority figure approach to care.)

—-> Because the MM embraces the scientific method and has a high value for evidence-based practices, this reinforces the power of physicians and other health providers who have had more scientific training in medical issues. In a culture and society that also values technology, scientific achievement and the latest medical research, it is difficult for clinicians to place equal emphasis on what the client/patient/consumer wants.  The MM can be used to justify seeing the client as an out-of-control individual who clearly is clueless about his life otherwise they wouldn’t be seeing the helping professional in the first place.  The MM clinician then is the expert whose job it is to identify the knowledge deficits, self-defeating patterns, pathological, manipulative and secondary gain behaviors that need to be confronted and corrected.  (Actually behavioral health clinicians who may rail against the MM frequently treat or mistreat clients with these same attitudes.)

—-> The MM traditionally sees pathology, not possibility and hope for recovery.  When there is a focus on what is wrong with person, there is little assessment on what works and is going right for the person.  A recovery-oriented approach looks for what strengths, resources and supports a person has as equally as important to assess as what is wrong.  But this is where we need a balance of looking at strengths as well as problems.  If a person wants to get housing or stay out of prison or keep a job, we have to help that individual identify both their strengths and weaknesses so as to get what they want. When the MM only looks to correct what is wrong, we miss the opportunity to harness a whole array of strengths and proven strategies that the client has utilized before.

—-> Treatment planning in a MM gives lip service to involving the client in the process.  But the heart of most MM treatment planning is about having the client sign off on a plan which is developed and recommended by the physician or other healthcare professional.  This approach gets reinforced especially for disorders where the patient is unknowledgeable about the pathophysiology of their illness and even less aware of treatment options.  But when it comes to behavioral health, the client and consumer is much more aware of what is important to them and what has worked or not in their life.

SKILLS

So if a clinician wants to retain all that is productive about the Medical Model (however you define that) and wishes to retire the counterproductive elements of the MM, here are some TIPS to move that along.

TIPS

1.  Value your clinical expertise and training, but also value equally the client’s expertise and life training.

As professionals we do have some expertise and experience in helping the people we serve.  Evidence-based practices do count for something as we need as many effective tools in our clinical toolkit as possible.  If the outcome is not going well, you can quickly switch to something more effective.

* By all means explain to a client what is your best recommendation on what to do to reach their goal of coming to treatment e.g., if you want to keep your job, you best work on staying abstinent so you don’t show up to work hung-over, or worse, miss days, especially Mondays.

* At the same time, collaborate with the client to fashion a plan that fits their style and approach if you want to create buy-in, adherence and a successful outcome.  Tease out of their demoralized history of pain and problems what strengths and strategies have worked for them before: What were you doing that you had a good job for five years? How did you stay out of the hospital for a whole year?  What worked that you were such an effective parent to your children for the first five years of their life? Include these strategies in their recovery plan.

2.  Create a therapeutic environment where the person who knows their treatment plan best is the client.

You have many people you are working with.  Clients have just themselves to focus on in the treatment planning process.  If you are utilizing a collaborative service planning process, the client should be even more familiar with their service plan than you who can’t be expected to know everyone’s plans.

* When the client views the treatment plan as a written expression of the alliance, the plan is their plan on how to get what they want.  They should be the one to know their plan best.  They should be the one to know what they want to get out of each group or individual session to advance their treatment plan.  If they do not, there is a good chance it is your treatment plan focused on what you want the client to do, not what interests them.

* For a person who is struggling with acute psychosis or cognitive difficulties there may be immediate barriers to a collaborative discussion.  But as soon as the client is able we are still focused on what they want that we can help them with.

3.  Empower people to be assertive and advocate for what they want.  But that doesn’t mean we blindly do whatever they say without discussing what will work or not.

Sometimes clinicians experience client-directed, client-centered work as an abdication of their professional training and clinical advice.  How can we just let a client decide what they want and how to get that when their judgment and decision-making seems so faulty and unproductive?

* To truly ally yourself with the client means to be directed by what is important to them but at the same time, to provide them honest feedback on whether what they want and/or how to get there is likely to succeed.  It is of no service to a parent to work with them on getting their children back if you know upfront that a decision has already been made that reunification is impossible.

* If a client wants 100 Oxycontin pills with ten refills, we don’t just write out a prescription.  But if the person is in pain, then we can join them in a pain management plan that may involve medication, but other strategies as well. If they respond “No, I just want medication,” then we will say: “Is there anything else you want that I can help you with?   What you want is outside of our Mission and best practices.”

SOUL

This is not a political blog.  It is a commentary about change, empathy and humility.  A year ago, Presidential candidate Barack Obama was elected President of the United States of America riding a wave of hopeful change that we “can believe in.” Candidate Obama “repeatedly promised to close the prison at Guantanamo Bay”; to try suspected terrorists in federal courts; he spoke eloquently of transparency and concerns about government secrecy. (TIME Magazine November 30, 2009).  By May, President Obama was “moving away from some promises he had made during the campaign and toward more moderate positions, some favored by George W. Bush.”  On trying suspected terrorists, “Obama will do so using some of the same Bush-era legal tools he once deplored.”

The TIME Magazine article continues stating the White House says Obama hasn’t changed, just adjusted. “He and the Administration have adapted as we have learned more and the issues have evolved…..” said spokesman Ben LaBolt.  I can imagine George saying to former First Lady, Laura: “See, it’s easy to criticize, demonize and make big promises.  Not so easy when you have all the information and have to think what is best for the whole country, not just your political party.”

As I said, this is not a political blog.  What I take from noticing these adjustments and shifts of President Obama is this:

* It’s easy to say you want to change, but change is a process of stick-to-itiveness – think about the last five New Year’s resolutions you made and how many you have actualized.

* It’s easy to be judgmental about others until you walk in their moccasins and see the world through their eyes – adjustments and adaptations with new information and evolving issues is good.  If only we were as adaptable to change our treatment plans and the way we design and deliver services, instead of blaming clients and patients for their non-compliance.

* It’s easy to lead through authoritarian intimidation and abuse of power. Much harder and more effective to practice servant-leadership – How may I serve you and so lead and attract you to recovery, wellness and serenity?

The Associated Press reported this month that “Robert Emmons, a psychology professor at the University of California-Davis, said those who offer gratitude are less envious and resentful,” and may “sleep longer, exercise more, and report a drop in blood pressure.”

In this Thanksgiving and holiday season, may I wish you change you can believe in, empathy and humility.  And also less envy and resentment; better sleep, exercise and blood pressure.

STUMP THE SHRINK

The Question:

“My question may be reductionist, but it is part of debate substance abuse counselors and teachers have here.  One aspect of charting has included an assessment of where the counselor believes a client is in the “stages of change” model. Some say, “She’s coming, so she is irrefutably in the action stage.”  Others say, “She is coming because of her external motivators, and, while there is action involved in her appearance at treatment, it is not indicative of a real shift in thinking; she is, at best, in the contemplation stage.”

Is there a qualitative aspect to this quantitative discussion?  Obviously, with our discussion of an individual’s needs and motivations, why ever they’re coming needs to be acknowledged, supported, and enhanced upon, but whatever thoughts you have on this would be most appreciated.

Thanks.

Leslie Kirkpatrick

Treatment and Services Manager

Mendocino County Alcohol and Other Drug Programs, CA

My Response:

Leslie:

Some don’t like Stages of Change as a model when it is used to label clients in relation to what WE think the client should be motivated for and ready to change.  If you use Stages of Change to align us with the client and form an alliance around what THEY are at Action for, then it is a useful model to help us stay clear on starting where the client is at.  All clients are at Action for something otherwise they wouldn’t be there.  All clients are motivated, but it is just that they may not be motivated for what WE think they should be motivated for.  But that is our problem not theirs.

So what they may be motivated for and at Action for may be to get their children back; or to get off probation; or to stay out of prison; or to keep a job.  We then join them in that goal, assessing what they are doing to “shoot themselves in the foot” and also what strengths, resources and supports they have to achieve their goal.

If we use Stages of Change in this way, it is more a model to keep us honest with where the client is at.  They may be in Contemplation for what we think they should change, but at Action for something we think is just secondary gain.  But motivational enhancement and alliance building starts with what they want and works to see if they can discover how what they are doing is productive or counterproductive to getting what they want.

Hope this helps.

David

UNTIL NEXT TIME

For December and January, there will be a combined edition of TIPS and TOPICS.  So we will see you later in January 2010.   It’s always a good time to visit Australia.  But December and January is especially a good time for family, Aussie summer fun and vacation.  I wish you a joyful holiday season and a peaceful New Year.

David

David Mee-Lee

DML Training & Consulting