TIPS & TOPICS from David Mee-Lee, M.D.
Volume 8, No. 8

December 2010

In this issue

– SAVVY: Can checklists help make good counseling?

– SKILLS: Checklists for improving care

– SOUL: What the New England Patriots have taught me

– Until Next Time

Welcome to the December edition of TIPS and TOPICS. Happy and healthy holidays to you all.

SAVVY

Over the years, I have occasionally invited trusted friends and experts to be guest contributor to Tips and Topics.  So when David Powell, Ph.D., President of the International Center for Health Concerns wrote to tell me how he had also been pondering about checklists for some time, I knew this was an opportunity to continue the conversation of the November edition into this month. 

David Powell is the leading expert on clinical supervision and has been for decades.  He provides training and consultation worldwide and shares his thinking in Savvy and Skills.

What makes good counseling? Can a Checklist help? – by David Powell

In the November edition of Tips and Topics, there was a discussion of checklists to promote best practices and reduce mistakes. There must be some degree of synchronicity happening in the world, as this has been a topic of great interest to me in recent months, especially after reading Atul Gawande’s book, The Checklist Manifesto: How to Get Things Right, cited in the TNT issue.

Gawande discusses how to apply checklists to medicine.  This has spurred a discussion in my clinical supervision work: –> Can we can apply similar checklist principles to therapy and addiction counseling?

Other books that have contributed to this topic of discussion for me are Cummings, Destructive Trends in Mental Health, Kottler, Bad Therapy, and Schwartz, How to Fail as a Therapist. Together they address what we don’t like to talk about: that we make mistakes as counselors and perhaps there are ways of decreasing our errors.

Data on patient retention

This data is startling:

  • 20-57% (depending on the study) don’t return after their first session. 2 out of 10 clients to 4 of 10 drop out after one session.
  • Of those who do return a second time, 37-45% attend only two sessions. In other words, 1/2 to 2/3 of clients drop out by the end of the second session.
  • Client dissatisfaction with their counselor is the #1 reason for early termination.

So, are there proven ways to keep people in treatment?

Might a checklist aid in improving patient retention?  After all, pilots, architects, educators, surgeons and even Rock-and-Roll superstar David Lee Roth
have checklists (he requires only a particular color of M & Ms in his candy dish at his hotel bedside). I suggest we should develop checklists of excellence for counselors.


Why do we need checklists?

Gawande points to several reasons:

  • Ignorance. We as counselors only have partial knowledge of what works.
  • Ineptitude. We may not be able to apply that knowledge correctly. People attend courses on evidence-based practices, but how many are proficient in these practices? Without quality clinical supervision, we may never know the counselors’ levels of proficiency.
  • Know-how and sophistication in treatment have increased remarkably.
  • Complexity and specialization. Just when you thought you knew DSM-IV, DSM 5 is on its way. I have an old copy of DSM II for which I was a reviewer many decades ago. It is about 1/10th the size of DSM IV. I can hardly wait to see how I can use DSM 5 as a paperweight, should be quite hefty.
  • Evidence-based practices require greater knowledge and sophistication. Fidelity to a model while adapting that practice to each unique clinical situation requires great skill and art.
  • Technology requires another skill that many of us lack. (I am a self-admitted technopeasant).

What did we learn from Hurricane Katrina?

Were the resulting failures due to a lack of sympathy on peoples’ and government’s part? No! The problem was the ensuing chaos that occurred and Orwellian bureaucracy which got in the way of the provision of services.

The same is true in medicine. Patients don’t die because the doctor doesn’t care. Patients die because of simple but significant issue’s infection, uncontrolled bleeding, unsafe anesthesia, the unexpected happening, and most importantly, the lack of teamwork. Everyone dutifully does their respective tasks, however the lack of communication between team members reduces our odds of success in medicine.

The same is true in counseling.

What are the “killers” in addiction counseling?

Certainly it is not because of a lack of caring or good intention.

> Bad counseling happens when the client or the counselor isn’t satisfied with the results, when the client is worse as a result of treatment.
> Bad counseling is when the counselor is passive, doesn’t listen or follows his own agenda.
> Bad Counseling occurs when trying to make “one size fit all”, when doing the same thing over and over again with the hopes of a different outcome. It happens when a counselor is inflexible in adjusting the treatment program to fit the client’s needs.
> When the clinician is unsure where she is going, acts in an overconfident/infallible manner, believing she knows better about what the client needs than the client knows, bad counseling takes place.
> When there is a failure to create a therapeutic alliance, when there are invalid assumptions made, acting on intuitions solely, bad counseling happens.
> Bad counseling takes place when clients are labeled by a diagnosis.

SKILLS

So, what do we need to improve care?  Here’s a checklist:

  1. Develop a sense of selflessness and teamwork – this requires discipline in the following procedures…..
  2. Develop a willingness of staff to say “wait” when things are not going well, and to redirect the process.
  3. Be diligent in doing the simple, mundane tasks – like paperwork, thorough aftercare planning, daily patient contact, staff communication, noting minor but significant behavioral changes.
  4. Avoid duplication of services within/between agencies -keep a paper trail; don’t cut corners.
  5. Make a science of performance – through tracking outcomes, becoming artisans at what we do. (An artisan combines service with a distinctive touch plus personal pride in their workmanship; they do that something extra for the patient.)
  6. Attend to details of self-disclosure, touch, countertransference in counseling.
  7. Develop ingenuity – by seeing that one size doesn’t fit all and treatment plans need to truly be individualized. This entails the freedom and insight to adapt to the patient’s needs.
  8. Obtain training, training, training, and close clinical supervision: -through direct observation of the clinician in action.
  9. Differentiate between evidence-based therapies and evidence-based therapists. What makes one therapist better when another counselor uses the same evidence-based practice? Perhaps it has to do with one’s ability to establish rapport.
  10. Count everything. Keep track of what we are doing- the number of patient visits, rates of recovery, frequency of re-treatment, attendance at 12 Step meetings. Count anything!
    And write something -What works and why? What did we learn from each clinical encounter? What needs to be changed? What could we have done differently?

What stops us from making these improvements?

Staff resistance, a Lone Ranger mentality, “we’ve always done it this way,” a lack of teamwork, and incomplete information.  We need to acknowledge first that we make mistakes. Counseling is a human profession. To improve, we must do things right and do the right things. What are the right things?


We all know rapport is critical, but what are the factors to improve rapport?

  1. A shared attention and feelings, mutual interest, joint focus, a “perceptual glue” that binds the counselor with the client. 
(Ask yourself: Am I working on the same goals as my client? Do we both have agreement on strategies and methods of treatment?)
  2. Mutual empathy where people experience being experienced; Seeing eye to eye opens the pathways to empathy.
(Ask yourself: Am I tuned in to what my client truly wants, feels, thinks and needs?)
  3. Good feelings. 
(This is demonstrated in tone of voice, facial expressions, non-verbal cues, a sense of positivity, and warm feelings towards each other)
  4. Coordination or synchronicity.
(This will be evident by timing, pace of communication, body movements, animation, expressions of thoughts/feelings. The clinician-client realtionship is a choreographed dance.)

Being obsessed is a good thing!

We need to be obsessed with client input.  Is it a good fit?  Are we addressing what the client needs?  Are we getting anywhere?  Does the client feel listened to/cared for? Fred Lee provides a thought-provoking approach in his book If Disney Ran your Hospital.

In summary:

  • We need to design a checklist of what makes good treatment, all the steps involved in promoting positive outcomes. We must religiously follow those steps.
  • People will need addiction treatment from counselors who have extra skills, pride and imagination in what they do, and the creativity to customize their care.
  • If we do these things- and follow a checklist- we will have satisfied clients who return to care. We will have a workforce of counselors who find their work meaningful and rewarding.

I encourage this dialogue to continue in designing checklists of what constitutes quality care.

If you would like to contact Dr. Powell, send your thoughts and ideas to djpowell2@yahoo.com <

David J. Powell, Ph.D., President, International Center for Health Concerns, Inc.
East Granby, Connecticut. www.ichc-us.org

SOUL

I’m not a sports nut, feverish football fan.  But I do like a winner. Having lived 17 years in the Boston area, it’s easy to be a New England Patriots fan. However, it’s not just the fact that right now they are the best team in the National Football League that I admire them.  It is their work ethic and their apparent rejection of the narcissistic, attention-getting sense of entitlement that too often pervades the world of celebrity and fame.

Here’s what coach Bill Belichick has taught me from how he manages and motivates a team of coaches and players under a lot of pressure and weekly scrutiny:

  1. Choose team members not just for what they can do now, but recognize potential and develop their talents.
  2. Focus on teamwork and expand team members’ range of talents.  Use those skills to assume a variety of roles to flexibly contribute to the overall team mission. “On a football team, it’s not the strength of the individual players, but it is the strength of the unit and how they all function.” Bill Belichick
  3. lan well,  work hard and focus on doing the job at hand excellently.  Success one day at a time creates overall success.
  4. Don’t dwell too much on past failures – “If you lose, don’t say too much.”
  5. Don’t dwell too much on your successes – “If you win, say even less.”

I’m sure with all the money, media attention and the macho sense of power that goes with professional football teams, that Bill Belichick and Tom Brady, cool, calm and talented quarterback, are no angels. But the temptation to believe the hype and adulation such players and coaches receive makes their public low-key, matter-of-fact, hard work, one game at a time personas all the more admirable.

The New England Patriots have the win records that could justify a haughty sense of pride and disdain for lesser mortals. That they seem to be able to keep their feet on the ground and their eye on the ball in the glare of celebrity and fame makes their success all the more admirable.

Managers, families and agencies could well learn from this football team.  May we all have the success of the New England Patriots.  In 2011, may we all have the good health they hope to maintain, all the way to the Super Bowl.

Until Next Time

Happy New Year. See you in January 2011.

David

David Mee-Lee, M.D.