TIPS & TOPICS from David Mee-Lee, M.D.
Volume 8, No. 9
January 2011

In this issue:
— SAVVY – ASAM multidimensional assessment for mental health and addiction
— SKILLS – Evaluating immediate needs in 5 minutes or less; 10 questions or less
— SOUL – Jump-starting recovery
— SHAMELESS SELLING – DAPPER and LOCI-2R
— Until Next Time

Happy New Year – even though it’s a bit late for that greeting now. Or you could receive it as a Chinese New Year greeting. Welcome to the January edition of TIPS and TOPICS (TNT).

SAVVY

One of the joys of training and consulting is the opportunity to see systems progress and clinicians improve their skills. Two such contracts form the basis of this month’s edition of TNT. Over the past 14 years, I have worked with Santa Clara County (Silicon Valley), California. One primary focus of the many training and consultation topics for the Department of Alcohol and Drug Services (DADS), has been implementing the Patient Placement Criteria of the American Society of Addiction Medicine (ASAM PPC).

A more recent and also ongoing contract is my work as consultant to the State of Delaware in their five year, Federally-funded Co-Occurring State Incentive Grant (COSIG).  This grant aims to improve systems, services and skills to better meet the needs of people with co-occurring mental and substance disorders (COD).

Both systems are expanding the competence of clinicians and counselors to better address mental health and addiction issues in the clients and the services delivered.  Both systems have chosen to use the ASAM PPC as an assessment and service delivery structure to provide a common language to bridge gaps, which have caused COD clients to fall between the cracks.

Recently I received the following message posing questions helpful to others involved in COD work. Even if you don’t use the ASAM PPC, this information can still be useful.  Here’s the message.  I will explain for those unfamiliar with the ASAM PPC:

“I work as a substance abuse counselor at the Indian Health Center. I was hoping you might be able to help me. There is a form that was generated a while ago regarding the Dimensions* and Stages of Change**.  It provides detailed information for each of the dimensions and examples of questions to ask. There are also detailed descriptions of the Stages of Change. It is very helpful. I am wondering if there is such a form tailored to Mental Health (MH)?  There are now Dimensions for 4b***, 5b***, 6b***.

I struggle with these while doing my assessments. How do you assess Relapse potential for MH? What does MH Stages of Change look like? How do you assess Recovery environment for MH? It would be extremely helpful, especially since most addiction counselors are not MH clinicians and have minimal knowledge. I look forward to your response.”

Desiree Nuzzi, RRW
602 E. Santa Clara Street, Suite 230
San Jose, CA 95112
(408) 445-3400 EXT 252
desireenuzzi@yahoo.com

Key to Asterisks

* This refers to six assessment dimensions in the Second Edition Revised of the ASAM Patient Placement Criteria, which includes criteria for Co-Occurring Disorders (2001). (See below for detail on the dimensions.)

** This refers to Prochaska and DiClemente’s Transtheoretical Model of Change, which Santa Clara County Department of Alcohol and Drug Services (DADS) requires counselors use to assess and document clients’ stage of change in Dimension 4, Readiness to Change.

*** This refers to Dimensions 4, 5 and 6, which Santa Clara County DADS requires counselors assess for (a) Substance Use Disorders; and (b) Mental Disorders.

* ASAM PPC Assessment Dimensions

Assessment Dimensions
Assessment and Treatment Planning Focus

    1. Acute Intoxication and/or Withdrawal Potential

      Assessment for intoxication and/or withdrawal management. Detoxification in a variety of levels of care and preparation for continued addiction services

    1. Biomedical Conditions and Complications

      Assess and treat co-occurring physical health conditions or complications. Treatment provided within the level of care or through coordination of physical health services

    1. Emotional, Behavioral or Cognitive Conditions and Complications
      Assess and treat co-occurring diagnostic or sub-diagnostic mental health conditions or complications. Treatment provided within the level of care or through coordination of mental health services
    1. Readiness to Change
      Assess stage of readiness to change. If not ready to commit to full recovery, engage into treatment using motivational enhancement strategies.  If ready for recovery, consolidate and expand action for change

    1. Relapse, Continued Use or Continued Problem Potential
      Assess readiness for relapse prevention services and teach where appropriate.  If still at early stages of change, focus on raising consciousness of consequences of continued use or continued problems as part of motivational enhancement strategies.
    2. Recovery Environment
      Assess need for specific individualized family or significant other, housing, financial, vocational, educational, legal, transportation, childcare services

TIP 1.

Use ASAM Multidimensional assessment to be comprehensive but succinct in assessing for potential co-occurring disorders

To assist in understanding the assessment dimensions and assessment of severity/function of each dimension, examples of brief questions include, but are not limited to, the following.

Assessment questions and examples have been expanded beyond addiction to include mental health issues:

Dimension 1, Acute Intoxication and/or Withdrawal Potential:
Is acute intoxication and/or withdrawal potential contributing to, or complicating the client’s condition? e.g., an intoxicated client is disinhibited and self mutilates or presents with suicidal behavior.

What risk is associated with the client’s current level of acute intoxication? e.g., is the client so intoxicated that suicidal or homicidal impulsivity is dangerous?

Is there serious risk of severe withdrawal symptoms or seizures based on the client’s previous withdrawal history, amount, frequency, and recency of discontinuation or significant reduction of alcohol or other drug use?

Are there current signs of withdrawal?  Does the client have supports to assist in ambulatory detoxification if medically safe?

Dimension 2, Biomedical Conditions and Complications:
Are there current physical illnesses other than withdrawal, that are contributing to, or complicating the client’s condition?  e.g., pregnancy, bleeding, cancer, heart disease etc.

Are there chronic conditions that affect treatment? e.g., wheel chair bound; chronic pain with narcotic analgesics.

Dimension 3, Emotional/Behavioral/Cognitive Conditions and Complications:
Are there one or more psychiatric disorders contributing to, or complicating the client’s level of function?

Are there current psychiatric illnesses or psychological, behavioral, emotional or cognitive problems, which need to be addressed?

Are there chronic conditions that affect treatment because of continued symptoms or disability? e.g., stable, but chronic schizophrenia, affective or personality disorder problems.

Do any emotional, behavioral or cognitive problems appear to be an expected part of addiction illness or do they appear to be separate co-occurring conditions? e.g., the mood swings are caused by the client’s use of “uppers” and “downers” versus mood swings symptomatic of Bipolar Disorder.

Even if connected to addiction, are they severe enough to warrant specific mental health treatment? e.g., depressed about alcohol-related loss of job, but now has suicidal impulses.

Dimension 4, Readiness to Change:

Does the client feel coerced into treatment or actively object to receiving treatment?  e.g., says they would not be here except for the judge mandating treatment; or that they are in drug or mental health court.

What does the client want that brought them to an assessment or treatment? e.g., are they really wanting to be “clean and sober” or not suicidal?  Or are they wanting to get the probation officer off his back; or have safe and warm housing and not be homeless tonight?

If willing to accept treatment, how strongly does the client disagree with others’ perception that s/he has a mental health or a substance problem? e.g., client agrees that anxiety is a problem but insists the voices and conspiracy are factual and troubling.

Is the client compliant to avoid a negative consequence, or internally distressed in a self-motivated way about his/her mental health or alcohol or other drug use problems? e.g., “I want to get my kids back” versus “Whatever happens, I have to get on top of this depression and anxiety.”

Is the client at a different stage of change for the substance problem versus the mental health problem; or ready to address one substance or mental health issue (alcohol or depression), but not interested in addressing another substance or mental health issue (wants to continue marijuana; or does not believe s/he is hallucinating and denies delusional thinking).

Dimensions 5, Relapse/Continued Use or Continued Problem Potential:
Is the client in immediate danger of continued severe distress and/or drinking/drugging behavior? e.g., is s/he in danger of overdosing from out of control substance use; or suicidal, self-mutilating, violent or homicidal impulses?

Does the client have any recognition and understanding of his/her mental health and/or addiction problems?

Does s/he have the skills to cope with and prevent relapse or continued problems and/or continued use? e.g., can s/he cope with craving and triggers to use; know what to do to manage panic attacks, compulsive behavior, cutting or suicidal impulses.

If the client is not successfully engaged into treatment at this time, what problems and further distress will potentially continue or reappear, ?  e.g., will out of control drinking worsen; or will the client become floridly psychotic if not stabilized on psychotropic medication?

To what degree is the client aware of relapse dangers and triggers?  Does s/he have ways to cope with any reappearance of psychiatric symptoms and/or cravings to use? What about skills to control impulses to harm oneself or others?  What about how to prevent continued alcohol/drug use?

Dimension 6, Recovery Environment:

Are there any dangerous family, significant others, living or school/working situations threatening treatment engagement and success?  e.g., threat of domestic violence tonight; or freezing to death because client is homeless and psychotic with poor activities of daily living and judgment.

Does the client have supportive friendships? e.g., a family member who is willing to have the client live with them so long as they are active in treatment.

What about financial, educational/vocational resources to improve the likelihood of successful treatment? e.g., client has been laid off from work, but has job skills and a consistent work history that are strengths in finding new employment; or client has a mental health case manager and a peer counselor to help client get to appointments.

Are there legal, educational, vocational, social service agency or criminal justice mandates that may enhance motivation for engagement into treatment?  e.g., Child Protective Services involved; employer mandating assessment and treatment; school requiring treatment; Mental Health Court or Drug Court client.

TIP 2.

Assess the person’s stage of change and interest in mental health and/or addiction recovery

Here is a summary of one model’s stages of change focusing on both mental health and addiction issues:

Transtheoretical Model of Change (Prochaska and DiClemente):

Pre-contemplation: not yet considering the possibility of change although others are aware of a problem; active resistance to or lack of interest in any change; seldom appear for treatment without coercion; could benefit from non-threatening information and information to raise awareness of a possible “problem” and possibilities for change. e.g., sent from Mental Health or Drug Court for an assessment and services; no awareness or acknowledgement of a psychotic illness; may be aware of an addiction problem, but no interest in directly addressing it; family distraught about dangerous weight loss in anorexic woman, but client insists they are “fat”; client feels they have a spouse problem not an addiction or anger problem.


Contemplation:
ambivalent, undecided, vacillating between whether he/she really has a “problem” or needs to change; wants to change, but this desire exists simultaneously with resistance to it; may seek professional advice to get an objective assessment; motivational strategies useful at this stage, but aggressive or premature confrontation provokes strong resistance and defensive behaviors; many Contemplators have indefinite plans to take action in the next six months or so e.g., “Maybe I drink too much, but I’m not as bad as them, I’m different.”; “Maybe I should take that medication, but I don’t think it will help me, so I don’t want to.”; agrees to come to treatment, but misses every other appointment and then does not participate very actively even when attending sessions’ “Perhaps I shouldn’t have hit her, but I told her to get away from me when I start getting angry.  She doesn’t listen and keeps arguing with me.”


Preparation:
takes person from decisions made in Contemplation stage to the specific steps to be taken to solve the problem in the Action stage; increasing confidence in the decision to change; certain tasks that make up the first steps on the road to Action; most people planning to take action within the very next month; making final adjustments before they begin to change their behavior e.g., “OK, I will make an appointment to see a therapist.  Where should I start to find one?”; “Next Monday, I’ll throw away my cigarettes.  If you’re my friend, don’t offer me a cigarette even if I beg you for one.”; “I have the medication now, but I want to learn more about the side effects before I start.”


Action:
specific actions intended to bring about change; overt modification of behavior and surroundings; most busy stage of change requiring the greatest commitment of time and energy; care not to equate action with actual change; support and encouragement still very important to prevent drop out and regression in readiness to change e.g., attending all scheduled sessions; adherent to medication; is collecting names and numbers to call for support in Alcoholics Anonymous (AA).

Maintenance: sustain the changes accomplished by previous action and prevent relapse; requires different set of skills than were needed to initiate change; consolidation of gains attained; not a static stage and lasts as little as six months or up to a lifetime; learn alternative coping and problem-solving strategies; replace problem behaviors with new, healthy life-style; work through emotional triggers of relapse e.g., has a home AA group that she attends regularly; attends a weekly peer support drop in community center; stays in regular contact with case manager who helps with transportation for monthly medication injection; volunteering regularly at the alumni group.


Relapse and Recycling:
expectable, but not inevitable setbacks; avoid becoming stuck, discouraged, or demoralized; learn from relapse before committing to a new cycle of action; comprehensive, multidimensional assessment to explore all reasons for relapse e.g., therapeutic alliance is such that client comfortable to call when relapsing and accepts help to get back on track; stops antimanic medication once stable complaining that he feels depressed when not so hypomanic; stops attending AA, feeling she was just under a lot of stress and that’s why her drinking got out of control; lost housing and became stressed and suicidal.


Termination:
this stage is the ultimate goal for all changers; person exits the cycle of change, without fear of relapse; debate over whether certain problems can be terminated or merely kept in remission through maintenance strategies e.g., hasn’t smoked tobacco for 25 years and views self as a non-smoker now; eating disorder and drugging behavior confined to her college years and has not had any out of control eating or substance problems for fifteen years.

References:

Mee-Lee D, Shulman GD, Fishman M, Gastfriend DR, and Griffith JH, eds. (2001). ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition-Revised (ASAM PPC-2R).  Chevy Chase, MD: American Society of Addiction Medicine, Inc.
American Society of Addiction Medicine – 4601 Nth. Park Ave., Arcade Suite 101, Chevy Chase, MD  20815.  (301) 656-3920; Fax: (301) 656-3815; www.asam.org; To order ASAM PPC-2R: (800) 844-8948.

Mee-Lee, D & Gastfriend, D.R. (2008): “Patient Placement Criteria”, Chapter 6, pp79-91in Marc Galanter & Herbert D. Kleber (eds) Textbook of Substance Abuse Treatment 4th Edition. American Psychiatric Publishing, Inc. Washington, DC.

Mee-Lee D, Shulman GD (2009): “The ASAM Placement Criteria and Matching Patients to Treatment”, Chapter 27 in Section 4, Overview of Addiction Treatment in “Principles of Addiction Medicine”  Eds Richard K. Ries, Shannon Miller, David A Fiellin, Richard Saitz.  Fourth Edition.  Lippincott Williams & Wilkins, Philadelphia, PA.,USA. pp 387-399.

The ASAM Patient Placement Criteria: PPC Supplement on Pharmacotherapies for Alcohol Use Disorders. Eds  Marc J. Fishman, M.D., David Mee-Lee, M.D., Gerald D. Shulman, M.A., MAC, FACATA, George Kolodner, M.D., and Bonnie B. Wilford, M.S. Published by Lippincott Williams & Wilkins 2010.

Prochaska, JO; Norcross, JC; DiClemente, CC (1994):  “Changing For Good” Avon Books, New York.

SKILLS

People can present in an emergency situation either on the phone or in person.  At a crisis center, emergency department or telephone hotline, one of the first tasks is to rule out any immediate life-threatening or urgent needs.

If you use the structure of the ASAM multidimensional assessment, you can quickly evaluate immediate needs – in just five minutes or less; just ten questions or less.

TIP 1.

Review relevant history information.  Obtain pertinent “here-and-now” information to develop an Immediate Need Profile.

Consider each dimension and with just sufficient data to assess immediate needs, checks “yes” or “no” for the following questions:

1. Acute Intoxication and/or Withdrawal Potential
(a) Past history of serious withdrawal, life-threatening symptoms or seizures during withdrawal? e.g., need for IV therapy; hospitalization for seizure control; psychosis with DT’s; medication management with close nurse monitoring and medical management? ___No___Yes;

(b) Currently having severe, life-threatening and/or similar withdrawal symptoms? ___No___Yes

2. Biomedical Conditions/Complications

Any current severe physical health problems? e.g., bleeding from mouth or rectum in past 24 hours; recent, unstable hypertension; recent, severe pain in chest, abdomen, head; significant problems in balance, gait, sensory or motor abilities not related to intoxication. ___No___Yes

3.  Emotional/Behavioral/Cognitive Conditions/Complications
(a) Imminent danger of harming self or someone else? e.g., suicidal ideation with intent, plan and means to succeed; homicidal or violent ideation, impulses and uncertainty about ability to control impulses, with means to act on. ___No___Yes;

(b) Unable to function in activities of daily living, care for self with imminent, dangerous consequences? e.g., unable to bath, feed, groom and care for self due to psychosis, organicity or uncontrolled intoxication with threat of imminent safety to self, others as regards death or severe injury ___No___Yes

4.  Readiness to Change

(a) Does client appear to need alcohol or other drug treatment/recovery and/or mental health treatment, but ambivalent or feels it unnecessary? e.g., severe addiction, but client feels controlled use still OK; psychotic, but blames a conspiracy ___No___Yes;

(b) Client has been coerced, mandated or required to have assessment and/or treatment by mental health court or criminal justice system, health or social services, work/school, or family/significant other? ___No___Yes

5.  Relapse/Continued Use/Continued Problem Potential
(a) Is client currently under the influence and/or acutely psychotic, manic, suicidal? ___No____Yes;

(b) Is client likely to continue to use or have active, acute symptoms in an imminently dangerous manner, without immediate containment?

(c) Is client’s most troubling, presenting problem(s) that brings the client for assessment, dangerous to self or others? (See examples above in dimensions 1, 2 and 3) ___No____Yes

6.  Recovery Environment

Are there any dangerous family, sig. others, living/work/school situations threatening client’s safety, immediate well-being, and/or sobriety?  e.g., living with a drug dealer; physically abused by partner or significant other; homeless in freezing temperatures ___No___Yes

What to Do

    • Yes to questions 1a and 1b; or 1b alone; 2 and/or 3 requires that the caller/client immediately receive medical or psychiatric care for evaluation of need for acute, inpatient care.
    • Yes to questions 4a and/or 4b alone, requires caller/client to be seen for assessment within 48 hrs, and preferably earlier, for motivational strategies, unless client imminently likely to walk out and needs containment.
    • Yes to question 5a alone, assess further for need for immediate intervention e.g., taking keys of car away; having a relative/friend pick client up if severely intoxicated and unsafe; evaluate need for immediate psychiatric containment
    • Yes to questions 5b, 5c and/or 6, without any Yes in questions 1, 2 and/or 3, requires that the caller/client be referred to a safe or supervised environment e.g., shelter, alternative safe living environment, or residential or subacute care setting depending on level of severity and impulsivity
    • Yes to questions 5b, 5c and/or 6, without any Yes in questions 1, 2 and/or 3, requires that the caller/client be referred to a safe or supervised environment e.g., shelter, alternative safe living environment, or residential or subacute care setting depending on level of severity and impulsivity

SOUL

Sure, homeless people disadvantaged by the ravages of addiction and mental illness can recover and start a new life! But have you ever seen recovery jump-started in just one day?  If you missed the story of homeless man Ted Williams, take a look:

http://www.youtube.com/watch?v=6rPFvLUWkzs&feature=related

http://www.youtube.com/watch?v=NND5revP2_c

Of course, recovery is a process and Ted Williams has been on the recovery path well before his January surprise.  Ever since his 15 minutes of fame though, Ted has experienced ups and downs.  That’s how recovery is.  That’s why we hang in with our clients, consumers and patients through relapses and recycling.  It’s about progress, not perfection, as they say in Alcoholics Anonymous.

What happened to Ted was unique to our fast-paced world.  With mobile media and social networking, current technology can turn a brief video clip into a YouTube sensation that can go “viral”.  Most people you attract into recovery don’t get such a chance to turn their fortunes around literally overnight.

But even a short intervention can create an amazing impact.

Some homeless women in the Los Angeles area have had a chance, in just one day, to gain a glimpse of what might be different for them.  These women never have the opportunity to dress up and feel great.  A makeover may seem pretty low on the list of necessities for homeless women.

However, there are three women (two from Los Angeles, California and one from Boston, Massachusetts) who believe a little bit of glamour goes a long way in helping homeless women gain confidence and get back on their feet.

Take a look at The Glamour Project. You’ll be pleasantly surprised.

http://www.glamourproject.org

Maybe your clients don’t have a “golden” voice like Ted, that can get them immediate voice over, announcer TV work.  And maybe it is difficult to see the potential in your clients’ disheveled, disorganized demeanor where they wear their low self-esteem and self-efficacy on their sleeve.  Like the Glamour Project, in your next client contact you could fashion some small interaction to ignite a different perspective and a glimpse of recovery.

Beneath that chronic diagnostic label lies a lost “golden” sense-of-self waiting to be seen, acknowledged, validated.

SHAMELESS SELLING

Norm Hoffmann, Jerry Shulman and I were some of the co-authors of the first edition of the ASAM Patient Placement Criteria published in 1991. To help clinicians and others document their assessment and placement information, we have developed some proprietary instruments.

Take a look at them online at http://www.changecompanies.net/placement-and-planning.php and call for more information.

Each instrument can be used for up to six assessments for the same client.
Ratings for each of these six evaluations are recorded side by side for easy comparison.
Then you can compare admission, continued service and treatment progress.  This helps explain admission, continued stay and discharge/transfer decisions to colleagues, supervisors or managed care.

Level of Care Index (LOCI-2R): Checklist tool listing ASAM PPC-2R Criteria to aid in decision-making and documentation of placement.

Dimensional Assessment for Patient Placement Engagement and Recovery (DAPPER): Severity ratings within each of the six ASAM PPC-2R dimensions.

To order: The Change Companies at 888-889-8866; www.changecompanies.net

For clinical questions or statistical information about the instruments, contact Norman Hoffmann, Ph.D. at 828-454-9960 in Waynesville, North Carolina; or by e-mail at evinceassessment@aol.com

Until Next Time

Thanks for joining us. See you in February.

David