Vol. 10, No. 12
Thanks for joining us for the March edition of Tips and Topics. Next month’s edition in late April will mark the 10th anniversary of Tips and Topics. We’ll share your comments.
David Mee-Lee M.D.
SAVVY and SKILLS
I don’t know about you…. but if you find yourself saving a good article you read, or keeping the notes of a great lecture you heard, it is easy to accumulate boxes and boxes of material over the course of a career. I wouldn’t classify myself as a hoarder, but you never know when you might want to refer to that article or lecture notes again!Trouble is, you rarely go back through those boxes of pearls of wisdom. All that valuable material clogs up file cabinets, boxes in the garage or piles on your desk. Or is this just me!?
Anyway, the point is: I am in the process of radical de-cluttering, meaning I am dumping boxes and boxes and boxes- old policy and procedure manuals, yellowed articles pulled from journals and magazines aeons ago, old lecture notes, handouts I knew I would review someday when I had some ‘spare time’….
In the course of that cleansing process trying to achieve good feng shui (look it up on Google), I came across a page of “Dr. Mee-Lee’s Cliches. ” A workshop participant had compiled these as he listened that day thirteen years ago in Phoenix, Arizona. At the end of the day, he handed them to me. I still have his yellow notepad page. I don’t know what the topic was – probably a workshop on the ASAM Patient Placement Criteria, which by the way, we are revising (more on that in another edition of Tips and Topics soon).
So for March, SAVVY and SKILLS is combined. I am covering some of the phrases on that list compiled by a good listener at my workshop…..or perhaps he was just trying to stay awake by writing stuff down.
Here are some clichés and the meanings and ideas behind them (or at least, my ideas)
Firstly, to say a person is using clichés is not necessarily a complimentary thing to say.
“The term is frequently used in modern culture for an action or idea that is expected or predictable, based on a prior event……A cliché is often a vivid depiction of an abstraction that relies upon analogy or exaggeration for effect, often drawn from everyday experience. Used sparingly, they may succeed, however, the use of a cliché in writing or speech is generally considered a mark of inexperience or a lack of originality.” (Wikipedia).
I don’t see myself as inexperienced or lacking originality. I’ll just ignore that part of the definition of a cliché and focus on the “vivid depiction of an abstraction…drawn from everyday experience.” Here are a few of the clichés that were on the list. I’ll address the meanings and ideas behind the saying as they relate to clinical practice and to systems issues.
1. Turn a blind eye or a deaf ear
Clinical: How often do we see and hear a client saying to us that they are not interested in abstinence, wellness and recovery while we steamroller on with mandates to go to 90 meetings that they don’t like in 90 days? Or comply with medication that gives them more side effects than benefits?
It is as if the focus is on what we think the client should do. It’s like we don’t care what we see in their body language and whether they participate, or not, in treatment. Also it is as though we don’t listen for discord and disagreements they may have with what we are prescribing for them.
Systems: When it comes to systems of care, it sometimes seems they are actually designed to be blind and deaf to the pain of the people we serve. Do we still provide and fund programs with limited levels of care and inflexible lengths of stay that force us to put people on long waiting lists? Or cause people to call everyday to demonstrate their motivation to access services, even those in severe withdrawal? Is there no way to see and hear the anguish such waiting lists cause? Can we really not design a better system of care that increases access to care, yet still uses resources efficiently and effectively?
2. Keep their feet to the fire
“Putting someone under pressure. Forcing, or trying to force, someone to do something.”
Clinical: Since all lasting change is self change, forcing change is not likely to last beyond the time you have the “big stick.” But an effective way to reframe this cliché is to hold a person accountable in their mandated treatment experience by focusing on what they really want.
Clinician: “I don’t see, Joe, how you are making a strong case for getting out of 24 hour care when you continue to threaten the staff and get into fights with your roommate. It makes it look like you are too unstable to manage things in the outside community.” This is how to keep clients’ feet to the fire, to stay accountable for their treatment without forcing them to do something.
Systems: The same principle applies if you have staff members more focused on complaining, gossiping, backstabbing or even dragging down morale through negativity and sub-par work. Theoretically you may have the power to write them up and order them to do their work. However if you would rather create a healthy work environment of accountable self-change, there are other ways to keep their feet to the fire.
Do you have a functioning conflict resolution policy, one which empowers people to speak up, advocate for what they believe in, while at the same time requiring respectful communication and resolution? Now there is no tolerance for gossip, negativity or intimidation. It is everyone’s right and obligation to resolve conflicts and keep communication healthy. Do you have effective supervisors who can support supervisees, but also set limits?
3.Keep your eye on the prize
Clinical: Clients and clinicians can easily get distracted into sidetracks that lead nowhere productive. How often do you struggle with clients more focused on telling you how the food or their counselor stinks, how unfair their parents, boss or probation officer are, or how they “don’t even have a problem”? It’s easy for both clients and clinicians to descend into arguments about treatment compliance around medication or rules of the program, and get distracted from “the prize”.
Clinician: “Joe, we can talk all day about how unfair your boss is, or we can put our energy into gathering the data to prove you don’t have an anger or addiction problem. That way we can show her you are a good worker who doesn’t deserve to be fired.”
Systems: Your agency’s mission, I imagine, is to help people achieve their full potential, grow and embrace health and wellness. Yet how focused are you on actually defining and measuring those outcomes for each person? Are you more focused on preserving your particular program model, levels of care, ideology and traditions than on measuring client outcomes to actually demonstrate efficacy and efficiency for the people we serve? Are there struggles between clinical providers and the judge/criminal justice personnel on how to handle positive drug screen results? How can we join together to realize we all want the same outcome: increased health and well-being, decreased crime and recidivism, increased public safety, and safety for children and families?
4.What floats my boat
“An expression which means you can do whatever your preference is.”
Clinical: When working with clients especially severe and chronically mentally ill, it can be challenging to actualize our desire to be strength-based, empowering and recovery-oriented. Our impulse to ‘fix’ what seems so obviously pathological, leads to parent-child type interactions; expert prescriptions on what the client or patient must do; and program and clinician-centered services.
Example: The client who wants people to leave him alone…
Rather than dwelling on his delusions, hallucinations and med. compliance, try conversing and exploring times in his life when he had the freedom and independence to come and go when he wanted, to do whatever he preferred. See if you can reawaken in him what “floats his boat”, turns him onto life. What would inspire him to have hope for joy? Perhaps he wants a job or to return to school for more education. Ask: What worked when you had the job you enjoyed, or attended a school you felt good about?
Systems: It doesn’t matter your role, whether administrator, supervisor or supervisee. Under the cost and time pressures in today’s healthcare system, it is easy to see personal and staff morale plummet. Self-care is not an option. It is an obligation if you are going to be healthily present to serve people – patients and fellow team members. Are you staying in your job out of habit or fear you could fail at something else you might prefer to do? Are you just going through the motions, having lost sight of what attracted you to the job originally? Can those benefits be reawakened? Perhaps the job (or you) has changed so significantly that it no longer matches your needs for fulfillment and meaning? Self-care may mean re-designing your job or moving on to something that “floats your boat.”
5.A sitting duck
“Something or someone that is easy to attack or criticize.”
Clinical: Have you ever wondered why a client is verbally attacking you for the well-intentioned advice and recommendations you are giving them? As a counselor, isn’t it “my duty” to confront them, point out how their impulse control and anger problems is the cause of their relationship breakdown or legal problems they now face?
Or maybe you don’t wonder why you are a sitting duck. Perhaps you simply tell yourself (and them) that they are “in denial” and need to take suggestions even if they don’t like it. In other words, it is their problem, their resistance, their pathology which explains their anger at you. What’s happening has nothing to do with your approach and interaction with them.
In Motivational Interviewing these “attacks” are evidence of discord (disagreement between two people – you and the client) not resistance (pathology in the client). It is about you and how you engage a person or not, which is as much a part of whether there is discord as it is a problem “in” the client. You’ll be a ‘sitting duck ‘if you always view it as something wrong with the client instead of an interactive process.
Systems: As healthcare reform becomes even more the reality, how you design and deliver services will increasingly be influenced by how you are paid compared to current models. In the current fee-for-service model, you make more money if you provide sick-care rather than health-care. When people are well, don’t need to see you or fill your beds and outpatient slots, you don’t make money. Of course it’s a contradiction: we want people to get well – we don’t purposely try to keep people sick just to fill beds and slots. However, currently, few financial incentives exist to focus more on prevention, or on low-intensity and low-reimbursed outpatient services. The trend to population-based funding and outcomes-driven payment will change that. You and your program will be a sitting duck for loss of business and revenue if you aren’t preparing to move to outcomes-driven services; and ‘health-care’ rather than ‘sick-care.’
–>I hope you discovered some new meaning from old clichés.
This month, my granddaughter and only grandchild turned one. A week later she was taking her first wobbly, yet independent steps. Soon, no doubt, she’ll be running around. You would think that with three children of my own, seeing them through all their developmental stages, that this would not be so amazing to witness. But it is.To see Luna develop from that uncoordinated newborn bundle of love I cuddled just a year ago, to now a walking little person who can wave goodbye, say “ciao,” stand and dance to music with one arm waving high (remember John Travolta, “Saturday Night Fever” style!)- it’s simply amazing.
With the joy of seeing her development, I can’t help but wonder about all the boys and girls her age who don’t have loving supportive parents and grandparents. Who is there for them to hold their hands and comfort them when they cry? Sometimes somebody is there, but sometimes there’s a father or mother passed out in a drug-induced slumber? How can they be emotionally present for this little one, when they are stressed out about how they will get their next meal or are struggling with disabling depression, anxiety or psychosis?
There are an estimated 28 million Americans who are children of alcoholic parents, nearly 11 million under the age of 18. And that is just alcohol-affected children. What about other addictive and mental disorders? Every parent or prospective parent you attract into recovery brings great dividends for the rest of the family.
Have you seen my granddaughter, Luna? (If you want to see more of her dad’s photography, go to http://www.paulodiasphotography.com)
P.S. – A request reminder:
Next month is the April Tips and Topics 10th anniversary edition. I’ll publish some of your “appreciation gifts” and celebrate together. So if you are moved to write a brief note of appreciation, or if you remember an edition of a SAVVY, SKILLS, SOUL or STUMP THE SHRINK section that was particularly meaningful or memorable for you, please let me know. Tell me what edition it was in and what was the meaningful part for you. (You can read all ten years of TNT at The Change Companies www.changecompanies.net. Click on Blogs.)
Until next time
Thanks for reading. See you in late April for our 10th anniversary edition.