Vol. 11, No. 6

Welcome to all the new readers and longtime subscribers to Tips and Topics.
Thanks for joining us for the September issue.

Senior Vice President

of The Change Companies®

SAVVY & STUMP THE SHRINK

I always enjoy and appreciate it when readers send their feedback about eLearnings, webinars, Tips and Topics or presentations I have done.

This month I received the following message which combines words of appreciation along with a “meaty” and substantive question I know is shared by many other clinicians, supervisors and clinical directors.

So I have combined SAVVY and STUMP THE SHRINK this month. Here’s the email:

Dear Dr. Mee-Lee:

I hope this email finds you well. I have a “stump the shrink” question I’d love to get your take on, if you have the time/interest. I find questions/struggles exemplified by this scenario have a tendency to show up again and again. I think our staff has a hard time in these situations because they are confronted by feelings of frustration, anger, annoyance, ineffectiveness and, if they’re willing to go there, their own expectations and values that they’d like our clients to adopt . . .

I recently attended case conference at our inpatient substance use rehabilitation center (length of stay is based on assessed need, however,28 days is still the accepted target) and the team was consulting regarding a client with whom they were extremely frustrated. The client is a middle-aged man who presents with mixed personality disorder traits (cluster B -antisocial, borderline, histrionic, narcissistic).

The client had been at our inpatient centre for 6 days and, during that time:
  • repeatedly violated house rules around pay phone and cell phone use, as well as daily living structure. 
  • He also had a tendency to tell the staff that our programming was “stupid” and that he had nothing to learn from them or our programming, especially since this was his 2nd treatment episode with us.
  • The staff was growing weary from constantly reminding him of the house rules and, at this point, were asking me permission to place him on a tight behavior contract (e.g., if we have to remind him X more times about the pay phone or cell phone rules, then he will be considered non-compliant and choosing to engage in treatment-interfering behavior, which may warrant an administrative discharge).
The staff were clearly tired, exasperated, and approaching the limit of being willing to work with this client.
  • I tried to balance empathizing with their frustration and feelings of ineffectiveness,
  • while also engaging them in a discussion about our mandate, realistic and reasonable expectations (especially given the enduring nature of personality disorders, learning & behavior, and the brief nature of our treatment),
  • empathy for the client, his own expectations and values,
  • and the difference between behaviors we absolutely cannot tolerate (e.g., verbal or physical aggression toward other clients or staff) and behaviors that require us to stand solid and yet have the capacity to bend in the wind, if you will.

I won`t give you all of the details (because I am eager to hear what type of recommendations you would give to a team that was tired, frustrated, and understandably reverting to hard nosed methods), but I will say that by the end of the discussion they agreed that the behavior contract they were proposing was unlikely to accomplish anything other than giving us a reason to discharge the client.

Given the lack of evidence-based or efficacious brief treatments/approaches with personality disorders, I find that it becomes increasingly difficult to advise/inspire our staff in their work with co-occurring Axis I and Personality Disorders. In all of your busy-ness, if you have the time and interest to give your take and how you would approach such a scenario (in the shoes of the therapist and floor staff working with this client), it would be greatly appreciated — especially since you are a bit of a celebrity around here :)

I circulate your Tips & Topics each month (with a bit of commenting and orienting on my part) and a common question we like to throw around is, “What would David Mee-Lee say/do?” lol.

Thank you so much for your time, and for the extremely useful and engaging Tips & Topics — I truly believe it is the staff’s favorite email that I send out!

Warmest regards,

Phuong-Anh

Phuong-Anh Urga, Ph.D.

Montreal, Quebec, Canada

My response (supplemented by Tips in SKILLS):

Hello Phuong-Anh:

 

Thank-you for that nice feedback. It is really gratifying to know that Tips and Topics is helping make a difference to you and your team.

As regards your Stump the Shrink question, indeed this is an often-heard issue.  It has come up a lot over the years, but especially with some programs in Alabama and Louisiana where I am currently doing teleconference supervision.

Take another look at SKILLS in the Feb., 2013 edition.  This link should get you there.  Especially note numbers 2 and 3 in SKILLS tip#1.
Most importantly, help staff begin to reframe how to use the behavioral problems and “rule-breaking” etc., as an opportunity:
  • To recognize that treatment progress and outcomes are not going well.  As with any poor outcome – whether stabilizing someone’s blood pressure or blood sugar, their asthma, their depression – their addiction is really the same.
  • After that, the next step is to assess what is not going well.
  • Then collaborate with the client on a modified treatment plan. Then watch if things improve.
We wouldn’t just criticize a patient for having their blood pressure go up. We wouldn’t expect them to contract to control their blood pressure on their own. We would explore with them what’s going wrong, and how we can help them fix it. The same with anger, outbursts and rule-breaking…….

 

In the case of this client, we would be asking these questions and assessing along with him:
  • Why is he even in the program?
  • What does he want?
  • What is so important to be on the phone all the time?
  • What does he feel is stupid about the program?
  • What made him decide to choose to be in the program in the first place?
  • Is he getting what he wants? And if not, what can we do together to reach his goal?
Use the six ASAM Criteria dimensions to re-assess:
  • Dimension 1, Acute Intoxication and/or Withdrawal Potential

Is he acting up because he is in some withdrawal or even using on the side?

  • Dimension 2, BiomedicalConditions and Complications
Are there some physical health problems making him more frustrated -e.g. pain or migraine headaches or something else going around a co-occurring physical health problem?
  • Dimension 3, Emotional,Behavioral or Cognitive Conditions and Complications
Similarly are there issues that are stressing him?  Anger over something going on at home – or whomever he is talking to all the time on the phone? (Dimension 6, Recovery Environment).  Does he have an unstable concurrent mental health diagnosis?
  • Dimension 4, Readiness to Change
Readiness to change -or not- is an important area of focus. When I hear cases like this, the first thing I want to check is:
…What is the treatment contract?
…What made the client decide to be in treatment?
…What does he want?
Many behavior problems arise when we clinicians try to do “Recovery, relapse prevention” when our client is actually at “Precontemplation” for recovery, but at “Action” perhaps for other things like: getting someone off their back, or keeping a job or a relationship, or for staying out of jail or getting off Probation?
  • Dimension 5, Relapse, Continued Use or Continued Problem Potential
Is it possible your client is having addiction cravings to use and doesn’t know how to handle those?  Are there mental health flare-ups? He is possibly exhibiting in your program all kinds of struggles that he similarly gets into at home or work?  All of this comesback to the central question: Why is he in treatment? What does he want?
  • Dimension 6, Recovery Environment

Your client may have some family, work or other recovery environment pressures – e.g., money, housing, legal issues frustrating him. That could be contributing to his negativity about being there.

—-> So what is the staff’s goal? 
  • What can he (the client) and we (the staff) learn from how he handles frustration here in our program, which also happens outside in the ‘real world’? (Assessment)
  • What alternate strategies and skills can we help him learn and practice in the program, which he can also apply outside? Then he won’t have to come to these “stupid” programs. (Skills)

 

—–> It isn’t about our just trying to clamp down and stop the behavior. 
  • How can we relate to clients in an Adult-Adult interaction (Transactional Analysis) rather than a Parent-Child relationship?
  • Behavioral contracts and the like just perpetuate a victim, Parent-Child interaction. This doesn’t help him, or the staff, learn from this microcosm of the real world.
 
Bottom Line 
…When there is “rule breaking,” assess what is not going well.
…Tie the behaviors to the client’s treatment plan.
…Don’t make separate behavioral contracts.
…Create programs to be a safe, supportive environment where clients can understand and practice new ways of being.

… The same frustrations and behaviors that happen ‘out there’ also happen in the program.

Thanks for being a faithful reader and spreading it around.
David

SKILLS

So… What do we do about clients’ behavioral and emotional outbursts, especially in residential treatment programs?

 

On August 9, 2013 National Public Radio’s Science Friday interviewed two experts in social-emotional learning: Marc Brackett, Director of Yale University’s Center for Emotional Intelligence; and Maurice Elias, Professor, Psychology Director of Rutgers University’s Social and Emotional Learning Lab.

http://www.sciencefriday.com/topics/body-brain/segment/08/09/2013/reading-writing-rithmetic-and-respect.html

 

The program’s theme was on emotional intelligence. While the focus was on what schools and teachers should be doing in educational settings, the conversation referred to many principles applicable to treatment settings. In behavioral health, we also create an environment of learning, to facilitate lasting positive self-change.

 

TIP 1

Consider these points about schools. How can we relate them to our daily work in behavioral health?

 

1. Emotional intelligence is our way of being smart in the world.
We develop the set of skills needed to get along in our interpersonal relationships.

  • People in treatment have often been raised in families who themselves were never taught about emotional intelligence.
  • Many have never developed the skills to be smart in the world. They are not skilled about negotiating relationships. Our clients need us to create a safe and healing environment to learn emotional intelligence.
  • What they don’t need is a “school” where the focus is on behavior control, rule-breaking and “punishments.”

 

2. Schools and teachers do not do direct instruction of these skills.
Yet these skills are teachable. Students can be helped to develop a sophisticated emotional vocabulary and research-based strategies to regulate their emotions. Many people can only identify a few emotions; many have no emotional vocabulary to make sense of what is bubbling up inside them.

  • Clients can often have defiant outbursts and don’t comply with house rules. They probably have a very limited understanding of what they are feeling, and what they are reacting to. They are not skilled at acting differently and constructively, since they most likely have a limited repertoire of emotions and behaviors.
  • What is our job in treatment? To help our client become an explorer of his/her own feelings and behaviors – to think through what is going on and how to thrive.
  • What must we watch out for? That we do not perpetuate our clients’ externally- oriented perspectives where others are blamed for what is going wrong. We can reinforce this by responding to outbursts with rules and procedures. This then puts the responsibility for controlling emotions and keeping the peace on the staff! It is our clinical challenge to harness the teachable moment of an outburst.

 

3. Ability to learn at school is affected by a student’s emotional state while they are learning.

  • Students can’t learn if preoccupied with feelings and fears they don’t have a good handle on.
  • It is the same in treatment. When clients struggle to understand what they are feeling, thinking and why they are, it is doubly hard to figure out what to do about it.
  • In treatment, we must create a therapeutic environment to promote learning, not compliance.

 

4. Teach students how to calm themselves down when stressed or even when they are elated.

  • We must help clients find strategies they can use themselves,not just in the program, but more importantly when they are on their own in their outside world.
  • Simply expecting clients to manage interpersonal disputes effectively when they have never been taught is like teachers expecting students to know calculus just because they have enrolled in the class.

 

5. Teachers need to pay attention to the students’ emotional cues and create an engaging learning environment.

  • Clients frequently behave in exasperating and frustrating ways. For the staff, that’s a signal that the client is out of their depth in emotional intelligence.
  • The clinician is now alerted to the need for engaging the client in a learning process, not a disciplinary process.

 

TIP 2

Help people “name their emotions to tame their emotions.

Marc Brackett coined RULER to develop critical and inter-related emotional skills. Whena person creates a mental model of what an experience is, then it’s possible to figure out what one’s feelings and needs.   This helps you regulate them.

Here is what the acronym RULER means:

 

Recognize emotions in oneself and others.

Understand where emotions come from and the causes of emotions.

Label emotions and increase your emotional vocabulary.

Express emotions rather than holding them in.

Regulate emotions so as to get needs met, be smart in the world to get along in interpersonal relationships.

 

Help clients identify and explore their RULER. Focus the therapeutic community and staff energies on learning and growing, not compliance and discharge.

SOUL

The headline in the Sacramento Bee newspaper on Saturday, September 28read: “
Obama, Rouhani break ice on phone” FIRST DIRECT TOP-LEVEL TALKS SINCE 1979 – “Barack Obama and Hassan Rouhani spoke Friday by telephone in the first conversation between the presidents of the United States and Iran in more than 30 years.

Experts on Iran used a wide range of superlatives to discuss the call: “hugely positive,” “historic but long-overdue moment,” a “groundbreaking event.” “The phone call lasted only 15 minutes, but it offered the best hope in years for the two countries to settle their disagreements.”

 

I know I am politically naive. But it seems to me that if you don’t talk to people, it’s hard to form any kind of working relationship, let alone hope to settle disagreements. So, yes, maybe in the world of politics, talking to someone for 15 minutes after 30 years is pretty amazing. But on another level, you don’t have to be a rocket scientist to figure out that if you:

  • don’t talk for 30 years
  • don’t try to give each side some mutual respect
  • don’t use any methods other than the threat of bombs, sanctions, force and violence

………….that the chance of settling disagreements might seem a little far off!

 

The world of international politics is way over my head and outside of my expertise. But what is amazing to me much closer to my area of expertise is that we do our own version of the “no talk, no relationship” method in behavioral health and criminal justice settings.

 

As we just discussed in SAVVY and SKILLS this month, it is too easy to stick to “behavior control” methods to manage behavioral and emotional outbursts rather than to talk and build a “working alliance” method to create a learning experience for our clients.

 

Worse still are how high-risk inmates of prisons are housed with very little human contact and relationship. They are allowed only an hour out of their cell, with all their comings and goings controlled electronically via switches and gates.

 

Some forward-thinking prisons have discovered that respectful human interaction works wonders. Previously out-of-control inmates have shown dramatic improvements in the health and safety of inmates, correctional officers and the overall facility.

 

So maybe there are some places and world regions where the “no talk, no relationship”, power and control methods work well to settle disagreements.  I just know I don’t want to be anywhere near those countries or politicians – oops, I take that back.

 

I don’t want to move away from the USA. (I wonder when politicians in the USA will discover talking and relationship to settle disagreements?) I guess I’ll just have to enjoy the Government shutdown looming this week.

SHARING SOLUTIONS

Here is Dr. Phuong-Anh Urga again:

Firstly, I’d like to congratulate you–and The Change Companies–on your work that has resulted in the ASAM (American Society of Addiction Medicine) e-learning modules.I have completed them myself and have piloted them with some newly hired clinicians. Based on the feedback, I intend to incorporate them into my organization’s training and integration of new staff (it will be much more cost efficient and effective than providing the trainings myself, which I have done for the past few years now). I wonder how/if the modules will change with the launch of the revised criteria — any insight you might be able to provide without violating top security clearance would be appreciated before I purchase the site licenses.

 

My response:

I’m so glad you appreciated the ASAM eLearning modules.  We will have a new eLearning module on the new edition; it will be about an hour long. Also we are updating the two original modules to take into account some terminology changes from the new edition. However the essential principles and content will be the same as what you took, just updated for the 2013 edition.  I’ll certainly announce that in Tips and Topics, but you can also keep up to date at www.ASAMcriteria.org and check out the special preorder offer for the new edition of The ASAM Criteria that is running out.

Until next time

Thanks for joining us this month. I’ll be back in late October.

David