Welcome to the February edition of Tips and Topics. Check out www.tipsntopics.com for everything all in one place.
David Mee-Lee M.D.
SAVVY & STUMP THE SHRINK
|Recently, a reader raised the issue of how to balance clinical thinking and judgment with strict interpretations of criteria and guidelines. “Criteria” refers to both placement and diagnostic types of criteria- for example, The ASAM Criteria or other utilization management criteria (placement) and DSM-5 (the Diagnostic and Statistical Manual of the American Psychiatric Association (diagnostic). There are also other sets of “Guidelines” like best practices or evidence-based practice protocols.Here is the STUMP THE SHRINK question I edited for clarity:
“I was hoping you could provide some feedback on a recent discussion I had with colleagues regarding ASAM Criteria assessment Dimension 4, Readiness to Change for Level1, Outpatient Services. My co-worker was asking for input regarding a client who met Level 1 placement criteria in every dimension except for criterion “a” in Dimension 4.
(Criterion “a” in Dimension 4, Level 1 states: “The patient expresses willingness to participate in treatment planning and to attend all scheduled activities mutually agreed upon in the treatment plan.” Page 192- this is my insertion for those not familiar with The ASAM Criteria 2013).
The client walked out at the end of the assessment unwilling to enter treatment. She was in denial that she had an alcohol problem that required treatment and had come to the assessment to avoid legal consequences.
The focus of the discussion with my colleagues was on the fact that the patient doesn’t fit Level 1 because she is not willing and walked out towards the end of the assessment. I thought the focus should be more on how do we motivate her to become willing. I would appreciate your thoughts.”
Compare and contrast strict interpretations of criteria with using clinical thinking and judgment
Strict interpretation: Criterion “a” says the patient expresses willingness to participate and attend treatment. She walked out at the end of the assessment unwilling to enter treatment. End of story. No further thinking required. Patient does not meet criterion “a” and can’t be admitted to Level 1 Outpatient Services.
Clinical thinking and judgment: The client showed up and stayed until the end of the assessment. She clearly wants something.If she didn’t, she wouldn’t have shown up in the first place. She appears to want to avoid legal consequences but doesn’t see she has an alcohol problem. That is a critical Dimension 4, Readiness to Change treatment priority- to engage her into treatment around what she wants: to avoid legal consequences.
Strict interpretation: The client is “in denial” and doesn’t want treatment for sobriety and recovery; and is not willing to enter treatment. I can’t make her be willing and stop her from walking out, so she can’t be in Level 1 because she didn’t meet Dimension 4, criterion “a”.
Clinical thinking and judgment: This client is a prime candidate for motivational enhancement and interviewing strategies. She is at ‘Action’ stage for avoiding legal consequences. At the same time, she is in ‘Precontemplation’ stage for working on alcohol abstinence and sobriety. If I proceed and present treatment as though she showed up for sobriety, recovery and relapse prevention, I will not be on the right path. This focus does not match her stage of change. My focus is not important to her, and I’ll fail to engage her in treatment. She is likely to be turned off treatment altogether, and encourage her to walk away. (Alternatively she may enter treatment, but just sit there and passively comply, instead of focus on change.)
Strict interpretation: The client does not meet all criteria listed for Level 1 in The ASAM Criteria. Case closed.
Clinical thinking and judgment: This woman certainly meets all criteria for Level 1 if I develop a “mutually agreed upon…treatment plan” focused on avoiding legal consequences not focused on abstinence, sobriety and recovery.
In each dimension and level of care, The ASAM Criteria is meant to guide clinical thinking. Using the criteria is not meant to shackle counselors and clinicians to check off a criteria checklist. They should not bypass clinical thinking in how to engage a client and how to collaborate on treatment goals which makes sense to the client.
Note what the American Psychiatric Association says about diagnostic criteria and clinical judgment
Diagnostic Criteria Sets
“For each disorder included in DSM, a set of diagnostic criteria indicate what symptoms must be present (and for how long) as well as symptoms, disorders, and conditions that must not be present in order to qualify for a particular diagnosis. Many users of DSM find these diagnostic criteria particularly useful because they provide a concise description of each disorder. Furthermore, use of diagnostic criteria has been shown to increase diagnostic reliability (i.e., likelihood that different users will assign the same diagnosis to an individual). However, it is important to remember that these criteria are meant to be used as guidelines informed by clinical judgment and are not meant to be used in a cookbook fashion” (italics added for emphasis).
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Arlington, VA, American Psychiatric Association, 2013.
Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies.
For more information on the new edition: www.ASAMcriteria.org
Another agency that also “uses” The ASAM Criteria provided documentation on a client case. They believed their paperwork explained and justified why their client needed Level 3.5, Clinically-Managed High Intensity Residential Services.
Below you can read excerpts from this counselor’s paperwork. It is an example of simply quoting from the Criteria book to justify a level of care. The “Clinical Observation” data does not support the criteria they quoted.
This case is especially relevant because the client had already been in their Level 3.5 service for over four months when she was discharged to outpatient services. Within a day of discharge, the client used alcohol. Now the treatment program readmitted her for more weeks in their residential program. In addition, the agency’s program is often represented to clients as being a six-month program, which is inconsistent with the spirit and content of The ASAM Criteria.
Here is the documentation on Dimension 4 assessment:
Dimension 4: Readiness to Change:
According to ASAM Criteria, the client meets criteria (d) Client requires structured therapy and 24-hour programmatic milieu to promote treatment progress and recovery,because motivational interventions have failed at less intensive level of care and are assessed as not likely to succeed in the future at a less intensive level of care.
(e) Client’s perspective impairs his/her ability to make behavior changes without repeated, structured, clinically directed motivational interventions, delivered in a 24 hour milieu. Interventions are judged as not likely to succeed at a less intensive level of care.
Clinical Observation: Client has acknowledged that she does have a drug problem and has verbalized that her desire for treatment is externally motivated. Client has not internalized motivation for change, and the causes of her addiction. She needs to internalize her motivation for treatment, and identify her relapse triggers. Client needs to continue to remain in Level 3.5 so that she learns to internalize her motivation and identify the reasons for her continued use.
Explaining why a client needs a certain level of care is much more than simply quoting the criteria from The ASAM Criteria book or any otherguidelines. You must demonstrate how the clinical assessment data and observations match the criteria quoted.
In Case #2, there was no clinical observation data in any of the six dimensions that demonstrated the client was in imminent danger needing 24-hour care in a residential setting. The criteria quoted for Dimension 4, Readiness to Change were referenced from page 258, criteria (d) and (e) in The ASAM Criteria (2013).
Here’s how the “clinical observations” do not match the criteria:
- The client had been admitted to Level 3.5, residential services for five months and no motivational interventions at a less intensive level of care were considered or attempted.
- Nor was there any clinical data provided indicating that motivational interventions would be unsuccessful in a less intensive level of care.
- The client acknowledged having a drug problem even though her desire for treatment was externally motivated for legal problems.
- Helping the client to internalize a connection between her drinking and the external motivators requires motivational strategies, which can be provided safely in an outpatient level of care.
- There was no clinical data demonstrating that motivational strategies could only be delivered in a 24-hour treatment setting.
- Readmitting the client to Level 3.5 residential treatment for even more weeks only further shelters the client away from developing the skills necessary for community reintegration.
Utilization management criteria such as in The ASAM Criteria are to help guide clinical decision-making and judgment…….not the other way around. In other words,clinical thinking and decision-making comes first and then that guides what criteria are chosen and used to explain decisions about treatment and level of care.
It is not the printed criteria (quoted from the book) which explains how to assign the level of care. It is the clinical decision-making about the client’s severity and needs that point to which criteria apply.
This month I worked and touristed in Hong Kong after my last visit 20 years ago. It was a fascinating experience as you can imagine. It wasn’t exactly getting in touch with my roots even though my ancestors did originate in southern China, not far from Hong Kong. After all, I was born and raised in Australia; so were my parents; and my mother’s mother too. So I am more familiar with CrocodileDundee than Chinese Dragons.
But since Chinese NewYear was just February 19, SOUL this month should be about some things Chinese!
Over the last few years, I have had my awareness and knowledge upgraded regarding a very Chinese art and science called Feng shui. Here are a couple of explanations:
- “Feng shui is a Chinese philosophical system of harmonizing everyone with the surrounding environment. The term feng shui literally translates as “wind-water” in English. The feng shui practice discusses architecture in metaphoric terms of “invisible forces” that bind the universe, earth, and humanity together, known as qi.” http://en.wikipedia.org/wiki/Feng_shui
- “Feng shui is an ancient art and science developed over 3,000years ago in China. It is a complex body of knowledge that reveals how to balance the energies of any given space to assure the health and good fortune for people inhabiting it.” http://fengshui.about.com/od/fengshuiglossary/
Our home has been transformed with the help of our Feng shui consultant who has opened my skeptical, Western-ingrained eyes to come to respect some ancient wisdom.
Here is just one example which might give you an idea of how this works:
For 17 years, we have had a TV and media cabinet in our bedroom. (True feng shui prinicples discourage TVs in bedrooms as it does not harmonize with the intention of the bedroom as a place for rest, rejuvenation and romance.) This cabinet had doors which allowed us to close them so the TV, DVD player would not dominate the room. It wasn’t especially large, but it did certainly jut out a bit so there wasn’t an easy flow walking by it. It also somewhat obstructed a peaceful view out to the trees and greenery n the backyard. For years, though,we had just become accustomed to moving around it. One day last month, it dawned on us that with flat screen TVs now, we didn’t need as large a space for such a cabinet. We moved it out of the room. Amazing!
This is where Feng shui “eyes” come in.
It was a surprisingly happy, satisfying feeling to suddenly experience what now felt like a spacious path from the bedroom door to the master bathroom. It wasn’t like we had to squeeze by the cabinet before, but for years the qi (or flow) had been blocked or at least impeded. Now the space flows beautifully. We can feel, see and enjoy it.
You might want to get in touch with any Chinese wisdom hiding within your being and take a look at the furniture arrangement in your home. You might just open up the qi to transform your space too.
Belated Happy Chinese New Year!
SHARING SOLUTIONS & STORIES
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Until next time
I’m glad you could join us this month. See you again in late March.