Vol. 13 , No. 4
Welcome to the July edition of Tips and Topics. I hope your summer is going well for our northern hemisphere readers. Stay warm Down Under.
David Mee-Lee M.D.
SAVVY & STUMP THE SHRINK
Earlier this month, I received a question prompting this combined SAVVY and STUMP THE SHRINK. This is especially relevant if you work in a program that focuses on rules and regulations, consequences for breaking the rules, and behavior contracts.
Even if it is the treatment plan that focuses your work with the client, it is easy to become distracted by behavior which disrupts the group and treatment milieu. Here is what Bob Fox of St. Paul, Minnesota wrote:
“I work in Level 2.1 Intensive Outpatient, mixed gender group. What is your view on policies about treatment peers forming exclusive, romantic relationships, or plain old sexual intimacy (hooking up) in treatment?”
Bob gave me three multiple choice options, but as you can see further below, I waxed eloquent and expanded way beyond the offered choices:
“a. Should the relationship be prohibited and one or both clients be discharged (referred to another program?)
b. Should the relationship be allowed, but the involved clients be separated into different groups? And then a focus of treatment is learning about healthy relationships, boundaries, etc.?
c. Or some other option?”
Think about how you deal with emotional, behavioral and cognitive issues that are potentially disruptive to the group and treatment milieu.
In general, my view is to see all emotional, behavioral and cognitive problems as treatment issues needing to be dealt with in the context of an individualized treatment plan. That plan should be frequently and collaboratively changed depending on what is working well (or not working well) in the client’s progress in treatment.
So in this case…. if peers are forming relationships and hooking up, that is behavior which is going to happen while a person is in treatment and certainly occurs when people are not in treatment. I suspect that for many clients in treatment the relationships and sexual behavior they engage in has created problems in their lives previously – both substance-related and non-substance-related.
In outpatient and residential treatment, we have an opportunity to create:
In addiction treatment and sometimes in mental health as well, we have had a tradition of creating a safe environment by having rules, policies and consequences if clients break the rules: like behavioral contracts; set back a level or phase in residential settings; loss of privileges; writing tasks; separating people into different groups; discharge etc.
We need to rethink our attitudes about what treatment is meant to do:
Help clients assess and evaluate the “differential diagnosis” of their emotional, behavioral and cognitive issues and the effect on their lives.
The answer to the STUMP THE SHRINK question centers around having a talk with the clients in the exclusive relationship. In addition, talk with all their peers in group regarding the dangers of becoming distracted by exclusive relationships and sexual behavior. Explore with all the clients about how this type of situation has distracted them in the past, how it distracts now in the present setting. Converse about how it can ‘de-focus’ people from recovery, from attending to their “work” of embracing new ways of being and doing.
1. Engage the group in talking. Where has this been an issue in other peers’ lives? What have they learnt from those experiences?
2. You can also discuss the dangers of forming intense new relationships early in recovery, especially if the new “love of my life” is also new in recovery and may even be less interested in recovery than I am.
3. How easy it is to turn to relationships and sex as a way to deal with pain e.g., regrets of past mistakes, lost relationships and jobs, mental health issues? Discuss this angle.
4. Pose this question for discussion: How can sex or a new relationship avoid the hard work of recovery? Can people avoid taking “a searching and fearless moral inventory of ourselves” (Alcoholics Anonymous 4th Step)? Looking at your life, whether in addiction or mental health treatment, can be a very hard thing to do.
5. Identify if certain mental health issues are contributing to such behavior e.g., unresolved issues with parents; or trauma or sexual abuse.
In other words, there is a whole “differential diagnosis” of what forming relationships and sexual behavior can mean. These are assessment and treatment issues to be opened up for the clients involved. There is also a rich opportunity for the other peers in the group to explore these issues for themselves for “there but for the grace of God go I.”
Consider what happens to treatment if the focus is on rules, consequences and discharge.
You can “prohibit” the exclusive relationship and sex, but are you also going to “prohibit”:
Treatment is not about us making people behave. It is about helping them make the right decisions in the dark of night when nobody is watching. If people do the right thing only when in our program, have we helped them to help themselves when we are not around? Have we facilitated a self-change process which enhances sustainable recovery? Or have we externally imposed compliant behavior that too easily falls away after “graduating” from treatment?
When is it appropriate to discharge people for their behavior?
A. There may be mandated clients who say they want treatment, but end up just “doing time”. They occupy and distract themselves by forming relationships and hooking up. They are not, in good faith, looking at the meaning of their behavior, the negative effects on their life and on others. Just sitting in a chair is not doing treatment. They are not choosing the work of treatment. At that point, you can talk about discharge.
B. If you ascertain someone is a sexual predator focused on disrupting treatment for themselves and others through forming relationships and hooking up, then discharge is appropriate. Why? Because you run a treatment place, not a dating place.
A friend and colleague recently said this:
“My mantra is, ‘this is the place where you don’t have to be at your best.’ If people are out of sorts or have a bad hair day, all the more material for the staff to work with.”
Andrea G. Barthwell, MD, FASAM
Oak Park, Illinois
If we expect people to behave and be at their best, then they probably don’t need treatment and have nothing important to change.
In June 2003, the 3rd edition ever of Tips and Topics, I wrote about “Discovery, Dropout” (D/D) prevention plans for people in early stages of change, those not yet interested in recovery. I also wrote about “Recovery, Relapse” (R/R) prevention plans for people at Preparation and Action for recovery. In 2015, you still find most treatment providers in general health, mental health and addiction treatment creating treatment plans which assume the client/patient is committed to recovery and relapse prevention.
(Aurel O Iuga and Maura J McGuire: “Adherence and health care costs”. Risk Management Health Policy. 2014; 7: 35-44. Published online 2014 Feb 20. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3934668)
What patients and clients actually need is a Discovery, drop-out prevention:
Consider these Sample Strategies for Treatment Plans
For more on Discovery plans, see SKILLS in the March 2006 edition.
Related past editions explain aspects of this too if you want to take a look:
Treatment Plan Strategies for Working on Relationships and Hooking Up
Referring back to Bob’s question: if the clients are interested in treatment, they will be willing to change their treatment plan in a positive direction using such strategies as:
Once you have done more assessment, there would be many other strategies that might fit better for this client. If they are willing to do this work, treatment continues. Don’t separate them or discharge them. Use the power of the group to implement these strategies.
Note of Caution:
You’ll notice that I define good faith working in treatment as “being open and willing to change their treatment plan in a positive direction.” Or as they say in AA “progress, not perfection”. We would like every person from Day 1, to be:
But if our clients and patients could do all that, they wouldn’t need our help in the first place! So if you have a notion to change their treatment plans by inserting: “Bob and Jane will end this inappropriate relationship and sexual behavior and focus on recovery” and then discharge Bob and Jane when they break their treatment plan, that is “perfection” not “progress”. It is not changing their treatment plan in a “positive direction”, it is expecting perfection and the final outcome immediately.
I just have to tell you my Medicare story. (So now you know I’m a senior citizen.) Last year when I joined Medicare, I was looking forward to that much lower monthly premium for health insurance…and yes, it was quite a bit lower. But then new notices came informing me that the bill was going to be higher because of my income. (So now you know I’m not a minimum wage senior citizen.)
I was OK with that, because I don’t mind contributing to the greater good if I can afford it. But then the amount I owed kept changing and I dutifully paid what the monthly invoice said. Here’s where the story gets interesting (or is a better word “frustrating”).
Time to call and talk to someone at Medicare. I called on a whim one night to see what hours they were open and amazingly you can talk to a “live” person- they are open 24 hours a day, 7 days a week. And it is not someone in the Philippines or India. Sounded like a regular ole American.
“Is there no way that I can go to a website, see my payments and what I owe, just like I do with my credit card, electric and phone bill etc.?”
“No, I’m sorry, we can’t even see that. I have to send a request to another department and they will call you to let you know where your account stands.”
“Could they not send me an email, because what if I miss their call?”
“Oh, well if they don’t reach you, they will send information in the mail.”
“You mean, regular snail-mail, not email?”
You get my drift. Now I think it is great that Medicare is open 24/7 and the hold time was very reasonable. BUT I spent at least a half an hour or more with people who receive more than minimum wage and nice government benefits only to find out that they can’t help me. The information I need will take much more time being spent by more government workers who will use last century’s methods to communicate with me.
I better stop here and recite the Serenity Prayer. But if any of you have the courage and wisdom to make government more efficient, please step forward. This old guy feels a bit hopeless.
Until next time
Glad you could join us this month. See you in late August.