Team Dynamics

Coaching vs Parenting Or Home Depot and Recovery

While reading an academic paper it made me smile when I came across this line:

“…coaching teams function like the Home Depot motto: “You can do it. We can help.

That is a wonderful reminder of how ACT clinicians ought to see their role in working with clients!

The line is from a paper titled The Work of Recovery on Two Assertive Community Treatment Teams by Salyers et al.  In it they explore how to best measure recovery orientation. Looking at two Indiana ACT teams and using observational measures and interviews over time, they identified “Recovery Critical Ingredients” in four areas: Environment, Team Structure, Staff Attitudes and Process of Working with Consumers (see table below or click to view online).

Recovery Critical Ingredients Table 1

In visiting the teams they found thatDespite teams’ similarities in baseline fidelity to the ACT model, we experienced many differences between the teams during our visits – both teams were meeting similar ACT model standards, but were approaching the work very differently.”

Some recovery measures are more objective, such as rating the environment looking for such features as “Open waiting area, posters about recovery, posted team mission included recovery” versus  “Separate waiting area and bathrooms, several signs with rules posted.”  More challenging to quantify are Staff Attitudes, which included looking at components of Positive view of Consumers, Positive expectations of consumers and Strengths-based Language.

They note that Concepts of risk and trust appeared central to treatment decisions and differentiated two distinct models of recovery work: coaching and parenting. Coaching teams have high trust in consumers’ ability to self-manage and view the risks as low” noting that “ The majority of consumers on coaching teams would manage their own medications and receive more intensive monitoring if repeatedly demonstrating need. This approach seems closely related to staff beliefs that consumers are “like us” in fundamental ways and should be afforded the greatest freedoms possible. As in Davidson’s view, coaching teams function like the Home Depot motto: “You can do it. We can help.”

So, should all teams be striving to become more coaching/recovery-oriented? The answer isn’t as clear as one might think.

“It may be easy to see these programs as though one team is “good” and the other ”bad,” particularly in light of recovery concepts. But both teams expressed feelings of genuine concern and care for the consumers and took pleasure in positive events in consumers’ lives. And, there were some downsides to the coaching approach. The team’s hands-off approach may foster independence quickly, but at least one consumer reported that the process was too fast — the team believed the consumer was more ready than he did. Differences in staff and consumer expectations of need are common, even in teams that are actively trying to be more consumer-directed. Another difficulty was that the team struggled with maintaining fidelity to the ACT model over time. At the time of our follow-up visit, the team was in danger of being de-certified for infrequent consumer contacts. Although the less frequent contacts could reflect staff vacancies, it is also possible that the initial coaching drifted into a mild form of neglect with the team not intervening enough, perhaps in service of the recovery ideal.” 

I’ve touched on this issue in previous blogs – in Tough Gig I expressed my view that Perhaps the most important role of the team leader is to set the underlying direction for the team.  Is our team focused on long term recovery or are we more focused on medication treatment and stabilization?”  In the blog Forcing Treatment and addressing the issue of outpatient commitment I wroteI believe forced treatment is of value. I don’t believe my conviction in any way diminishes my firm belief in recovery principles and client-centeredness. At times it’s the illness, not the individual that’s making the decision to refuse treatment. The goal of forcing treatment is to allow the individual to find their healthy, true voice”.

Consider using Salyer’s paper for a team education session to look at how your team operates.  Maybe put out questions such as

  • Are we maintaining our recovery orientation?
  • Are we too assertive?
  • Does everyone on the team have to be of the same mindset?

I think leadership has to bring a recovery-orientation to the team, not as a mandate but as a guiding principle.  Otherwise teams can fall into the trap of becoming mobile medication clinics.  Medication is unquestionably necessary – if someone is psychotic they can’t really engage in meaningful work – but medication should never be an end in itself. (see my blog Ultimat-hmms?)

As always thank you for your time.  Happy Holidays!

Shalom Coodin MD FRCPC

November 29, 2017



Beyond Workshops

There isn’t much simple about Motivational Interviewing.  Yes, there are ‘simple’ reflections, but, as Bill Miller points out, learning to form them isn’t simple.  Throw in using summary and double-sided reflections, mastering reflective listening, using open-ended questions, being continually aware of engagement with the client, listening for change talk, understanding ambivalence…  well it’s complicated.

If it’s complicated for individuals to learn these skills how much more challenging is it for an agency to take on the task of training their staff in MI?  And to make it even tougher here’s what Miller and Rollnick have to say about learning MI in the third edition of their great book: MI cover

 “One thing that is relatively clear at this point is that self-study or attending a single workshop is unlikely to improve competence… Reading or a single workshop can increase knowledge of MI, but there is little reason to believe that it will instill skill.

Worse, we know from firsthand experience that if we imply that participants will become skillful in MI through attending our workshop, they are likely to believe mistakenly that they have learned it. 

In a first evaluation of our own 2-day training workshop, participants showed very little improvement in skills, certainly not enough to make any difference in how their clients responded, but we did manage to significantly decrease their interest in learning more about MI. Why? It was not because they didn’t like MI or thought it was ineffective.  It was because they believed they had already learned it.”

So what’s an agency to do?  M&R write “Our recommendation, then, is not more workshops but ongoing coaching with feedback based on observed practice…”

ACT teams provide a perfect forum for ongoing MI skill development; a group of clinicians who are together daily, working with common clients.  Then there’s the secret ingredient for success – a team leader who recognizes and embraces the importance of making MI skill development not as something special, but rather as a normal expectation of all staff, like charting and being at morning meeting.

There is a second ingredient that I believe can make this task even more successful – that the team’s psychiatrist be involved.  The psychiatrist practising (and teaching) MI can really help teams take it to another level.

If you’re unconvinced as to the value of training ACT staff in MI read Manthey, Blajeski & Monroe-DeVita’s 2012 paper Motivational Interviewing and Assertive Community Treatment: A Case for Training ACT Teams. 


BTW Professors Miller and Moyer are doing a workshop in Odense, Denmark in early June. So do attend a workshop, just remember, afterwards repeat to yourself – “I learned so little, must learn more, must get feedback and practice, practice, practice”…(and repeat again and again and again)

You can find a wealth of info at Check it out.

Shalom Coodin

Psychiatry in ACT-ion

We are delighted to have Dr. Lorna Moser as a guest contributor to the interACT blog. 

Lorna Moser, Ph.D. is the Director of the North Carolina ACT Technical Assistance Center at UNC-Chapel Hill’s Center for Excellence in Community Mental Health. Lorna is the co-developer of the Tool for Measurement of ACT (TMACT), a comprehensive fidelity assessment tool, and has been working on, researching, evaluating, and/or training ACT teams for the past 16 years.

I’ve met many psychiatrists on ACT and have come to appreciate there’s a difference between a psychiatrist assigned to work with ACT, and an “ACT psychiatrist.”

High Five to those “ACT psychiatrists” I’ve met this past year who:

– Don’t wince at the idea of going into the community – in people’s home, or other places not in an office or hospital – to see people, and in fact, embrace it. They appreciate how much more they get to understand the person when they meet them in their own environment, as well as how it can help level that playing field, if only just a bit (“I’m a guest in their house.”)

– Like our awesome nurses, understand the importance of whole healthcare, and the barriers for many to getting access to physical health treatment (“We did go to medical school … I think some psychiatrists are too narrow in their idea of our scope of practice”). Not only will they help connect people to primary care doctors and specialists, they will address many issues as an interim (bridging medication orders; taking out stitches for the guy who is paranoid and unwilling to go back to doctor)

– Get their hands dirty, quite literally! I’ve met several ACT psychiatrists who have helped with moving an individual into a new place, including pitching in to help the team frantically gather a person’s belongings from an apt to put in storage while the landlord threatened lock changes in an hour. Or the psychiatrist who helped fix a person’s car, or another who “showed up at my house on Saturday with some kids from church, and helped lay my kitchen floors.”

– Really embrace the idea of being a “team player,” such as helping someone fill out job applications, or sit with someone at Social Security office for over two hours (“That gave me an appreciation of the many frustrations our folks deal with on a day-to-day basis”).

– Are willing and wanting to tap into their clinical training, and make it a point to provide therapy (as opposed to symptom, side effect, med checks).

– Operate with a value that they are a consultant to the person, offering ideas and thinking through options – “It’s their body and ultimately their decision what they put in their body.” These same psychiatrists understand that choosing not to take a medication is within a person’s right, and may be well-reasoned (“people have different margins of tolerance and ability to do fine without meds – some start becoming quite sick after three days of no meds, some have gone years managing their symptoms without meds”)

– Care. It bothers them when they see people have set-backs, and cheer when people make gains — you’d think this should just come with the job, but it doesn’t, likely because “ACT psychiatrists” see their role as more than a “job.”

Lorna Moser