SG’s Landmark Report

In November the Surgeon General came out with a comprehensive report titled facing-addiction-in-americaFacing Addiction in America.  Much of the content won’t come as a surprise to ACT clinicians.  For example in the executive summary it notes that:

“Our health care system has not given the same level of attention to substance use disorders as it has to other health concerns that affect similar numbers of people. Substance use disorder treatment in the United States remains largely segregated from the rest of health care and serves only a fraction of those in need of treatment. Only about 10 percent of people with a substance use disorder receive any type of specialty treatment. Further, over 40 percent of people with a substance use disorder also have a mental health condition, yet fewer than half (48.0 percent) receive treatment for either disorder.”

It’s a definite step forward when the Surgeon General, Dr. Vivek Murthy is making the rounds of various media outlets  trying to get the message out on the need for change.  Watch his interview on PBS Newshour (click to view)


When I was a young psychiatrist I had a simple solution for patients who had substance use problems – “you have to go to AA (or CA or NA or GA or …)”.  I did my patients no good.

Two years ago I wrote a blog titled RUCCIS (click to view) pointing out how Ken Minkoff has, for years, been calling on mental health programs to provide Comprehensive, Continuous, Integrated System of Care (CCISC). He writes how

In a CCISC processevery program and every person delivering clinical care engages … to become welcoming, recovery- or resiliency-oriented, and co-occurring capable.  Further, every aspect of clinical service delivery is organized on the assumption that the next person or family entering service will have multiple co-occurring conditions, and will need to be welcomed for care, inspired with hope, and engaged in a partnership to address each and every one of those conditions in order to achieve the vision and hope of recovery.”

In that blog I commented how “on Minkoff’s webpage, the word ‘chronic’ appears only once! That word has a pernicious, disempowering effect on clients and care providers. It should be expunged from our vocabularies. Long lasting, long term, long-standing – I’m okay with all of these, but chronic – NO!”.  The Surgeon General’s report does use the ‘C’ word and I appreciate that the authors have their reasons for this.  I do think we need to see these problems realistically but we also have to leave room for that mysterious element of recovery.  Tony Bennett just celebrated his 90th birthday and I just recently learned that he went through years of addiction and nearly died of a cocaine overdose.  Meeting him at that time in his life could anyone have seen where he would be 35 years later, what with having a ‘chronic’ condition?

There are no simple answers.  ACT teams should, as always, focus on delivering the best services possible.

With the holiday season upon us, Roman, Kevin and I want to wish you and yours all the best of the season and a happy and healthy New Year!

Shalom Coodin

It’s a Trap!

“Many workers and agencies fall into the assessment trap, as though it were necessary to know a lot of information before being able to help … the usefulness of all this questioning is not necessarily apparent to the client, who already knows the information being conveyed.”

Miller and Rollnick, Motivational Interviewing, 3rd Ed.

Its a Trap

Assessment is an integral part of what ACT clinicians do. But is it possible to do too much assessment?

One of the most interesting additions to the 3rd edition of Motivational Interviewing (yes, I know you’re sick of Shalom always writing about M&R) is on The Assessment Trap under the section Some Early Traps That Promote Disengagement (pg 40)

As a psychiatrist I’m always doing assessment – assessing risk of self-harm and suicide, of violence, of substance use etc… I’m doing this in my conversation with my patient. I have not used paper and pen assessments enough.  On the other hand I’ve also worked in settings where clients are bombarded with paper assessments to complete. If I were the client I would certainly endorse the idea that I “already know the information being conveyed”.

There are different ways of doing assessments. There are the questionnaires, given to clients to complete on their own, ticking boxes, sometimes endlessly. For example the Personality Assessment Inventory which the company website points out its “Fast, cost-effective administration. Clients generally complete the 344 items in less than an hour.” I can hear the client commenting “boy, that hour went by so fast!

Then there are assessment templates that a clinician can take into an interview, not to rigidly dictate what’s discussed but as a reminder of different areas to explore.

M&R include a quote from Rogers who, in 1942, observed:

“The disadvantage of using tests at the outset of a series of therapeutic contacts are the same as the disadvantages of taking a complete case history. If the psychologist begins his work with a complete battery of tests, this fact carries with it the implication that he will provide the solutions to the client’s problems… Such “solutions” are not genuine and do not deeply help the individual.”

For most ACT clients there are rarely simple solutions.

The other drawback of overly focussing on ‘assessment’ is that it can set the client into a passive role of answering the clinician’s questions rather than exploring the issues collaboratively. M&R write:

“The structure of an assessment-intensive session is clear; the interviewer asks the questions and the client answers them. This quickly places the client in a passive and one-down role”

How does your agency fare? Have you found the sweet spot for the right amount of assessment?

If you haven’t already seen them I hope you’ll consider checking out my previous MI-related blogs, Beyond Workshops and Just Three Things.

Shalom Coodin

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 www.motivationalinterviewing.org. Check it out.

Shalom Coodin

Just Three Things

I’ve often said that at its core ACT is about three things – relationship, relationship, relationship. Medication, recovery planning, psychosocial rehab all have to occur within the context of relationship.

In terms of the practical skills ACT clinicians need to do their work, I recommend three things – MI, MI, MI (you saw that coming now, didn’t you?) The skills of Motivational Interviewing – active listening, open-ended versus closed-ended questions, acknowledging ambivalence, using reflection, enhancing self-efficacy etc… – are absolute necessities for the day to day task of helping people effect change in their lives.

MI TitleMI is not a panacea. Even if you become most skilled at it you’ll still be working with clients who will continue to have profound struggles with addictions, with symptoms and with relationships. It’s like what Churchill said : “democracy is the worst form of government, except for all the others”. MI is better than bombarding with questions and much better than confrontations and ‘interventions’. Yes, there are times when I’ve laid it out in black and white to a patient – “Joe, you’re either agreeing to go into hospital or you’re not agreeing on going into hospital, but you ARE going into hospital.” But that kind of conversation should never be my ‘go to’ tool for anything.

How to acquire MI skills? Wish I could tell you it’s ‘quick and easy’ but it’s not. It’s worth investing time and energy learning them but it’s like exercise, I have to keep doing it and doing it and…

Miller, Rollnick and MoyerMiller and Rollnick’s Professional Training DVDs are an invaluable tool. Better than their book – is it ever as good reading an exchange between client and clinician versus watching and hearing? – these discs should be made available to all ACT clinicians.

If you’re an agency director buy your ACT team the set for $110 through the University of New Mexico. (Click to open the pdf order form) If you’re a team leader, program director or the like and have $110 left in your budget, buy the set. If you’re a front line clinician put it on your Xmas/ Hanukah/Kwanza/Winter Solstice wish list and casually leave this visible to your team leader come November. When you get the DVDs start watching them; watch with others, watch just 10 minutes then discuss some of the concepts; bring it to a team education session and talk about one thing. Slowly, slowly clinicians start to pick up some of the lingo, then become more aware, hearing that little voice in the back of their head asking “What I just said, was that a closed-ended question? How could I have made it into an open-ended question? How could I have put it as a reflection?”

On the DVD Theresa Moyers’ interview with ‘Jim’, demonstrating how to Roll with Resistance is masterful and it alone is worth the price of admission. Yes, the client may be an actor but Moyers is going in cold, no script, and her technical skills are so wonderful to watch. I’ve seen it at least a dozen times and still learn something new each time.

Try not to think of learning MI as an event; it’s a process, a long-term one that has to be returned to again and again.

I’ll be back with more on MI.

PS: I was saddened to get the recent email that ACTA will be shutting down. Thank you Cheri Sixbey and Alexandra Sixbey-Spring for keeping it going as long as you did.

To paraphrase Joni Mitchell, sometimes you don’t know what you’ve got till it’s gone.

Shalom Coodin