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



Horror, guns, mental illness.

I have no special knowledge about what happened in Orlando this past weekend in which 50 innocent people were murdered and a greater number wounded.  It is unimaginably horrific.  There are no words.

I do not in any way mean to suggest that the Orlando killer was mentally ill.  This may have been just an act of evil.

The subject of severe mental illness and violence is a perennial one.  ACT clinicians know some of the issues, which are complex.  Consider reading  Metzl and MacLeish’s  Mental Illness, Mass Shootings, and the Politics of American Firearms in the American Journal of Public Health (2015 February).  The authors review the literature and

“critically addressed 4 central assumptions that frequently arise in the aftermath of mass shootings:

(1) Mental illness causes gun violence,

(2) Psychiatric diagnosis can predict gun crime before it happens,

(3) US mass shootings teach us to fear mentally ill loners, and

(4) Because of the complex psychiatric histories of mass shooters, gun control “won’t prevent” another Tucson, Aurora, or Newtown.”

The authors note that “… in the real world, these persons [persons with mental illness] are far more likely to be assaulted by others or shot by the police than to commit violent crime themselves. In this sense, persons with mental illness might well have more to fear from “us” than we do from “them.” And blaming persons with mental disorders for gun crime overlooks the threats posed to society by a much larger population—the sane.”

As a Canadian, where handgun ownership is rare, I’ve felt a certain distance from what goes on south of the border.  Yet the issue is one Canadians must confront as well.  Last month Justice Eric Macklin concluded that 23 y/o Matthew de Grood who in April 2013 went to a house party in Calgary and stabbed to death five young people – “was experiencing a psychotic episode at the time of the slayings.” And “that at the time he caused their deaths, was suffering from a mental disorder that rendered him incapable of appreciating or knowing that his actions were wrong” and concluded that “… Matthew de Grood committed the acts that resulted in the deaths of these five individuals, but he is not criminally responsible for those deaths on account of mental disorder.”

Does mental illness cause violence? Yes, but there’s far more to it. And is ease of access to guns the determining factor? It’s a factor but there’s far more to it!

Metzl and MacLeish conclude that:

… gun violence in all its forms has a social context, and that context is not something that “mental illness” can describe nor that mental health practitioners can be expected to address in isolation.

My heart goes out to all those affected by violence.

Shalom Coodin

June 12, 2016




Found it! Well, maybe not!

In the January 2016 American Journal of Psychiatry is an article titled Finding the Elusive Psychiatric “Lesion” With 21st-Century Neuroanatomy: A Note of Caution.  The first author is Dr. Daniel Weinberger, a big, big name in psychiatry for many, many years. (to learn more about Dr. Weinberger click here).

It makes it that much more noteworthy when someone of Weinberger’s stature writes “It has become research lore that structural changes in the brain are characteristic of many psychiatric disorders and are likely clues to primary neurobiology.” and then goes on to sound a cautionary warning that “the evidence that findings are neurobiologically meaningful is inconclusive and may represent artifacts or epiphenomena of uncertain value.” 

In other words what was found on scans may not be a real change in the brain but rather may be due to head movement (or other possible factors) during the scan. As they point outIs it so far-fetched to imagine that some patients have a harder time remaining motionless during the 10-20 minutes of the typical scan procedure compared to control subjects, many of whom are paid volunteers who often have considerable prior exposure to the constrained and noisy MRI environment?”MRI

Even more admirable is how the authors preface their technical critique (my bold):

Before offering our comments (with full acknowledgment that we ourselves have contributed in the past to the very literature that we are now raising questions about), we first advise the reader about the scope of this commentary:”.  Wow!!!

If you are a psychiatrist or psych resident I highly recommend reading the whole article (sorry but ya gotta pay to read the AJP).  If you’re an interested clinician who just wants the short overview click here to read the abstract.

I know someone who’s skeptical of medical science, pointing out that what’s recommended this year gets turned on its head the next.  This is actually what I love about it – the constant questioning of what is known and what we think we know.  I don’t think Weinberger undermines his credibility by pointing out that he is cautioning about work that he “contributed in the past to the very literature that we are now raising questions about”; it enhances his street cred.

MRI MAchine

Weinberger and co-author Radulescu conclude: “… we opine that current studies are plagued by so many possible systematic confounders that one can only wonder whether, like Wolfgang Pauli, “These results are not only not right, they are not even wrong!” We would caution that researchers and clinicians pause and rethink carefully the conclusions that can be drawn from these various MRI findings in psychiatric research.”

The human brain is the most complex thing in the universe (that we know of so far).  It doesn’t yield its secrets easily.  And as far as our understanding the complexity of it, well, as The Carpenters sang, we’ve only just begun.

It’s not that all the previous research on structural changes associated with psychiatric illness is bunk.  It’s just that we have to proceed carefully,  to realize how much we know, especially compared to not long ago and even more importantly, to know the limits of what we know.

Shalom Coodin



Dying Young

“Persons with schizophrenia have an exceptionally short life expectancy.”

Laursen TM et al

Persons with schizophrenia die much too young! In their 2014 review Excess early mortality in schizophrenia Lausen et al note that:

“High mortality is found in all age groups, resulting in a life expectancy of approximately 20 years below that of the general population.” 

In a 2012 article Life expectancy and cardiovascular mortality in persons with schizophrenia Lausen and co-authors wrote how

“Patients with schizophrenia have two-fold to three-fold higher mortality rates compared with the general population, corresponding to a 10-25-year reduction in life expectancy.”

Last month a paper was published in JAMA Psychiatry that looked at premature mortality with schizophrenia in the U.S. The authors dug deep, looking at more than 1.1 million persons with schizophrenia between 2001-2007 with 74,000 deaths of which 65,500 had known cause. They found that:

“Adults with schizophrenia were more than 3.5 times as likely to die in the follow-up period as were adults in the general population.” They go on to note that “Cardiovascular deaths has the highest mortality rate” and that “Accidental deaths accounted for more than twice as many deaths as suicide.”

During my time working in ACT our team had clients die from unintentional drug overdoses, cardiac arrests, an apartment fire and cancers. I doubt this is different from what other teams experience.

I wish I could give you hard data for mortality rates for our clients but I don’t have it.  In my search for reports on mortality in ACT clients I’ve come up with nothing.

We know  ACT decreases hospitalizations, increases client and family satisfaction, improves housing stability and has other outcomes.  We should know if ACT improves longevity at least relative to individuals not receiving ACT services.  There is reason to think it might; ACT has nurses and a team that helps clients connect with and follow up on medical concerns around diabetes and heart disease.

I look forward to there being an ACT conference in the not too distant future.  Perhaps that would be a setting where teams could share and compare their data.  Maybe teams could submit their anonymized data and someone with the requisite number of crunching skills might present it.

We should know more.

I hope you’ll consider reading Measuring Up, a previous blog on the importance of gathering and using data.

Shalom Coodin


It’s about the money

Is ACT worth it?

There’s no argument – ACT is expensive!  But so is most health care.

In a 1999 paper Economic Impacts of Assertive Community Treatment: A Review of the Literature Dr. E Latimer analyzed the available info and concluded that “an ACT program must enroll people Dollar signwith prior hospital use of about 50 days yearly, on average, to break even.

ACT teams should undoubtedly be accepting individuals with the highest use of hospital resources.  But there are other indicators to consider – use of jail or emergency services, co-occurring addictions, functional deficits (which Latimer notes).  But what about family burden? I’ve seen situations where an individual has lived in the community for decades without hospitalization only because family – almost always a mother – has been there to support them.  What should be done in those situations?

As always I don’t have clear answers.  I think Latimer’s 50 day mark is valuable and should be kept in mind.  One of the strongest arguments for ACT is that, from its origins, it has been researched and thus been accountable.  It should continue to be.  But I suggest there also be openness to exceptions;  should an individual with an average of 47 days of hospitalization per year over the preceding 5 years be declined by ACT?

In a 2005 paper Economic considerations associated with assertive community treatment and supported employment for people with severe mental illness Latimer points out that  One way of understanding why ACT teams can increase the efficiency of a mental health system is to contrast the relatively inflexible manner in which hospital resources are deployed when a patient is admitted to hospital with the much more adjustable deployment of the resources of an ACT team.”

In one of his papers Dr. Kim Mueser noted that  “it may also be that the right community-based services are inherently cheaper … because they allow a much more flexible and targeted allocation of care resources to clients.”

I worked on inpatient units for for than a decade; flexible allocation of resources ain’t what hospitals specialize in.  It’s good to be flexible!

What are your thoughts? Should hospital use be the most important determinant for acceptance for ACT?

Shalom Coodin

No to cats? Not yet!

ACT clinicians should know some of the theories around psychotic illnesses.  For this reason it’s worth reading Andre Picard’s article in today’s Globe and Mail  The family cat is not Typhoid Tabby.

Picard Cats Globe

The possible connection between cats and schizophrenia– it’s not the cat, it’s the toxoplasmosis, a tiny parasite that many cats carry – has been posited for decades.  Dr. E. Fuller Torrey, a very respected American psychiatrist, has written on this for years citing research dating back as far as 1953.  Recent re-analyses have ignited new discussion.

Picard is a respected Canadian public health journalist.  Read his article if only to be able to reassure families that they didn’t cause their child to get schizophrenia because they had a cat.

If you have time consider reading or watching Picard’s convocation talk (available on the Globe site) to the graduating med school class at U of Manitoba, delivered May 14th this year.  A short excerpt:

picard talk vid

“One of the greatest privileges in our society is to have the letters MD after your name. Those two letters confer great power. And with that power comes great responsibility, to quote Voltaire – or Spider-Man, depending on your literary predilections.

Shortly, you will be taking the Hippocratic oath. You’ve probably all heard that it says: “First do no harm.” It doesn’t actually – that’s just bad media reporting.

But it does say a lot of important things. I think the line that matters most in the oath is this: “Whatsoever house I may enter, my visit shall be for the convenience and advantage of the patient.”

Sadly, too many physicians fail to honour that part of the pledge.

We have built a sickness care system rather than a health system. We have designed that system for the convenience of practitioners, not patients.”

Read the whole thing – it’s worth it.

Shalom Coodin

PS: My friend  – and team leader – Roman Baranowski is going to be doing not 1 but 2 presentations at the Third European Congress on Assertive Outreach – in Oslo, Norway being held June 24-26.  If you’re there say hello and tell him I sent you – he’d love to meet you and to talk ACT.

Delusions and Violence

Delusions, especially paranoid ones, lead to violence, right? Well maybe it isn’t quite so clear.

The MacArthur Study of Mental Disorder and Violence followed 1136 patients who’d been admitted to acute care psychiatric units and measured a whole slew of factors at 10 week intervals for a year. In a 2003 article Violence and mental illness: an overview Dr. Stuart  writes that the MacArthur Study “stands out as the most sophisticated attempt to date to disentangle [the] complex interrelationships” between mental illness and violence. The resulting book Rethinking Risk Assessment is worth a read.  Rethinking Risk Assessment cover

In setting up the question the authors write (bold is mine):

“Delusions and violence have long been linked in the minds of both lay people and mental health professionals. Indeed in the popular media, the prototypical dangerous mental patient is driven by “crazy ideas,” often stoked by hallucinated voices, to commit unspeakable acts of violence. The professional literature has numerous case reports detailing the link between delusions and violence. Even though systematic studies of forensic and civil patient populations have confirmed that most violence perpetrated by psychotic persons is not motivated by delusions, a substantial minority of their violent acts appears to stem from their delusional thoughts. Although no one would quarrel with the conclusion that violence may be precipitated by delusions, these studies fail to address the question of whether delusional persons are more violent than other persons with or without mental illness.”

Reporting their results the researchers note that “…delusions at baseline did not have a significant relationship with violence during the first 20 weeks, but did have a weakly significant negative relationship with violence over the entire year of follow up. That is, subjects who were delusional in the hospital were less likely to be violent after discharge… The presence of violent content in the delusions, even if the violence was directed toward others, did not predict violence during the follow up period.”

They point out that “Contrary to popular wisdom and to the results of several studies, the data from this study suggest that the presence of delusions does not predict higher rates of violence among recently discharged psychiatric patients… On the other hand, nondelusional suspiciousness – perhaps involving a tendency toward misperception of others’ behavior as indicating hostile intent – does appear to be linked with subsequent violence and may account for the findings of previous studies.”

The authors do temper their conclusion by pointing out that “These data, of course, should not be taken as evidence that delusions never cause violence. It is clear from clinical experience and from many other studies that they can and do.”

As to why, they note that delusions are often associated with chronic psychotic conditions, which are frequently attended by social withdrawal and the development of smaller social networks. Delusional subjects in the community, therefore, may have less desire and fewer opportunities to engage in the interpersonal interactions that lead to violence compared with less severely ill patients.”

Fascinating – the presence of delusions, even violent ones, did not predict violent acts.

No matter how you look at the prediction of violence we always seem to come back to Yogi Berra’s wisdom that “It’s tough to make predictions, especially about the future.”

In an upcoming blogpost- MacArthur part 2: What’s the relationship between hallucinations and violence?

Shalom Coodin

ACT Curriculum, Part II

” In the ongoing battle against mental illness, some of our most valiant warriors are on the front lines ITDD Coverworking with dually diagnosed, seriously ill individuals – that is, individuals who present not only with chronic and severe mental illness such as schizophrenia or bipolar disorder, but also with substance abuse. These patients confound the best efforts of public mental health systems and networks of treatment programs for addiction. As the authors of this book point out, the traditional approach has been to choose one diagnosis and focus treatment efforts on that before moving on to treat the second diagnosis. Typically and tragically, these efforts have most often been futile. Now Kim Mueser and his coauthors describe in this ground-breaking work a treatment for these difficult patients that provides a “Seamless integration of psychiatric and substance abuse interventions in order to form a more cohesive unitary system of care.”

                                                                                                                Dr. D. Barlow, from the Editor’s Note

If your team doesn’t have a copy of Integrated Treatment for Dual Disorders you must, must, must get a copy. This compilation covers a slew of stuff, from the basics, to assessment, group interventions to working with families and more. It really is a necessary resource that every ACT team should have on the bookshelf.

“…persons with severe psychiatric illness are at much greater risk for developing a substance use disorder than people in the general population. What accounts for the very high rate of comorbidity of the psychiatric and substance use disorders? Understanding the factors that contribute to the high rate of comorbidity may provide clues useful in the treatment of dual disorder.”

Rather than expecting clinicians to read it cover to cover use the chapters as jumping off points for education session discussions. Has your team ever tried offering persuasion groups (see Chapter 9)? How is a persuasion group different from an active treatment group? What are the problems associated with traditional twelve-step groups for clients with dual disorders (see page 187)?

Norway1 And if you’re going to be in Norway this June consider attending the EAOF’s 3rd European Congress on Assertive Outreach and hear Dr. Robert Drake, one of the authors addressing Assertive outreach for people with co-occurring disorders. (btw sunrise in Oslo on June 24th is 3:55 AM, sunset 10:44 PM!)

Shalom Coodin

104 Years Later

In 1911 Eugen Bleuler wrote Dementia Praecox or the Group of Schizophrenias and for a BLEULERcentury we’ve used his construct of this mysterious condition. Bleuler realized how limited was his knowledge in writing:

“At the present time, we cannot solve the problem of dissecting schizophrenia into its natural subdivisions. Nonetheless, we do have the practical need for characterizing the various clinical pictures that present themselves to us in this disease by terms corresponding, at least, rather broad and crude subdivisions. This much is possible, but not much more.

Even then, however, it is not a question of defining and delimiting different disease entities, but of grouping symptoms… A case which begins as hebephrenic may be a paranoid several years later.”

I doubt Bleuler would object to DSM 5 now having done away with the four subtypes. The APA wrote that “The DSM-IV subtypes of schizophrenia (i.e., paranoid, disorganized, catatonic, undifferentiated, and residual types) are eliminated due to their limited diagnostic stability, low reliability, and poor validity.”

The focus now is on deciphering the genetics behind what’s going on. It seems clear that whatever the genetic underpinnings there isn’t going to be a single gene responsible.

In a recent paper with a mouthful of a title Uncovering the hidden risk architecture of the schizophrenias: confirmation in three independent genome-wide association studies (Am J Psychiatry 2015 Feb) the authors conclude that

“Schizophrenia is a group of heritable disorders caused by a moderate number of separate genotypic networks associated with several distinct clinical syndromes. “

Even when the genetics becomes clearer, there will still be much to sort out: How do any genetic changes  result in manifestations of illness? Why is the concordance in identical twins only 40-50%?

Back to Blueler:

“… even in the event that all of our hypotheses should eventually prove correct, we would still be acquainted with only a very small part of all the mechanisms which are probably involved in the symptomatology of this disease. Conversely, it is obvious that at this time no one can claim to explain all or even the greater part of the symptoms.

The pathology of schizophrenia gives us no indications as to where we should look for the causes of the disease. Direct investigation for specific causal factors has also left us stranded. Certainly we know that “mental diseases” are more common in the families of schizophrenics than in those of the healthy.”

 We know more than we did in 1911 but there’s so much more to learn. In the meantime those of us working in the field will need to continue to use the tools that we know work – client-centred recovery work, PSR and MI.

To be continued…

Shalom Coodin

An Audit and a Cup of Chai

Atul Gawande is an endocrine surgeon and a great writer. His 2013 New Yorker article Slow Ideas: How Do Good Ideas Spread is about the history of anesthesia and hypothermic newborns in India. Could this have relevance to Assertive Community Treatment? It does!Gawande

ACT is still very new. Well-studied and proven but still new. We need to press for more access to ACT services for only a few more decades I suspect. And that’s what Gawande is writing about – how do new ideas and new practices, take hold? Gawande writes of how trainers such as Sister Seema teach nurses in rural hospitals in India to better care for newborns. Initially, this process feels critical but over time, and over cups of chai, the conversation shifts.

“When Sister Seema pointed out the discrepancy between the teaching and the practice, the nurse was put out. She gave many reasons that steps were missed… At her second and third visits, disinfection seemed more consistent. A thermometer had been found in a storage closet. But the nurse still hadn’t changed much of her own routine. By the fourth or fifth visit, their conversations had shifted. They shared cups of chai and began talking about why you must wash hands even if you wear gloves, and why checking blood pressure matters. They learned a bit about each other, too… With time, it became clearer to the nurse that Sister Seema was there only to help and to learn from the experience herself. Soon, she said, the nurse began to change. After several visits, she was taking temperatures and blood pressures properly, washing her hands, giving the necessary medications—almost everything. Many of the changes took practice for her, she said… But, step by step, Sister Seema had helped her to do it.

“She showed me how to get things done practically,” the nurse said.

AG: “Why did you listen to her?” I asked. “She had only a fraction of your experience.”

In the beginning, she didn’t, the nurse admitted. “The first day she came, I felt the workload on my head was increasing.” From the second time, however, the nurse began feeling better about the visits. She even began looking forward to them.

AG: “Why?” I asked.

All the nurse could think to say was “She was nice.”

AG: “She was nice?”

“She smiled a lot.”

AG: “That was it?”

“It wasn’t like talking to someone who was trying to find mistakes,” she said. “It was like talking to a friend.”

I like the image of ACT auditors and reviewers being like Sister Seema, looking carefully at what ACT teams do and being part of an ongoing process of quality improvement. How does change happen? Gawande writes (my bold): “… technology and incentive programs are not enough. “Diffusion is essentially a social process through which people talking to people spread an innovation,” wrote Everett Rogers, the great scholar of how new ideas are communicated and spread. Mass media can introduce a new idea to people. But, Rogers showed, people follow the lead of other people they know and trust when they decide whether to take it up. Every change requires effort, and the decision to make that effort is a social process.”

ChaiFor those of you who have the important task of being an ACT reviewer/auditor, read the whole of Gawande’s article. I’d be interested to hear what it’s like being in that role – share a comment if you have the time.

Shalom Coodin