Ultimat-hmms?

When do you “draw the line” in working with a client?  Is there a time when ACT clinicians have to put out a “you must – or else!” statement?

I think there are rare occasions where an ultimatum is understandable.  Mostly in my experience it’s been related to concerns of violence towards the team or others.

In a 1990 paper  titled The Use of Ultimatums in Psychiatric Care (Click to view) Dr Schwartz looks at this thorny issue.  While not directly addressing ACT I think the issues are very pertinent.

I believe in the use of contingencies but as Schwartz points out:

“The threat to end treatment is not just another contingency in the context of ongoing treatment.  When we make that threat, we invoke the final contingency available when all the usual contingencies we employ have failed.  At that moment we issue an ultimatum: “Either you do as I say [enter an alcohol treatment program, take this medicine, come to sessions regularly] or I will not work with you”.  Only the language of ultimatums captures the unique power of this moment…”

He goes on:

“An ultimatum can be very powerful indeed, but the particular nature of its power must be appreciated.  Often it represents an abuse of power or a disregard of responsibility.  Yet it may be the only way out of meaningless or harmful treatment.”

Schwartz then lays out 7 principles for consideration.  The first is, beyond ethical issues a reminder as to practicality.

“An ultimatum controls the psychiatrist’s future behavior and limits the range of responses to the patient”. ultimatum-cartoon

Ain’t that the truth – the ultimatum restricts the one putting it out there leaving them little choice as to what path to take next.  And using an ultimatum doesn’t exactly invite a collective problem solving approach now does it?

Another point:

“Do not neglect the potential gain in therapeutic alliance that comes from trusting the patient unless the trust is proven to be misplaced.”

I especially admire Schwartz’s sixth point:

“Be wary of institutional pressures to trust conventional wisdom over the patient’s understanding of his own needs”. 

Read the whole article.  Even better – present it to the team to read it together as part of an educational session.  Open it up for discussion. And let me know what you think.

Thanks again for stopping by.

Shalom Coodin

Rhymes with Compliance

Depot antipsychotics – the kind which are given by injection once every few weeks – just got a lot longer-acting. The release of a‘new’ agent – it’s a medication that’s been around for awhile but has been modified – allows for just one injection every 3 months.

“With a dosing interval that can be measured in seasons, not days, people living with schizophrenia and their treatment teams can focus on recovery goals beyond short-term symptom control,” said trial investigator Joseph Kwentus, MD”.

Medical ampoules and syringe

There’s a part of me that bristles at the use of use of the term ‘recovery’ by a pharmaceutical company.

Depots have a role and I do not doubt the data. The company points out that “… 93 percent of patients treated with [this new agent] did not experience a significant return of schizophrenia symptoms.”  That is commendable.

Several months ago I attended an educational session where the speaker, a psychiatrist, gave what I thought was a sales pitch for depot meds.  After hearing the speaker use the term ‘compliance” for the umpteenth time a senior psychiatrist in attendance commented how “I like the word compliance because it rhymes with alliance”.

I agree; compliance is not what we should be striving for but if it takes us towards alliance that’s a positive step.  So-called ‘maintenance’ on depot antipsychotics should not be a recovery goal.

I believe in using depot meds and I believe there are times when forced medication treatment is the right thing to do (see my blog on Forcing Treatment).  But the goal should be to help patient/clients take on more and more responsibility for their recovery.

In a previous blog titled On Being Sane I included a comment from Lorna Moser that I see as relevant to this issue.  On forcing treatment Lorna wrote:

… It’s a very grey space to work within, and that is often underappreciated by many. In trainings, I have spoken about some teams/agencies/staff seemingly either too risk tolerant in the “name of recovery and personal choice,” and then there are those who are very quick to take control and be coercive. Finding the “sweet spot,” is knowing that conditions for outpatient commitment (as an example) are rarely black and white (“Must receive treatment” — what does that mean? receive therapy, but no meds? refuse 2 of 5 recommended meds?) — there is still personal choice within the apparent constraints of IOC/assisted outpatient treatment (AOT). It’s the skillful and caring clinician who knows how to best use such a shared decision making approach within the parameters of those leverages, and knowing the extent of the risks, which may in turn call for pushing the lever down — but in a measured way, where possible (you don’t have to go full throttle right away). For many people, whatever leverages that are in place will at some point go away, and if you didn’t do your work to build a trusting and caring relationship in the meantime, they, too, will go away when the leverage is lifted.”

Lorna recently posted a link to a 2014 video of Sam Tsemberis Interviews Len Stein about Assertive Community Treatment.  ACT clinicians should definitely watch it!  Thanks Lorna.

Share your thoughts. Maybe see you at the OAA Conference later this month.

Shalom Coodin

October 5, 2016

 

Seeing Everything

Nothing about me without me!

This idea of NAMWM should be a basic right for all users of health care including ACT clients.  But how to put it into practice? And how might NAMWM affect what clinicians record and  what clients get to read?

I have an interest in EMRs – electronic medical records – having been involved pts-logowith the design of the PACTwise database over many years.  I have some questions including this partial list:

  • Should EMRs incorporate ways for clients to access information?
  • Is it necessarily good for clients to see everything recorded?
  • Are there times when information should be withheld?
  • Will knowing clients are able to read what clinicians are writing change the way clinicians record information?
  • Are there differences between the clients and information recorded in an ACT program versus for example an oncology clinic?
  • Should clients have a way to record their own observations in the EMR?

Let me take these on one at a time.

Should EMRs incorporate ways for clients to access information?

Yes, yes, yes.  The courts in both Canada and the US have decided the issue – patients (clients) can request and must be provided with copies of their medical information.

Is it necessarily good for clients to see everything recorded?

Maybe not but the alternative – paternalistically protecting patients is probably worse in my opinion. In a 2010 report to the British parliament titled Equity and excellence: Liberating the NHS the authors note that “We want the principle of “shared decision-making” to become the norm: no decision about me without me. International evidence shows that involving patients in their care and treatment improves their health outcomes, boosts their satisfaction with services received, and increases not just their knowledge and understanding of their health status but also their adherence to a chosen treatment.”

Are there times when information should be  withheld? 

Maybe.  I do think there are occasions where clinicians should be able to record things that perhaps aren’t immediately shared with a client.  This violates the principle of NAMWM and maybe feels like a bit of a shaky answer on my part.  I’m open to discussion and need to think this one through more.

Will knowing clients are able to read what clinicians are writing change the way clinicians record information? 

Yes, probably.  Is that a bad thing? Probably not.  If I knew patients were reading my notes I’d likely be more careful, not in a politically correct way but in a more “sensitive to the effect of my words” way.  I think I can adjust.

Are there differences between the clients and information recorded in an ACT program versus in an oncology clinic? 

No.  To treat mental health clients as ‘different’ is to add to the longstanding stigma around mental health and mental illness.

Should clients have a way to record their own observations in the EMR?

Yes.  To create a portal to an EMR for clients by which they can read and access information in their record while denying them a chance to input anything seems misguided, giving an implicit message of “you can look but not touch!”  Clients should have ways to add their thoughts.  The goal need not be to turn the EMR into a kind of Facebook page with ongoing dialogues.  There can be a middle ground allowing clients to flag information they want to comment on without this leading to clinicians having to revise their observations and assessments.

Kevin, Roman and I will be at the OAA Act III – Beyond the Standards OAA International ACT Conference in Niagara Falls October 26-28, 2016.  If you’re OAA Logothere have a look for the PACTwise table and stop by.  We’d be delighted to meet you and hear your thoughts about EMRs, about ACT, about making things better.

If you haven’t registered for the OAA conference just click the logo at right to get the conference brochure.

Shalom Coodin

Down On The Farm

Recently I was listening to an interview on CBC radio – the Canadian equivalent of NPR – with Kay Parley. (Click image below to view the CBC website). At age 93 Kay recounts her experience of being admitted to a psychiatric hospital as a young woman – the same hospital where her father was a patient and where her grandfather had been treated.  While the webpage plays up the LSD treatment piece,Kay Parley Interview this is really an aside.  The more interesting elements of Kay Parley’s story, for me at least, were around her recovery journey and her discussion of how important certain professionals were.  She talks of how valuable it was to have recreation therapists who engaged her in tasks and of how important working on the hospital farm was for many patients.

I’ve met older psychiatrists who also spoke with real appreciation of the value of the farm work that went on years ago in the large psych hospitals of years ago.

Meaningful work is tremendously important for most of us including persons with severe and persistent mental illness.  At the same time I have very mixed feelings about the history of work in the asylums for which patients were rarely adequately paid.Farm work 1929

In teaching psych history I ask trainees to consider the case scenario below.  It could also be used for an ACT teaching session, maybe facilitated by the vocational specialist on the team.

Consider listening to the Kay Parley interview – it’s really quite interesting.

Shalom Coodin


Case Scenario:  It’s 1930.  Dr. David Young, medical superintendent of the Manitoba Asylum ( or insert name of large hospital in your area) has died and you’ve been asked to take over the role.

One of your first challenges is to make a decision around the Asylum’s farm facility.  For years patients have performed a variety of  tasks and such activity has always been considered therapeutic.

Several labour unions have threatened to protest in front of your office and to launch legal action unless you put a stop to the practice of making patients do unpaid work.  While you point out that patients are never forced to perform work, the union reps are unmoved.  You’ve appealed to the provincial/state government for funds to pay patients and this request has been repeatedly rejected.  (Keep in mind it is the Great Depression with roughly 30% unemployment across the country)

How would you address this?

Some additional questions to ask might include:

  • If rehabilitation is important isn’t it reasonable to press patients to work?
  • If lack of motivation is a symptom of schizophrenia might patients benefit from being encouraged to work?
  • What is the difference between rehabilitation and recovery?

 

 

Spirituality and Psychosis

How comfortable are you talking with clients about spirituality/religion/God?

In a 2010 article titled The Assessment of Spirituality and Religiousness in Schizophrenia Mohr et al published results of surveying patients in Geneva, Switzerland and in Trois Riviere, Quebec.  Interestingly, the Quebec subjects were clients receiving ACT services!

They write:

“Spirituality and religion have been found to be important in the lives of many people suffering from severe mental disorders, but it has been claimed that clinicians “neglect” their patients’ religious issues.” They go on to note that “… in the last 10 years, studies conducted in Canada, the United States and Europe have highlighted the crucial role of spirituality and religion in patients’ daily lives and in coping with their illness, notably through its role in the recovery process.”

So what did they find? That:

“The clinical interview may be used … to elicit the importance of religion to cope with daily difficulties, either linked to the illness (for patients) or other daily difficulties (for clinicians). For both patients and clinicians, religion was very important in providing meaning to life, in coping with life difficulties, in giving meaning to these difficulties, in gaining control or in obtaining comfort…

For this research Mohr used the Semi-Structured Clinical Interview for Assessment of Spirituality and Religious Coping for Use in Psychiatric Research  – a bit of a cumbersome title if you ask me –in the appendix of a 2007 article by Mohr et al – click to view (sorry but the 2010 article is still in the pay to view domain).

I wish I’d talked more with patients about how their faith affected their lives.  I think it a great idea to have some kind of assessment tool to use for this.  At the same time ACT clinicians already have so many tasks to juggle, does it make sense to add more? I hear you thinking “Shalom are you kidding – another assessment?”  What about not trying to do this in the first year a client is working with the team.  But maybe in the second year, when hopefully, the client has more stability in their life?

All ACT clinicians should be comfortable talking with clients about things such as family relationships, about voices and Eartheir impact, about substance use (this should NOT just be foisted on the substance use specialist on a team!). Why shouldn’t ACT clinicians also feel comfortable talking with clients about faith? 

And, like so much of the work that is ACT, it’s mostly about turning oneself into an extra-sensitive giant ear – to just listen!

Shalom Coodin

 

 

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

 

 

 

Denial Denier

Working with individuals with addiction problems is challenging.  Part of the challenge is to balance multiple theories and ideas.  In talking with a client for the first time, or the hundred and first time, I have to be thinking Stage of Change (SOC) – where is this person in relationship to this problem?  Are they precontemplative?  Are they in a preparation stage? Are they in an action stage with regards to their use of cocaine but precontemplative when it comes to tobacco?

SOC is a model that all clinicians need to understand.  It allows us to identify where a client is at, but it can become like bird watching – “there’s a white-throated sparrow”.   It’s a one way process.

Motivational Interviewing takes it a step beyond; it teaches that SOC is one part of the equation but what’s going on in the conversation between client and clinician can itself be a factor in how things unfold.  It’s not that we are just birdwatchers/diagnosticians, we are more like dancers, inviting the person to join us on the dance floor.  And like a couple dancing, one person’s dance steps has an effect on the others.

I recently picked up a book on Substance Abuse Treatment and SOC. The authors write that

“Persons in the precontemplation stage generally are unaware or ignorant of their drug use problem.  If aware, they are not thinking seriously about their drug use or about making changes in it.” 

and

“Denial has been described as a core strategy used by substance abusers to deal with life and to avoid awareness of their substance use problems.”Denial Calvin

It’s not that I don’t believe substance abusers use denial – I think pretty much everyone (including me) uses it at times.  But I keep coming back to the issue of ambivalence.

William L. White, reflecting on his career working in addictions writes:

“The history of addiction as experienced by America’s addicts is a history of ambivalence.  Addicts simultaneously want – more than anything – both to maintain an uninterrupted relationship with their drug of choice and to break free of the drug” …

That’s it! I’ve met patients/clients where initially they appear in complete denial but as we talk, as the person becomes more comfortable to discuss things that often trigger a judgmental response, their ambivalence starts to come out.

Ambivalence! Grasp this concept and it will help you understand so much more than just using the construct of Denial.  Plus it will make you a better dancer partner!Lessons Learned Prezi

Consider checking out the Prezi I put together with a series of quotes from White’s book Slaying the Dragon.

Shalom Coodin MD FRCPC

1 June 2016

 

 

 

Spring Has Sprung – And Fall Is Coming!

Spring has sprung but October will be here soon and with it the Ontario ACT Association’s biannual conference happening October 26-28, in Niagara Falls, Ontario. They recently posted a call for workshop and poster proposals for ACTT III Beyond the Standards.

There aren’t enough ACT-specific events out there and this conference is a rare opportunity.  The location is ideal for those on both sides of the falls to attend. Bonus is that an American dollar gets you $1.30 worth of Loonies (yes, that really is how we refer to the Canadian dollar coin).  Add visiting a few of the wineries in the Niagara area and you have a perfect conference/holiday combo.

Even better than just attending consider submitting a poster or workshop proposal (click to view the pdf for workshop and poster submissions).  Maybe have a look at my Aug 2014 blog titled Measuring Up.

My favorite ACT ethics article-see Bill’s Barbeque – is by two Ontarian ACT physician researchers (at least they were in 2006).  I still think teams should use this article once a year – take just a few of the case scenarios and add/embellish based on your team’s experiences.

OAA LogoFinally, kudos to the OAA for their tag line which, to my mind captures some of the essence of ACT work : “If we can, we must.” 

Maybe see you in the fall.

Shalom Coodin

Powdered dog lice and crab eyes

“A typical physician attending the insane in 17th century America administered an assortment of concoctions made from such ingredients as human saliva and perspiration, earthworms, powdered dog lice, or crab eyes. Special importance was attributed to an herb called St. John’s wort which was blessed, wrapped in paper, and inhaled to ward off attacks from the devil. LiceAstrological lore found expression in prescriptions: one physician instructed that bloodletting and blistering be timed with phases of the moon; another called for boiling live toads in March and then pulverizing them into powder, a delicacy credited with preventing and curing all kinds of diseases. From his medical treatises the doctor might prescribe ancient and medieval remedies. Hellebore, an herb used by the ancient Greeks to cure mental disorders, was specified as being “good for mad and furious men.”  A preparation known as “spirit of skull” involved mixing wine with moss taken from the skull of an unburied man who had met a violent death. Hot human blood, as well as pulverized human hearts or brains, presumably helped control “fits.” While these prescriptions represented the best-known “cures,” the nauseating quality of the mixtures suggests that the remedy rather than the illness was the more formidable obstacle to recovery.Crab eyes Vomiting may actually have been helpful, and certainly had powerful psychological effects. In any event, the “cures” reflect the state of medical knowledge in colonial America, a time when physicians and laymen read and use the same medical recipe books. Most doctors remained preoccupied with commonalities and epidemics.”

This excerpt is from Treating the Mentally Ill: From Colonial Times to the Present, a great book with a boring cover that I suspect you’d have a difficult time finding (if you indeed wanted to hunt down a copy).

In a hundred years what treatments that we use now to treat major mental illness might end up in such a list?  Will clozapine, with all its side effects, be seen as having been a misguided remedy? (and I think clozapine is the best! click to read more).

I teach a bit of history next month to psych residents.  I’ll get the residents to read another quote from this same book by Leland V. Bell where he writes of how “psychiatry has supported a bewildering array of therapeutics that have followed a roller-coaster pattern of fashionability” (Read and watch more at Cycling History)

My goal is not to make trainees cynical about psychiatric treatment but to make them humble. Physicians should always be a bit skeptical.  One needs to find the balance point between therapeutic optimism  and humility.  We understand so much more about the brain than a century ago; and yet there’s still a huge amount to learn.  I think we’re doing better than powdered dog lice, or crab eyes but let’s wait a hundred years just to make sure.

Shalom Coodin

Relativity Risk

Professor David Nutt, a British mental health researcher, surveyed addiction experts for their views on the risks of various drugs.  Dividing the issue into personal risk (i.e. harm to self) and social risk (harm to others), they assembled the results into a paper published in The Lancet in 2010.  The graphs below summarize the results.

Nutt - Mean Harm graph
Drug Harm Graph 1

Examining such a subject shouldn’t be a big deal right? Well, Dr Nutt’s Wikipedia entry notes that:

“…Nutt published a controversial study on the harms of drug use in The Lancet. Eventually, this led to his dismissal from his position in the Advisory Council on the Misuse of Drugs (ACMD)…  Subsequently, Nutt and a number of his colleagues who had subsequently resigned from the ACMD founded the Independent Scientific Committee on Drugs. “

The Guardian newspaper published an article on the work titled Alcohol ‘more harmful than heroin or crack’.

Professor Nutt challenged conventional thinking in pointing out that:

“We saw no clear distinction between socially acceptable and illicit substances. The fact that the two most widely used legal drugs lie in the upper half of the ranking of harm is surely important information that should be taken into account in public debate on illegal drug use. Discussions based on a formal assessment of harm rather than on prejudice and assumptions might help society to engage in a more rational debate about the relative risks and harms of drugs”

Others have replicated Nutt’s survey and come up with their own graphs that differ slightly.  A Scottish group did a similar survey and their graph looks like this:

Drug Harm Graph

Dr. Nutt has been an outspoken advocate for medicalizing drugs of abuse. In a blog entry a few years ago he writes:

“I strongly believe that we should focus on public health approaches to the drug problem, and decriminalise the possession of drugs for personal use, for the following simple reason;- If users are addicted then they are ill, and criminal sanctions are an inappropriate way to deal with an illness.”

How should this information affect and inform how ACT clinicians approach their clients?  Will  ACT teams in the future be providing certain clients with methadone? With needles for injection drug users?  Should they? If they did would they risk consequences such as losing funding?

What do you think?

Shalom Coodin MD