assertive community treatment

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

Coexist

 

Change The Topic

By July 2018 Canada will have legalized marijuana. Will this result in  northern reefer madness? I think not.  I do hope the discussion shifts to more pressing issues than that of marijuana.  However the next topic – that of medicalizing drugs of abuse  – is likely to be even more polarizing for the psychiatric community.

The opiate crisis needs to be addressed.  A New York Times article reports NYT OpiateDeathsthere were an estimated 59,000 drug overdose deaths in 2016 in the U.S.  Drug overdose is now the leading cause of death for Americans under 50.

At least half of ACT clients will struggle with co-occurring substance use problems at some point.  This, in combination with psychotic illnesses, poverty and the multiple other challenges ACT clients face, may make them even more at risk than the general population.  (I haven’t found any publications on how the opiate crisis is affecting ACT clients. If you  know of any please let me know.)

I blogged about this issue previously – if you have time read Relativity Risk (click to view).  Note where cannabis falls on the graphs!Drug Harm Graph

Dr. Nutt, an expert in the field wrote how:

“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.”

Some European countries have moved to medicalizing drugs of abuse.  In a 2014 legal journal article titled Uses and Abuses of Drug Decriminalization in Portugal (click to view pdf) the author says  that “The dire predictions of critics—“from rampant increases in drug usage among the young to the transformation of Lisbon into a haven for ‘drug tourists’ ”—did not come to pass.” She points out that “Portugal’s 2001 decriminalization law did not legalize drugs as is often loosely suggested. The law did not alter the criminal penalty prohibiting the production, distribution, and sale of drugs, nor did it permit and regulate use. Rather, Portugal decriminalized drug use…”

So what has been the effect? While still debated, the author concludes that “The removal of criminal penalties for drug use was intended to de-stigmatize addicted users and encourage treatment. According to Portuguese drug policy officials, the new system has effectively done just that.”

The fentanyl-related deaths that have hit communities such as Vancouver  – but also smaller centers, including my home of Winnipeg – have prompted the Canadian government to take steps, even ordering prescription-grade heroin.HealthCanadaHeroin

I know some will shudder at the thought of physicians ‘prescribing’  heroin.  I do!  However the issue isn’t whether we, as physicians and mental health professionals, ‘support’ drug abuse.  I think using drugs is BAD!  However the choice is not between good and bad options – it’s between bad and worse. Nearly 60,000 Americans and 2,500 Canadians died of opiates in 2016!

ACT clinicians, like other front-line staff may be equipped with naloxone kits, but naloxone is a fleeting intervention for what is almost always a long-term problem.  ACT clinicians should always be listening for opportunities to help clients work towards abstinence but the reality of the work is going to remain focused on harm-reduction.  There are not enough treatment options out there to begin with. For ACT clients who, for multiple reasons, can’t tap into or benefit from conventional treatment settings, there are even fewer.

BTW if your team doesn’t have a copy of Muesser et al’s Integrated ITDD CoverTreatment of Dual Disorders, buy one now! (click to view my previous post on this)  

I don’t  presume to have the answers but I do think we need to have discussions.

Thank you for listening.

Shalom Coodin

 

Train ’em and Pay ’em

Can mental health consumers act as teachers for mental health professionals? Should they? If so do they have the pedagogical skills to be educators?

In a 2014 paper titled Consumer involvement in the tertiary-level education of mental health professionals: A systematic review the authors look at the research on this. Interestingly the first citation is of a Judy Chamberlain paper – (see my recent post).

While it’s important to research how to best involve consumers in teaching perhaps it’s time to, as a certain footwear company recommends, just do it!

First we have to recognise the value of lived experiences. On the issue of what we call patients (yes, I am a physician and I still use this term to remind me of my role) I’m increasingly comfortable with the title of Expert By Experience (see my blog I Got A Name on this)   Consumer, client and patient all have validity.  But when a patient asks what I think they should do – whether it’s to use or not use a medication for example, or to try returning to work – usually, before me answering, I’ll point out that my patient is truly the expert. They’ve lived with depression, PTSD, anxiety, psychosis, addiction or all of the above.

It’s well past time for psychiatry residency programs to have included consumers as instructors.  I suggest a plan on how to do this.  Step 1 – Pay Them!  I don’t work pro bono, why would we ask consumers to do so? Step 2 – Train Them!  One of the fallacies in Medicine is that by virtue of going through medical school and then a residency that you automatically acquire teaching skills along the way.  That ain’t necessarily so.  I don’t really know if I’m any good as a teacher – I certainly would have valued learning more about how to be a better teacher.  Medical schools have increasingly recognized this, offering teaching faculty training in how to be better educators.Apple

Just being a mental health consumer or expert by experience doesn’t necessarily make one a good teacher. There are individuals who are better able to articulate and communicate than others.   We need to invite, entice and did I mention PAY those consumers and involve them in ongoing training, not one-off seminars.

I have no doubt that there are such individuals out there because I’ve met them.  We psychiatrists may not like all of what they have to say but that can make for more interesting conversations.

Can those with the most severe, disabling illnesses – ACT clients – be part of this? Yes, I think there are some.  And ACT clinicians, who know their clients so well, would be a great resource for identifying individuals who might take on the role of becoming educators.

It’s way past time.  As I near the end of my career I’m saddened to see so little having been achieved in my community on this.  Maybe the next generation.

Shalom Coodin MD FRCPC

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

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

 

 

 

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

“I Got A Name”

Like the pine trees lining the winding road

Croce

I got a name, I got a name

Like the singing bird and the croaking toad

I got a name, I got a name

And I carry it with me like my daddy did…

Jim Croce

What should we call people?  As a physician I don’t have a problem with the term ‘patient’ but recognize its limitations.  It doesn’t really empower individuals.  With my PACT team we used the term ‘participant’ which I came to like.  There are other options including ‘client’, ‘consumer’, ‘service user’  or one I’d not come across before – ‘Expert by Experience’.

In addressing the issue for social workers C. McDonald writes:

The words we use to describe those who use our services are, at one level, metaphors that indicate how we conceive them. At another level such labels operate discursively, constructing both the relationship and attendant identities of people participating in the relationships, inducing very practical and material outcomes (McDonald, 2006, p. 115).

 I think there are merits to each of the various options – for a thoughtful consideration have a look at this article in the (click to view) British Journal of Social Work: What’s in a Name: ‘Client’, ‘Patient’, ‘Customer’, ‘Consumer’, ‘Expert by Experience’, ‘Service User’—What’s Next? British Journal of Social Work: What’s in a Name: ‘Client’, ‘Patient’, ‘Customer’, ‘Consumer’, ‘Expert by Experience’, ‘Service User’—What’s Next?

I do have a preference in terms of recording – I think clinicians should write using the patient/participant/consumer’s name.  For reasons I haven’t yet figured out many clinicians feel they must write using ‘client’ rather than the individual’s name.  I end up reading many, many notes that have the word ‘client’ many, many times.

Rogers CarlIf you’ve been reading my blog for a bit you know I love Motivational Interviewing.  MI grew out of the work of Dr. Carl Rogers, who introduced the idea of using the word client.  I support the non-judgemental acceptance Rogers advocated.  However I don’t think calling people ‘client’ rather than using their name does anything in helping operationalize Roger’s ideas.

Years ago I asked the director of medical records at the large teaching hospital where I worked whether there was some medical-legal requirement to use the term ‘client’ or some prohibition on using names.  She knew of none.  I think some believe that using ‘client’ in notes somehow is indicative of good professional boundaries.  I’m all for good professional boundaries but don’t believe using someones name in my notes in any way diminishes my commitment to maintaining such boundaries.

I like narratives.  People’s lives are stories they share with us.  When we document, why not make note of it as a story?

When you’re doing your notes this week try using the person’s name rather than the ‘c’ word.  If you’re an ACT team leader consider using an educational session to raise this with your team and allow people to express their thoughts.

And thank you, Dear Reader, for your time.

Shalom Coodin, MD FRCPC

Still Caged

In Shakles“There is nothing so shocking as madness in the cabin of the Irish peasant…when a strong man or woman gets the complaint, the only way they have to manage is by making a hole in the floor of the cabin, not high enough for the person to stand up in, with a crib over it to prevent his getting up. This hole is about five feet deep, and they give this wretched being his food there and there he generally dies”

 Report of an Irish member of parliament c 1800

A couple of months ago my office neighbor Dr. Vivienne Rowan pointed out an article in the New York Times  titled The Chains of Mental Illness in West Africa (click to view).  It is very powerful and well worth reading.  NYT Chains of Mental Illness

At a point in life when many of us are taking up bridge and golf Vivienne, a psychologist,  is volunteering with Doctors Without Borders/Médecins Sans Frontières (MSF).  She shared with me the  picture below, which she’d taken while in Aceh province Indonesia on a MSF assignment.  The man had a psychotic illness. Family had previously been able to pay for psychiatric treatment but had run out of resources.  With no other option the family caged him. While there Vivienne helped arrange for the man to get an injectable antipsychotic and he could then be unchained.Man In Cage pixellated

ACT clinicians should remember what many of our client’s lives would have been like in the not too distant past.  Even with all the challenges posed by severe and persistent mental illness, addictions, poverty and the myriad of other problems clients face, it’s a big step up from what conditions were, and still are for some.

Shalom Coodin