MI

“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

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

Haunted!

“We have consensus in the U.S. about what alcoholism is and what it is not, a consensus so nearly complete that to question its basic assumptions is to be either rejected as a dangerous heretic or pitied as misguided and misinformed.”

William R Miller

In his paper Haunted by the Zeitgeist Miller goes on to question those basic assumptions.  And yet I don’t think anyone would label Bill Miller – of MI fame – a dangerous heretic, misguided or misinformed. HauntedZeitgeist

Haunted by the Zeitgeist is a great piece for ACT team teaching!  Though published in 1986 it remains just as relevant today.

Miller touches on six assumptions on alcoholism that are still firmly held on this side of the Atlantic. He asks:

So what is alcoholism, really? If you ask most any informed American you are likely to have it explained to you that alcoholism is an irreversible disease that causes a person to lose control over drinking. Broken down into its component assumptions, the elements of this traditional American conception of alcoholism are as follows:

  1. Alcoholism is a disease. It is recognizable as a unitary syndrome with certain symptoms and a predictable progression.
  2. Alcoholism is a disease. Although the etiology is not completely known at present, it probably has a physical cause as well as psychological and spiritual elements.
  3. Loss of control is the central symptom. An alcoholic loses the ability to control his or her drinking. “One drink, one drunk.”
  4. Alcoholism is irreversible. One can never become a recovered alcoholic, only a recovering alcoholic. Return to drinking causes resumed deterioration. “Once an alcoholic, always an alcoholic.”
  5. The only possible hope for an alcoholic is total and permanent abstinence from alcohol.
  6. Far and away the most effective means for achieving this is through the fellowship of Alcoholics Anonymous (AA)…

The origin of these assumptions is not scientific data… The pervasiveness of this view in the US is difficult to explain to those living in other nations, where wholly different assumptions may be held…

He goes on to address each of these assumptions, presenting evidence to support or challenge them. For example on the idea that Alcoholism is Irreversible he writes “…to any reasonable reader of the scientific research on alcoholism treatment outcome, this assertion must be regarded as soundly refuted…Suffice it to say that there is no scientific basis for maintaining the possibility of nonproblem drinking outcomes, and that there is substantial evidence to the contrary.”Alcohol and Culture

He concludes with “Perhaps our best guiding principle through all of this is to remain close to the data. The current American conception of alcoholism and the treatment system that has been perpetuated by it exemplify how far it is possible to stray when a particular theory becomes more important than evidence itself… It is premature to claim to have the answers when we are still searching for the right questions.”

The ideas Miller presents are still very true and this article provides food for thought and discussion.  It’s worth taking small pieces of it and using it for a team education session. Get someone on the team to distil it down and present some of the ideas – perfect role for the team psychiatrist!  (Don’t make everyone read through the whole paper.)  After such a session your team members should have more questions, not less.  And isn’t that the goal?- to have better questions, not simplistic answers.

Sorry I can’t post a pdf of the whole article- I did ask the NY Academy of Sciences and was politely told that it is accessible online for a fee (as little as $6 – click here to view).  Or you can still buy a used copy of this publication (click to view via Amazon) for about the cost of a venti pumpkin spice frappuccino.at Starbucks.

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. 

MINT

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