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



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


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

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

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

History Shorts

In the next few weeks I’m doing a couple of teaching sessions with psychiatric residents on the History of Psychiatry.

Several years ago Francine Chisholm and I put together a PowerPoint module to try to grab trainees attention for what can be a tough-sell subject.  It’s meant to be a self-driving experience where the user gets to click where they want to go (this was pre-Prezi). I haven’t yet figured how to make the whole thing available online but will keep looking into this.  In the meantime here are three video clips that give a taste.  The third one, a poem by a woman in an asylum, I still find moving.

Benjamin Rush 


Ode to a Key

My goal isn’t to judge the past (though I do).  The goal is to make residents (and me) aware of our limitations and to leave us humble about how much we still don’t know.  Readers of this blog know I believe clozapine is a valuable medication.  At the same time I sincerely hope it’s obsolete in fifty years; I suspect people will look back and think “what was he thinking using a medication like that?”.

“Those who cannot remember the past are condemned to repeat it.” – George Santayana

As far as learning psychiatric history, that’s a good enough reason for me.

Shalom Coodin

Beyond Workshops

There isn’t much simple about Motivational Interviewing.  Yes, there are ‘simple’ reflections, but, as Bill Miller points out, learning to form them isn’t simple.  Throw in using summary and double-sided reflections, mastering reflective listening, using open-ended questions, being continually aware of engagement with the client, listening for change talk, understanding ambivalence…  well it’s complicated.

If it’s complicated for individuals to learn these skills how much more challenging is it for an agency to take on the task of training their staff in MI?  And to make it even tougher here’s what Miller and Rollnick have to say about learning MI in the third edition of their great book: MI cover

 “One thing that is relatively clear at this point is that self-study or attending a single workshop is unlikely to improve competence… Reading or a single workshop can increase knowledge of MI, but there is little reason to believe that it will instill skill.

Worse, we know from firsthand experience that if we imply that participants will become skillful in MI through attending our workshop, they are likely to believe mistakenly that they have learned it. 

In a first evaluation of our own 2-day training workshop, participants showed very little improvement in skills, certainly not enough to make any difference in how their clients responded, but we did manage to significantly decrease their interest in learning more about MI. Why? It was not because they didn’t like MI or thought it was ineffective.  It was because they believed they had already learned it.”

So what’s an agency to do?  M&R write “Our recommendation, then, is not more workshops but ongoing coaching with feedback based on observed practice…”

ACT teams provide a perfect forum for ongoing MI skill development; a group of clinicians who are together daily, working with common clients.  Then there’s the secret ingredient for success – a team leader who recognizes and embraces the importance of making MI skill development not as something special, but rather as a normal expectation of all staff, like charting and being at morning meeting.

There is a second ingredient that I believe can make this task even more successful – that the team’s psychiatrist be involved.  The psychiatrist practising (and teaching) MI can really help teams take it to another level.

If you’re unconvinced as to the value of training ACT staff in MI read Manthey, Blajeski & Monroe-DeVita’s 2012 paper Motivational Interviewing and Assertive Community Treatment: A Case for Training ACT Teams. 


BTW Professors Miller and Moyer are doing a workshop in Odense, Denmark in early June. So do attend a workshop, just remember, afterwards repeat to yourself – “I learned so little, must learn more, must get feedback and practice, practice, practice”…(and repeat again and again and again)

You can find a wealth of info at Check it out.

Shalom Coodin

The CMHR and Nazi Psychiatry

The Canadian Museum for Human Rights (CMHR) opened recently in Winnipeg, my hometown.  CMHRIt is powerful in both form and content. The focus is on human rights and the creators wisely didn’t try to replicate the Holocaust Museum in Washington.  The exhibits are engaging and diverse.  The sections on First Nations / Aboriginal peoples are particularly moving.

There is some focus on the treatment of the mentally ill, the experience of the asylums and the unpaid labour done in those institutions.  There are also details on Action T4, the program put in place by the Nazis for identifying and murdering those seen as “useless eaters“, first by starvation and lethal injection and later by poison gas. Before the Jews were put into gas chambers the technology was perfected on those with mental illnesses and disabilities.

Psychiatry during the Nazi era: ethical lessons for the modern professional, available in its entirety online, is well worth reading . In it Rael Strous writes:

“During the Nazi era, for the first time in history, psychiatrists sought to systematically exterminate their patients. It has been acknowledged that the medical profession was profoundly involved in crimes against humanity during this period, with various publications describing this malevolent period of medical history. It is less known, however, that psychiatrists were among the worst transgressors.”


“Much of this process took place before the plan to annihilate the Jews, Gypsies and homosexuals of Europe. Hitler never gave the order to kill patients with mental illness. He only permitted it in a letter written in October 1939 and backdated to September 1, 1939. Psychiatrists were therefore never ordered to facilitate the process or carry out the murder of mentally ill…they were empowered to do so.”

ACT clinicians are often working with individuals who have devastating illnesses that are life-changing for them and their families.  It’s important to remember that one’s value as a human being is not contingent on whether one has, or doesn’t have, a major mental illness.

Read Strous’s paper and, in 2015 come visit the CMHR – you’ll be moved by both!

Wishing you and yours – including your clients – a Happy and Healthy New Year.


Shalom Coodin

Family Matters

It often takes years before a client is connected with an ACT team. This can mean years of crises, hospitalizations and incarcerations. Family members have similarly been dragged along, experiencing the vicarious trauma of witnessing, and being directly affected by, a loved one having severe and persistent mental illness.

Beyond the day to day contact our team maintained with families, Roman and I would periodically facilitate a family group. We did not do this often enough but their effect felt lasting. If your team hasn’t been operating a family group consider giving it a try. Here are a few suggestions for how to arrange it:

  • Offer it in an evening, starting at 7 or 7:30 and allow for around 90 minutes.
  • Serve cookies or pastry, coffee and tea.
  • Hold it in your normal workspace where the team does morning meeting. Throw a drape over the chart rack (if you still have such a thing) to block names.
  • Don’t worry if you’re in the middle of the work area and evening staff are coming and going – it’s good for family members to see how the team operates.
  • Have the team leader facilitate and see if you can get the psychiatrist to come in even if it’s just for 15 or 20 minutes. Other clinicians are usually more than willing to help with this kind of group.
  • Have 30 to 45 minutes worth of material to present. Early in a team’s life the focus should be on the basics of how the team operates, how ACT services are delivered and the like. Don’t present too much – you want to leave ample time for those attending to talk and share. More on what to present below.
  • Invite twice as many people as you expect to attend and aim to have between 10-20 attendees (14-16 is ideal).
  • Welcome all; invite parents and siblings but don’t restrict.  Sometimes there’s an aunt, uncle or grandparent who has been very involved – they should attend.
  • Occasionally you may have a family member who is hurting and monopolizes the discussion. This can be challenging but allow them to talk and try not to cut them off. Family members need time to share the narrative of their experience, which has often been incredibly painful. Let people talk, let others share, don’t feel you have to over-control the process.
  • Don’t feel you have to be an apologist for the mental health system.  Don’t get defensive – listen actively and solicit others’ thoughts and experiences.

A Family Resource Guide cover

Several years ago our team had two excellent nursing practicum students, Lindsay and Uzoma  (see my previous blog on From Treating Team to Training Team), who did a wonderful job of putting together A Family Resource Guide.  It deserves to be shared and used. Consider taking a part of it and using it as the basis for a family session. (Note that on our team we used the term ‘participant’ rather than ‘client’ and you’ll find this term used throughout the document).  Chapter 1, an overview of PACT, is perfect for a first session.

I suggest trying to do a family group twice a year – spring and fall.  Bringing families together to learn from their experiences can be a most gratifying part of our work.

Shalom Coodin

Cycling History

The history of psychiatric treatments has, in the words of Leland V. Bell:

remained in a state of flux.  Indeed, institutional psychiatry has supported a bewildering array of therapeutics that have followed a roller-coaster pattern of fashionability.  A new therapy is introduced with great excitement and enthusiasm.  Sophisticated, detailed reports verify its effectiveness and show remarkable cure and improvement ratios.  This excitement and interest soon fade.  Follow-up studies and additional research challenge the initial reports and reveal that the therapy has limited applications, that it should be given only a modest place in psychiatry’s armamentarium.   Even the most dramatic therapeutics have followed this cycle of hope and disillusionment.”

Pick the treatment – insulin coma, Metrazol, malarial treatment of tertiary neurosyphilis (for which a Nobel Prize was awarded), ECT, lobotomy (for which another Nobel Prize was given) – the cycle has repeated. More recently the same pattern has emerged, to a lesser degree, with SSRIs and second generation antipsychotics. It’s not that these are ineffective treatments – they were and are of benefit! It’s just that when each first arrived they were overvalued and overused. They become another tool, not the only tool.

Why bother studying history? Because it raises our awareness of where we came from, where we are and, hopefully, makes us think where we’re going.

It is all too easy to forget the kind of lives many clients had not so long ago.  With onset of a psychotic illness, usually in early adulthood, they would’ve been admitted to an asylum, might well have lived their entire lives there, died there and been buried in the asylum’s cemetery.

While there’s still a long way to go in finding effective treatment tools our clients are, for the most part, living radically different lives than they would have had they been born 100 years before.

The attached video shows Dr. Heinz Lehman with three men suffering with catatonic schizophrenia. I wrestle with the ethics of posting this as I doubt these men ever gave consent for the use of their images. At the same time this footage has been in the public domain for decades. The images are powerful; keep in mind what Dr. Lehman says in the intro – these men have been in this state for between 5 and 15 years and that their symptoms are less severe than they had been.


Heinz Lehman was a distinguished Canadian psychiatrist who is credited with bringing chlorpromazine – Thorazine to Americans, Largactil to Canadians – to clinical practice. He did not invent or discover it but was the first to start using it, in his own admission out of desperation to help patients.

Most of psychiatric history is a history of psychiatrists. There is another history that needs to be told – that of patients. Pat Deegan’s film The Politics of Memory powerfully presents this.

To help clients find their voice, to speak their history, will remain one of the most important tasks for ACT clinicians.

Shalom Coodin

PS: To find a copy of Treating The Mentally Ill; From Colonial Times to the Present by Leland V. Bell,  check on Amazon.