The measure of a society is, to a degree, reflected by how its vulnerable people are treated under the law. In the modern world, society is also measured by the character and prevalence of its crimes and misdemeanors. Without a doubt, drug and alcohol-related crimes are the most prevalent today.

Outlaws used to rob banks and railroad cars, but in October of 2010, a pharmaceutical truck was robbed and the driver was kidnapped. The thieves stole only Vicodin and OxyContin, a painkiller thought of as synthetic heroin. The crimes, they are a changin’.

Also in October, 52 people were arrested for organized crime racketeering involving Medicare fraud. Some of them may face allegations of forged prescription sales involving OxyContin. Racketeering for prescriptions? This is a cultural wake-up call without a snooze option.

The modern news is filled with similar cases, and heaven knows our jails and prisons are filled with people who would not be where they are without some connection to alcohol and drugs. Alcohol and drug-related crimes and misdemeanors account for the vast majority of American crimes committed. Ask any defense attorney and they will tell you of the tragedies that would never have happened had someone not been under the influence, regardless of whether it may have been the person accused, their family members or others. How did this happen?

Since the 1960s, pop culture has reflected a degree of “cool” rebellion in the illegal use of drugs and excessive use of alcohol to get high. Currently, one of the most tragic modern trends for trying to get high among teenagers is the self-imposed choking/asphyxiation game. Sadly, criminal charges have begun to be filed in these cases in recent years. In 2010, in Wheat Ridge, Colo. a teenager was criminally charged with reckless endangerment when she performed the choking game on her friend, Gabrielle Abuzhars. Is criminalization really the best way to encourage kids to stop trying to get dangerously high? How can society popularize a mainstream advancement of effective positive solutions? The asphyxiation game is a clear cultural STOP sign. What’s next?

There are healthy alternatives to soothing and stimulating the oversized and often overactive human brain. For openers, simple exercise works pretty well. John J. Ratey, MD, Associate Clinical Professor of Psychiatry at Harvard Medical School authored the book Spark: The Revolutionary New Science of Exercise and the Brain. He stated, “Be clear. My analysis of the findings and testimonies and stories make it clear that exercise can play a huge role in the initial withdrawal, the initial and prolonged dealing with cravings, and offer a substitute activity addiction, like AA to help repopulate the frontal cortex choices of what and how to respond to eventual stressful situations and losses.”

Statistically, Alcoholics Anonymous has the highest success rate in the long-term treatment of alcoholism and addiction. It would appear to be a no-brainer that exercise and nutrition can play an important treatment-enhancement role. There are many other creative alternatives for treatment enhancement, too. We as a society clearly need to use our healthy brains to develop and encourage more. Needless to say, it would help if some of the alternatives were perceived as cool. So how exactly does a society make exercise, nutrition and other healthy alternatives cooler than getting high? What if a few more trendy rock stars and former bad girls were selected to do some Nike commercials? Here’s a campaign slogan: “Just Do It Naturally – One Step at a Time.”

Now, Drs. Bill Miller and Stephen Rollnick have applied that same logic to the change method they call Motivational Interviewing, or MI” They recognized that stopping using was a choice. People make choices because the choice feels good. That’s why users use. So they developed a form of substance abuse counseling in which sobriety feels good.

Underlying Principles

• The Client Makes the Choices. Nothing is more natural than for counselors to believe that they can somehow “make the client to see the right thing to do and do it immediately” before something really problematic happens. That sets up a power struggle. Not helpful.
• The MI Therapist Is Consistently Supportive and Calm (Even a Bit Casual). Almost nothing is more natural than for the therapist to start getting upset when the client then doesn’t change, despite the therapist’s best efforts (and all that lengthy training). That introduces a bit of tension into the therapeutic encounter. Not necessarily helpful. Not to worry – in MI, you just relax. As you relax, the client relaxes.
• The MI Therapist is Patient. Patience works. So, MI counselors are patient. The client has to make the positive choice, and that can take time.
• The Client Will Make a Healthful Shift Under the Right Conditions. Therefore, the main thing the MI counselor is doing is creating the conditions in which the client can make a healthful shift in thinking and behavior. Calm, casual, relaxing, patient; no pressure; no demands. Mainly, just a lot of polite questions at first – an interview. And, eventually, a shift from the negative (the laundry list of stressors) to the positive (the client’s successes). Clients thrive on success.
• Ambivalence. Initially, people with serious substance issues will often proclaim clearly to anyone who will listen that they do not have a problem, and that they do not, therefore, plan to change. And no one can make them. However . . . in their heart of hearts they know things have gotten out of control and are careening toward disaster. In their heart of hearts, they want to change. In other words, they are ambivalent. Ambivalence is the key to MI.

People who use too much think using is both good and not so good. How does that help? How does that make choosing sobriety comfortable and satisfying? Here’s how:

Techniques

• Allow the Client Plenty of Opportunity to Speak. Use a calm, patient, casual/no-pressure manner. You’re really waiting for the client’s ambivalence to surface, waiting for the client to shift from the negative side of life to the positive side of life; from a destructive approach to living to a constructive approach to living. “Yeah, I use. Maybe too much. I don’t know.”
• Positive Active Listening. Active listening in client-centered counseling means that as you listen to the client you reflect – paraphrase and summarize – what the client is saying to make sure that you actually understand. Reflections are typically neutral. However, active listening in MI is both neutral, as in client-centered counseling, and strategic, meaning that the bulk of the reflection emphasizes the positive side of what the client is saying. For example, the client says, “I’m pretty sure I’m going to go drinking this weekend, but . . . I’m not sure that’s a great idea”. A neutral reflection (good to use when you’re not sure what the client is actually saying) would be, “So, you’ve been thinking about drinking, but you feel it would just make things worse. Is that right?” However, a reflection with a positive bias, keying in on only the positive side of the ambivalence, might be, “Uh-huh – you’re having second thoughts; you think it might be best to not drink. Is that right?” That would look like this:

Negative Side: “I’m going drinking this weekend”
Positive Side: “I’m not sure that’s a great idea” Reflect this side!

•    A more subtle form of this kind of positive reflection would be to give a more balanced reflection, but to emphasize the positive side: “Mmmm, so you’re thinking about drinking, but you’re also thinking, ‘Hey, uh-oh – here I go again. Drinking too much!” You’re asking yourself, “Is this really a good idea?’ Is that right?”
•    Roll with the resistance. Initially, there’s a lot of resistance in recovery. Resistance is the negative side of the ambivalence. Here’s a typical expression of resistance: “I don’t know why I even have to come here. You’re not really helping. I just come here because I have to, because other people are making me. I don’t really care, anyhow.” The technique here is just to go along with the opposition, or roll with the negativity. It doesn’t matter what you say. Just go along, because it’s going to pass anyway. You are just waiting for, and helping the client to ease back onto, some kind of a constructive track. So, a workable response, a combination of reflection and self-disclosure – agreeable, yet moving back into the positive frame might be, “Yeah, you’d really like to not be here. I don’t blame you. I’d probably feel the same way in your place.” There’s a lot of resistance in recovery. You just wait it out.
•    Appreciate the Positive. A second positive technique is just to give straightforward praise for the positive side of the client’s thoughts and actions. For example, a typical, mostly negative statement in counseling might go something like this. “Well, I drank again. I know I promised I wouldn’t. I even stayed out all night. Blew my paycheck, of course. Now I’m stuck for the week again with no money. I only did one good thing – I went to my daughter’s sixth grade graduation.” Throughout the negatives the client is waiting for you to pounce and seize on the them, just as the client does all the time. But as an MI counselor you don’t do that. You are casually present, maybe using a little active listening here and there, but mostly just rolling with all that resistance. However – and this is critical – at the point where the sixth grade graduation is mentioned, then you becomes really excited and interested. “No kidding? Your daughter’s sixth grade graduation! How did that go? Tell me about it.” You showcase the successes. You allow the client to expand on this very positive piece of parenting. As an MI counselor, you genuinely appreciate the clients’ own excited movement toward growth, and focus on that. You shine a light on their best features, and they begin to do the same.
•    Intrinsic, Self-Reinforcing Motivation. Now, here’s what starts happening in this process. The client slowly discovers that you’re not going to belabor all the negatives. You don’t even really seem all that interested, except as it affects the client. What the client discovers is that you are fascinated by the client’s successes. What the client discovers is that counseling is a showcase for things that make the client feel proud and happy. The client begins to pay attention to personal ambitions and successes in the real world. Every day, every week brings new successes. The client starts to feel good, to experience hope, self-esteem, and excitement in living. The client learns positive self-regard, and acquires the habit of positive self-talk.
•    Sobriety. Clients no longer needs substances to feel good. The costs of using now outweigh the benefits. Therefore, they make the positive choice.
Benefits of MI
•    Fewer power struggles.
•    Less stress on the client.
•    Less stress on the counselor.
•    A positive approach to self and others that the client can learn and pass on to family and friends.
•    Sobriety that is based on feeling good about living and thus is intrinsically motivating.

Resource:
Miller, William, & Rollnick, Stephen. (2002). Motivational Interviewing: Preparing People for Change (2nd ed.). New York: Guilford Press

Dr. Steve Davidson is in practice in Newport Beach. He specializes in ADHD and other disorders of impulse management and goal-seeking. sdavidsonphd@aol.com; www.newportbeachpsychology.com.

MOTIVATIONAL INTERVIEWING – Steve Davidson, PhD

Objectives

1.    The student will learn how to use active listening that has a positive bias.

2.    The student will learn how to roll with client resistance by using casual, agreeable responses.

3.    The student will learn how to decrease client negativity and how to increase client positiveness by focusing on the positive side of ambivalence.

Post-Test

1.    T F Active listening in MI means that all reflections by the counselor of client statements should be balanced, neither emphasizing the negative side of the client’s statements, nor the positive side.

2.    T F Rolling with the resistance means the MI counselor should wrestle with the client’s negativity and not allow the client to expand on negative issues.

3.    T F The MI counselor should showcase the client’s successes, even if those successes are more than outweighed by numerous problems calling for immediate correction.

• A majority of patients (80%) seeking treatment for SUDs report having experienced intense trauma.
• Approximately 50% of women and 20% of men in chemical dependency recovery programs report having been victims of childhood sexual abuse (CSA). CSA doubles the number of alcohol abuse symptoms in adulthood.
• PTSD is three times more common among SUDs patients than it is in the general population.
• Trauma victims report greater involvement and higher expected future involvement for engaging in substance abuse than do non victims.
• SUDs patients with PTSD show a more severe substance abuse profile and they tend to use drugs to reduce the impact of negative affect and hyperarousal symptoms (exaggerated startle response, nightmares).

Patients with comorbid disorders of PTSD and SUDs have more severe levels of psychopathology, with greater symptomatology for each disorder; more life stressors (e.g., more medical problems, higher unemployment, higher arrest records); higher health care utilization; less effective coping strategies and poorer response to treatment than do patients with either PTSD or SUDs alone. They are also more likely to experience additional comorbid affective disorders (panic attacks, major depressive disorders, suicidality, personality disorders). In addition, there are important gender differences that require gender-specific treatments (Brady et al. 2009).

Assessment Implications

Given the complexity of the clinical picture, there are several assessment implications that should inform treatment planning. These include the need for a life-span perspective that considers the sequence of the respective disorders. In most instances, mental health problems precede the onset of SUDs. There is a need for an ongoing risk assessment, given the high incidence of suicidal behaviors in this comorbid clinical population. In addition, there is a need to allow enough time to elapse in order to ensure that the respective disorders are not masked. A comprehensive Case Conceptualization Model that includes the range and severity of presenting problems, current and past patterns of use, polysubstance abuse, family history and signs of strengths and resilience should be included. As the adage goes:

“A clinician without a Case Conceptualization is like a captain of a ship without a rudder, aimlessly floating about with little or no direction.”

The Case Conceptualization Model provides a means to collaboratively establish with the patient and significant others doable, measureable short-term, intermediate and long-term goals and the means (and possible barriers) by which they can be achieved.

Treatment Implications

There are three major sets of findings that should guide treatment decision-making with patients who have PTSD and SUDs. First, there is an increasing appreciation that such treatment should be conducted on an integrative, rather than on a parallel or sequential basis, and that doing so improves long-term effectiveness (Mueser et al. 2003). Second, a series of meta-analyses of both the treatment research on PTSD (Benish et al. 2008) and on SUDs (Imel et al 2008) have demonstrated the comparability of various treatment approaches and the critical role of the therapeutic alliance and engagement treatment strategies. As Mee-Lee et al (2010) highlight, the quality of the therapeutic alliance contributes 5 to 10 times more to outcome than does the specific treatment approach that is used. Given the high dropout and noncompliance rates by patients with comorbid disorders, there is a critical need to focus on facilitation procedures using Motivational Interviewing. A critical feature in treatment is the need for the development of a Recovery-oriented System of Care and on relapse prevention treatment procedures.

Finally, the third major research focus has been on evidence-based treatment approaches that use integrative cognitive-behavioral interventions that educates patients about the interconnectedness between trauma exposure and the development of PTSD and SUDs (See Ford et al 2009 and Najavits, 2002).

At the Clearwood Treatment Center in Grand Rapids, Michigan, where I am a consultant, we are training clinical and front-line staff to provide a total integrative milieu treatment approach. Treatment includes such features as a carefully detailed assessment and an accompanying Case Conceptualization Model that all staff members use to coordinate services; collaborative goal-setting with patients in order to nurture hope and to build into treatment a person-centered, strengths-based approach; individual and group treatments that build intra- and interpersonal coping skills with a major emphasis on including generalization procedures; the integration of 12-Step AA and family-based activities, and ways to build and sustain a balanced lifestyle. A comprehensive treatment approach that recognizes the “chronic” nature of such comorbid disorders and provides long-term continuity of care is a treatment objective of the Clearwood residential program. The clinical decision-making at Clearwood will be “data-driven”, using ongoing feedback to both patients and the clinical staff.

References

Benish, S.G., Imel, Z.E. & Wampold, B.E. (2008). Relative efficacy of bona fide psychotherapy  for treating PTSD: A meta-analysis. Clinical Psychology Review, 28, 746-758.

Brady, K.T., Back, S.E., and Greenfield, S.F. (2009). Women and addiction: A comprehensive handbook. New York: Guilford Press.

Ford, J.D., Fallot, S. & Harris, M. (2009). A trauma-focused, patient-centered, emotional self-regulation approach to integrated treatment for posttraumatic-stress and addiction. American Journal of Psychotherapy, 60, 335-385.

Imel, Z.E. & Wampold, B.E. & Miller, S.D. (2008). Distinctions without a difference: Direct comparisons of psychotherapies for alcohol use disorders. Psychology of Addictive  Behaviors, 22, 533-543.

Mee-Lee, D., McLellen, T. & Miller, S.D. (2010). What works in substance abuse and dependence treatment. In B.L. Duncan, S.D. Miller, B.S. Wampold & M.R. Hubble  (Eds.), The heart and soul of change. (2nd Ed.). (pp. 393-417). Washington, DC:  American Psychological Association.

Meichenbaum, D. (2009). Trauma and substance abuse. Guidelines for treatment. Counselor: The Magazine for Addiction Professionals, 10, 10-15.
Mueser, K.T., Noorday, D.L., Drake, R.L., & Fox, L. (2003). Integrated treatment for dual  diagnoses: A guide to effective practice. New York: Guildford Press.

Najavits, L.M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York: Guilford Press.

Ouimette, P., & Brown, P.J. (2003). Trauma and substance abuse. Washington, DC: American Psychological Association.

The mind of an addict is like an untamed horse, running wild
and full of emotion; it cannot be controlled. DBT and 12-Step
work tames that wild horse, bringing the mind into focus and
regulating emotions.

Dialectical Behavior Therapy (DBT) has found its way into addiction treatment. Originally developed as a therapeutic tool for women diagnosed with Borderline Personality Disorder, DBT currently has been modified by many treatment professionals for use in the field of addiction. Numerous published articles describe its effectiveness within this population (Linehan, MM, Schmidt, H, Dimeff, LA, Craft, JC, Kanter, J and Comtois, KA 1999; Kienast, T and Forester, J, 2008).

Addiction literature demonstrates the utility of 12-Step programming in supporting recovery (Galanter, M, 2007; Piderman, KN, Schneekloth, TD, Pankratz, VS, Maloney SD and Altchuler, SI, 2007), and the 12-Step approach is commonly integrated into addiction treatment programs. The Center for Dependency, Addiction and Rehabilitation (CeDAR) at the University of Colorado Hospital has successfully developed programming that integrates DBT and 12-Step philosophy. We have learned that the two modalities complement and support each other in strengthening our patient’s recovery.

The focus of DBT is to create a dialectical lifestyle that reflects balanced behavioral patterns, such as balanced actions, balanced emotions and balanced cognition (Linehan, 1993). Similarly, working the 12 Steps results in creating a balanced lifestyle. Alcoholics Anonymous (AA) offers “the promises of the steps” and Narcotics Anonymous (NA) gives the promise of “freedom from active addiction”; both of these gifts of working the steps complement DBT’s focus.

DBT Targets and 12-Step Philosophy

DBT literature identifies specific targets that must be addressed in the therapeutic process (Linehan, MM, 1993). These targets can be found throughout 12-Step literature and are an integral part of step work.

The DBT target of Emotional Dysregulation focuses on affective lability and problems with anger. Internal unmanageability, as described in 12-Step literature, is closely linked with the DBT target of emotional dysregulation as it focuses on the emotional volatility of addiction.

“Emotional volatility is often one of the most obvious ways in which  we can identify personal unmanageability” (NAWS, 1998, p 4).

Interpersonal Dysregulation involves the development of chaotic relationships and fears of abandonment. The Big Book (AAWS, 2001) describes the progressive destruction of relationships:

The alcoholic is like a tornado roaring his way through the lives  of others. Hearts are broken, Sweet relationships are dead. Affections  have been uprooted. Selfish and inconsiderate habits have kept the home in turmoil. We feel a man is unthinking when he says that sobriety is enough. He is like the farmer who came up out of his cyclone cellar to find his home ruined. To his wife, he remarked, “Don’t see anything  the matter here, Ma. Ain’t it grand the wind stopped blowin’?” (p 82).

Prior to entering the 12-Step fellowships, many addicts find themselves in a state of mental, emotional and spiritual bankruptcy. Bankruptcy then becomes a common topic of recovery in 12-Step meetings. Mental bankruptcy is connected with the DBT target of Cognitive Dysregulation. The focus is addressing dissociative responses and/or paranoid ideation.

“We were prisoners of our own mind and condemned by our own guilt” (NAWS, p 7).

In 2007, after careful review of DBT and 12-Step literature, CeDAR developed an integrated group model for primary care and extended care patients.

Mindfulness

Mindfulness is the foundation of DBT practice (Linehan, MM, 1993). It has been described as “moment to moment, nonjudgmental awareness, cultivated by paying attention” (Kabat-Zinn, J, 2007). Linehan (1993) conceptualizes our “States of Mind” as Reasonable Mind, Emotional Mind and Wise Mind.

Reasonable Mind is described as the state of mind we experience when do not have an emotional attachment to what we are focusing on; we are logical and rational. In Emotional Mind, our emotional state controls the way we see the world and make decisions; we don’t use logic or rational thinking to solve problems. Wise Mind is the balanced state of mind; we use logic and rational thinking, along with an awareness of our emotional state, to become aware of what is and to act in a thoughtful manner. Mindfulness practice supports patients in centering themselves in the Wise Mind state. Moving from extreme thinking to a Wise Mind involves finding the middle ground, living in the spiritual principle of surrender and staying balanced.

There are many examples of the three states of mind in 12-Step literature. For example, the Big Book (AAWS, 2001) describes Emotional Mind on page 36:

“Suddenly the thought crossed my mind that if I were to put an ounce of whiskey in my milk it couldn’t hurt me on a full stomach. I ordered a whiskey and poured it into the milk. I vaguely sensed I was not being any too smart, but felt reassured as I was taking the whiskey on a full stomach. The experiment went so well that I ordered another whiskey and poured it into more milk. That didn’t seem to bother me so I tried another.”

This reading demonstrates how Emotional Mind can be a trickster and will create the illusion of being reasonable. This concept is extremely important in recovery, since it emphasizes how an individual’s thought process is compromised and difficulty arises when relying on one’s own thinking and willpower. NA states, “it is a ‘we’ program” and AA reminds us that “your best thinking got you here”.

Mindfulness meditation, emphasized in step work, allows for quieting the mind and focusing energy and strength.

“Quieting the mind through meditation brings an inner peace that brings us into contact with the God within us… A basic premise of meditation is that it is difficult, if not impossible, to obtain conscious contact unless our mind is still” (NAWS, 2008, p 46-47).

The core concepts taught in the mindfulness module of DBT are to quiet the mind and to begin to trust one’s own perceptions, judgments and decisions. Addicts reinforce negative behaviors by acting judgmentally. The skill of “acting non-judgmentally” (from the “how” skills) emphasizes “principles over personalities” and strengthens the concept of open-mindedness:

“A new idea cannot be grafted onto a closed mind. Being open-minded allows us to hear something that might save our lives… Open-mindedness leads us to the very insights that have eluded us during our lives…we no longer need to make fools of ourselves by standing up for non-existent virtues. We have learned that it is okay to not know all the answers, for then we are teachable and can learn to live our new life successfully” (NAWS, 2008, p 96).

Distress Tolerance

There are five groups of skills taught in the DBT module of distress tolerance. These skills teach individuals to tolerate uncomfortable situations and to decrease intense emotional reactions. Prior to recovery, the addict medicates, numbs and avoids experiencing unwanted emotions. In early recovery, the intensity of new emotions may be overwhelming. Practicing distress tolerance provides the individual with skills to get through difficult times.

The five groups of skills taught in the distress tolerance module can be identified in 12-Step literature. For example, the skill of contributing has to do with helping others in order to help oneself. On page 115 of the Big Book (AAWS, 2001), Bill describes how going to his old hospital and talking to another alcoholic would move him from self-pity, resentment and despair and “save the day.” Contributing can be seen as similar to service work, a vital element in any 12-Step fellowship.

Accepting reality is the last of the five skills groups within the distress tolerance module. The concept of Radical Acceptance has to do with ceasing to fight reality and being tolerant of whatever the situation brings. A central concept of Radical Acceptance is that pain creates suffering only when we refuse to accept the pain. One 12-Step slogan that relates to this concept is “pain is inevitable, misery is optional.”

The AA Big Book devotes an entire chapter to the concept of acceptance. The Serenity Prayer, said in thousands of 12-Step gatherings, reminds those in the fellowship of the importance of accepting what is and “letting go.”

Radical Acceptance and the 12-Step concept of surrender are imperative for those moving toward successful recovery. Without either, internal unmanageability and the inability to “let go” will continue to be roadblocks in the process of recovery. Step One emphasizes the essential need for surrender. Individuals must surrender in order to move through the remaining steps.

CeDAR has found that providing DBT skills groups complements other aspects of the program. Staff continuously witnesses the benefits of integrating DBT skills into 12-Step programming. By putting these ideas into practice, the foundation of recovery is reinforced and patients begin moving toward a life worth living.

The authors will present this material at the West Coast Symposium on Addictive Disorders (WCSAD) in June 2010. The Symposium offers the opportunity to share innovative clinical practice with other addiction professionals.

References

Alcoholics Anonymous World Services, Inc. Alcoholics Anonymous, Fourth Edition. New York City: Alcoholics Anonymous World Services; 2001.
Galanter M. Spirituality and recovery in 12-Step programs: an empirical model. J Subst Abuse Treat 2007;33:265-72.

Kabat-Zinn J. Arriving at Your Own Door: 108 Lessons in Mindfulness. New York City: Hyperion Books; 2007.

Kienast T, Foerster J. Psychotherapy of personality disorders and concomitant substance dependence. Curr Opin Psychiatry 2008 Nov;21:619-24.

Linehan MM. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York City: The Guilford Press; 1993.

Linehan MM, Schmidt H, Dimeff LA, et al. Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. Am J Addict 1999 Fall;8:279-92.

Narcotics Anonymous World Services, Inc. The Narcotics Anonymous Step Working Guides. Van Nuys, Calif.: Narcotics Anonymous World Services; 1998.

Narcotics Anonymous World Services, Inc. Narcotics Anonymous, Sixth Edition. Van Nuys, Calif.: Narcotics Anonymous World Services; 2008

Piderman KM, Schneekloth TD, Pankratz VS, et al. Spirituality in alcoholics during treatment. Am J Addict 2007 May-Jun;16:232-7.

For the purpose of continuing education, the course objectives of this article are:

• Discus how Dialectical Behavior Therapy is successfully used in addiction treatment.
• Describe the similarities between the “DBT Targets” and 12-Step philosophy
• Review how 12-Step philosophy has been integrated with DBT Skills Groups and identify DBT Skills within the 12-Step literature

We live in a time when the need for addiction treatment has never been greater and in an era where technology has the potential to improve the human condition as never before. Unfortunately, this potential is not being fully used in the treatment of addiction and concurrent disorders, where providers are continually pressured to do more with less, as finances or insurance limitations dictate treatment. At the same time, funding agencies are looking for quantified results of program effectiveness, and treatment programs are looking for ways to gather that information.

This fact points to a strong need for a Web-based system that combines effective, consistent, research-based and easy-to-use educational content; self-application e-workbook exercises; and self-awareness tools to deliver a powerful treatment and recovery experience. To be effective, a Web-based system needs to provide interactive educational and clinical tools that support and enhance all stages and modalities of treatment.

However, it is important to remember that a Web-based system is not treatment in and of itself, but can enhance and facilitate addiction and mental health treatment through its educational and self-awareness tools. A system that can quantify the client’s program and personal progress through a series of quizzes, assessments, exercises and self-awareness inventories will provide clinical teams with valuable information to support their clients and treatment centers with the necessary statistical data to satisfy their funding sources.

Addiction and mental health recovery is a lifelong process that needs to provide a continuum of care. A Web-based delivery system could be used to extend the educational window to include the time period before traditional treatment, during treatment and after treatment to create this long-term, continuing care. So, potentially, care could start even before the client arrives for primary treatment and extend years beyond their initial treatment experience.

In this system, treatment becomes the core therapeutic recovery process in the continuum-of-care model by pushing some content and clinical tools into pre- and post-treatment. By doing this, providers can gather data about their clients that can be used to enhance and personalize the treatment process, which then becomes less educational and more therapeutic — truly client-centered. Treatment is no longer a time-limited process but evolves over time to meet an individual client’s needs.

At the beginning of treatment, counselors often have to put most of their time, effort and focus on the educational process. Implementing a Web-based system that delivers consistent educational content would allow counselors to focus more on the therapeutic process. This new technology also enables treatment programs to monitor individual clients to ensure everyone receives the crucial educational material necessary for a successful treatment outcome.

When a client leaves primary treatment, he or she often lacks evidence-based relapse prevention education and self-awareness tools to continue their recovery process and avoid relapse; nor are they adequately equipped to transition from the safety of the abstinence-based setting to the real world. A Web-based system can facilitate this process by helping clients with their ongoing recovery needs. Continuing care or post-treatment is very similar to treatment in a continuum-of-care model. The main difference is the level of involvement by the treatment center and the level of responsibility expected from the client.

A Web-based delivery system can empower a client, with the guidance of his or her support team, to create an ongoing recovery plan. This system gives clients complete charge of, and responsibility for, their recovery process. Clients who have worked through their denial and successfully completed treatment are then given the opportunity to follow through on their own with education and self-awareness tools that deliver an ongoing recovery experience. The value of a Web-based delivery system is in its ability to assist the treatment process by offering effective, consistent, science-based, easy-to-use educational content, as well as its ability to assess and quantify a patient’s progress.

Keeping a client motivated to recover is a major challenge that treatment providers face. The ease of access, the recovery team and community concept, as well as the philosophy that the client has not left treatment — just moved on to a different phase of treatment — can support clients to stay motivated. Only time will demonstrate how effective such a Web-based delivery system will be, but for now it is possible that many of the difficulties the addiction treatment field faces in delivering effective, evidence-based, affordable care can be addressed.

Terence T. Gorski and Dr. Stephen F. Grinstead have partnered with Wayne Blampied and Cognit™ to provide Web-based education and clinical tools. Their program, Gorski E-Care™ will continue the legacy of Terence T. Gorski and allow him to achieve his personal mission that “By the year 2010, all people will have access to affordable resources for developing effective recovery and relapse prevention plans for addiction and coexisting mental and personality disorders.”

Many of Freud’s disciples departed in different ways from Freud. Most moved away from certain aspect of Freudian theories, while elaborating on other aspects. Jung, for example, elaborated on the theory of unconscious and extended it to the concept of universal unconscious. However, almost all of his disciples minimized the significance of his Libido Theory and gradually moved away from it to the extent that nowadays in psychoanalytic schools there is very little talk, if any, about Libido Theory. One can say that Freud’s Libido theory is almost abandoned. Reich, however, took a different approach. Reich considered Freud’s Libido theory the most basic theory, that other theories, such as topographic theory-the theory of conscious and unconscious-and structural theory-the theory of Id, Ego, and Super Ego-are based on it and are consequence and secondary to it.

Reich’s definition and distinction of health or sickness of the human organism is based on the proper movement of energy in his organism, the energy that Freud called “Libido Energy” and Reich named “Orgone Energy.”

In order to explain certain phenomena that he was observing in children and in his patients, Freud had to hypothesize an existence of a psycho-sexual energy that flows in the body and gets concentrated in certain areas. The concentrated areas of this energy, Libido Energy, were considered to be Erogenous zones, such as mouth, anus and genitals. The investment of this energy on different areas is in relation to the developmental stage of the child. In the newborn this energy is mostly concentrated around the oral area, later between the ages of one and two, the investment of Libido Energy is mostly in the anal area and the sphincters and around age 3, Libido energy moves into the genital area. Freud hypothesized that this energy energizes instincts. Emotions get its power from instincts. As Freud’s disciples gradually moved away from this theory and elaborated endlessly on other aspects of his theories, such as the theory of conscious and unconscious and the theory of Id, Ego, Super Ego, Freud himself also moved away from his own Libido theory.

Reich contended that Libido theory, the theory of psychosexual energy, is the basic and central theory and understanding of the functioning of human organism depends on this theory.

Reich called this energy “Orgone Energy” because of its Function in the body organs and its pertinence in the function of the orgasm. Reich realized that the proper metabolism of this energy, production and discharge of this energy, the proper economy of this psychosexual energy is an essential factor in human health. Any hindrance in the flow of this energy from center toward periphery, from head toward pelvis, disturbs the physical and emotional functioning of the organism and causes psychiatric as well as physical illnesses. Freud himself described stasis neurosis, the neurosis which manifests itself by palpitation, hyperventilation and anxiety, the result of abstinence; an unhealthy sexual life, which causes accumulation and stagnation of Libidinal energy.  Based on Reichian theory hindrance to the flow of this energy mostly is caused by physical and muscular contractions as well as by psychological means, which happens concomitantly.

Children control their emotions, their sexual and aggressive impulses or their sadness in different ways, including psychological repression and physical contractions. The children usually breathe shallowly; develop contractions of the throat muscles to hide their sadness or anger. They contract their abdominal muscles and they develop stomach and abdominal pains and aches. These somatic features gradually become chronic and do not go away by the patient’s will, even when the external factors that had caused these contractions disappear. These physical and muscular contractions, which after a while become permanent in the Reichian school of thought, are called “muscular and physical armor.” These physical contractions have psychological counter parts. They have a counter part in character armoring. The child, and later the grown up adult’s character structure is a reflection of their muscular and physical contractions and visa-versa. They are inseparable from each other; they are two sides of the same coin. Tense and serious attitudes, or over-friendly smiles, or indifferent and apathetic attitude and so on are all part of the person’s character, which has physical and muscular counterpart. Character armor and physical armor are functionally identical with each other and serve the same purpose. They both prevent expression of emotions from within and protect the person from without. Armoring of the human organism becomes the most important factor that distorts and impedes the flow of biological sexual and physical energy of the body, the organismic orgone energy or as Freud called it “Libidinal Energy.”

This distortion of the flow of energy then causes different pathologies and symptoms. It causes wide range of different physical illnesses, as well as psychiatric and psychological illnesses including compulsive disorders. Those who work in the field of psychiatry, and those who see patients in psychiatric hospitals or clinics are aware of the stubbornness of psychiatric symptoms. They know how psychiatric patients become a revolving door in hospitals and in clinics and how their symptoms persist in spite of conventional treatment and in occasions, they become loaded with different psychiatric medication so much that the side effects of the medications make them worse than the illness itself. This is also true for compulsive disorders. From the Reichian point of view the reason for this difficulty is the fact that psychiatry and psychology have failed to recognize the roots of the symptoms that partially is anchored in the body, the physical armoring.

In the treatment of patients by Psychiatric Orgone therapy, the goal is to restore the healthy and orderly flow of energy in the human organism. The most important factor in achieving this goal is the resolution of muscular and character armor. The psychiatric orgone therapists have to recognize the armoring of the patient and try to resolve it with different techniques that are available in this treatment approach. The character armoring as well as physical armoring responds to some extent to different psychotherapeutic measures. This is why patients show some improvement by psychotherapeutic approaches, however, the improvement in many cases is only partial and in some cases no improvement happens and the illness continues to progress and destroys the person’s life. In psychiatric orgone therapy, the recognition of the somatic and physical roots of the illness and the resolution of the physical armoring brings quicker and more profound and pronounced improvement, symptoms disappear quickly and fundamentally.

Unfortunately, Wilhelm Reich who is the founder of this treatment approach, and the body of knowledge that he left behind, which is called Orgonomy, has been largely unknown to psychiatric disciplines, residency training programs, psychology training programs, and social workers training programs. Nevertheless this body of knowledge offers a theory based on which many psychiatric and physical symptoms can be explained, which is inexplicable with present theories and it also offers techniques that is able to penetrate deeper and cure the illnesses which is not been attainable by other approaches.

Today, I feel that I am providing treatment to the grand children and great grandchildren of these early patients.  Addictive disease is like a bomb going off in a room; everyone is hit with flying fragments of the addiction bomb.  With each generation that passes, the trauma increases but unfortunately, trauma and the impact on the brain often does not become a part of treatment.  Our population in treatment today very frequently have dual disorders; personality disorders, major problems with anxiety, depression, stress and anger, process addictions such as eating or restricting, gambling, shopping, internet and pornography, and most of all post traumatic stress disorder.

We have understood for many years that addiction runs in families and that the genetic sensitivity sets family members up to have this disease themselves much in the same manner as other chronic disorders and/or diseases in a family.  What we have not looked at enough until lately, are those family members who are not born with this genetic sensitivity but still develops the disease of addiction.  I am suggesting that an additional reason that this disease runs in families is the stress and trauma that children experience growing up in a family with addiction.  Even the adult children of alcoholic/addicts, who do not have addiction, may have developed patterns of emotional behavior that can negatively impact their children, and set up the brain for drug addiction.   Trauma, which causes a stress reaction, is often created when one or both parents (or primary caregivers) have addiction, mental health issues and/or rage issues.  The children of this stress or trauma often do not know they have been impacted and tend to believe they will be “OK” if they leave and create their own families.  Trauma has been shown to change the structure and chemistry of the brain.  These children then pass on to their children both the trauma and the fragmented intimacy issues they developed as children.

Expressions of trauma include;  emotional detachment including dissociation or “numbing out”, dissociation leading to a person seeming emotionally “flat”, preoccupied, distant, or cold, super controlling, hyper vigilance and anxiety and sleep problems.  The brain uses epinephrine to execute autonomic and neuro-endocrine responses serving as a global alarm system.  The autonomic nervous system provides the rapid response to stress known as the flight-fight-freeze response.  The interactions between the mental state, nervous and immune systems can impair developmental growth in children, which later can alter their perceptions of, and reactions to stress.

Anxiety is the response of the organism to a threat, real or imagined.  Objective manifestations include increased responsiveness, restlessness, and autonomic nervous system changes such as increased heart rate and blood pressure.  There are important differences between acute anxiety and chronic anxiety.  Chronic anxiety often strains or exceeds an individual’s ability to adapt to it.  Chronic anxiety is fed by a fear of what might be.

All human beings have a primal drive towards pleasure and away from pain.  With a brain that is anxious, depressed, always in “alert” mode for some un-named danger, the initial effects of a drug, alcohol, marijuana, opiates or cocaine, give the user an initial euphoria not previously experienced.  This experience is recorded in the limbic system as a “good thing”.  Away from pain, towards pleasure.  Memory of past trauma or traumas is quieted, hyper-arousal is, for the moment, quieted, and fear recedes.  The most natural thing would be to repeat the experience of drug taking to re-experience the relief of stress symptoms

Now, with one alcoholic with four children, we may have 2 of the children with addiction; perhaps one genetically sensitive and one whose brain changes are the result of the stress of living with the uncertainty and fear of an alcoholic parent.

Only a small percentage of people with addiction receive treatment.  When they do go to treatment, they receive on average 28 days of treatment and then return to the same environments from which they came. We now know that not much changes in the brain in 28 days, that we need 90 days to be of real help.  In the last 5-7 years, there has been an explosion of information regarding addictive disease as a Brain Disease!  However, even in the face of new information, most of us are using the model of emotional/behavioral approaches to treatment.   I am not saying this is wrong but I am saying that before applying emotional behavioral solutions, we need to TREAT THE BRAIN-FIRST.

We have for many years asked people to sit and listen to lectures and sit in process groups while they work on written assignments.  There is nothing wrong with this approach but we need to first help the brain and body to heal for this approach to be effective.

People with anxiety have developed a changed manner of breathing in a shallow way.  They are continuously breathing in a manner that deprives the brain of necessary oxygen.  In addition, they often use food for comfort with extremely high levels of sugar, which increases blood pressure, causes the body to work twice as hard and can have a harmful effect on the brain.  Their diets often don’t contain necessary nutrients and they often take very few, if any, supplements for brain building.  It is almost impossible for a person to learn and apply what they have learned with a brain that is anxious about the loss of the chemicals it has learned to rely on, while simultaneously experiencing the pain of withdrawal and post acute withdrawal.

The Three Legged Stool for Brain building

In addition to traditional treatment these are the activities that help the brain begin to heal in a significant manner.

First, clients need to detox from not only the addictive chemicals that brought them to treatment but also from sugar and caffeine.  The diet needs to be only extremely low on the glycemic index, but fresh food instead of frozen or canned.  Items such as potatoes, white breads and flour, sweets of any kind, should be removed from the daily diet.  All items with caffeine should be removed.

Second, the use of an exercise designed to help clients learn to breathe from the belly and practice some form of aerobic breath needs to be a part of a daily regimen.  At Malibu Beach Recovery Center, we use yoga and a very special style of yoga breath three times daily in addition to traditional treatment methods.  Whatever a facility designs around teaching breathing, it is central to helping to heal the brain.  Because this is a dramatic change for the body, resistance to this exercise should be expected.  The body will fight what it is not used to.  It is possible to achieve an aerobic workout through breath work alone which means that even people with physical challenges can participate.  Closing the day, the use of meditation is extremely helpful.

Third, we can all become more knowledgeable in the use of amino acids and natural supplements that provide amazing help for the brain to heal itself from the assault of stress and chemicals used over many years.  There are so many good authors of help in this area.  I recommend starting with books by Julia Ross, “The Mood Cure” and Dr. Hyla Cass,  “8 Weeks To Vibrant Health” and, “Natural High” but there are many good books on this subject.  Supplements are something a physician, working with clients in treatment will want to be in charge of as they should be used with careful diagnosis and monitored in the early stage of treatment.

I have been calling this unique approach of supplements, yoga and yoga breath and low glycemic diet, “A SPA FOR THE BRAIN”.   In my thirty plus years of working in the field of addiction, I have never seen such vibrant health as is produced by this “three legged stool”.

Obviously the number of people seeking recovery has declined dramatically. It’s just a fact that people aren’t about to drop $15,000 or more — much more in some cases — to get sober in a bad economy. There are simply fewer people seeking recovery to go around.

So, what can be done to get through this tough time? Belt tightening? Okay, that’s a start. By now you’ve probably already tightened until you’re squeezed purple. What about lowering your price? Or adding more value? Or both? The instinct of most businesses is to cut marketing dollars in hard times – which is basically suicide. While you may save a few dollars right away and feel some easing of the pressure on your budget, it virtually guarantees that your revenue is going to decline later on. There is, in most businesses, a ratio of dollars spent to sales – it’s a metric by which businesses evaluate their marketing dollars and how well they’re being spent. This is even more critical in a business like ours. Many businesses have repeat customers, who come back time and time again – they only need to capture people once for a lifetime of revenue. While that may be the case with some clients in recovery, it certainly isn’t the goal. We need to find fresh bodies all the time. So, marketing dollars are even more important as you try and get out to more potential clients. This is when marketing plays a vital role — every aspect of it.

The two critical issues are these:

One: are the people who are ready for recovery seeing you as an option?

And, two: are they choosing you?

If they’re not even aware you’re there, that’s a problem. If they’re aware you’re there but not choosing you that’s another problem with a different answer.

We are here! We are here!

Getting the attention of the people who need you is the single most important job there is. But what are the efforts you can do to increase awareness of your facility.

Well, one is networking – which is why you’ve become a member of Recovery View. This is an excellent example of networking within an industry.

Another way to network is with the trade associations you belong to, or should belong to, and with organizations that work directly with consumers regarding addiction. Marketing to physicians is another way, as well as to hospitals where many people with addictions end up through overdose or some form of accident, or attempted suicide, etc.

You could advertise, but you need to plan where and how. There are specialty magazines, or trade magazines, to consider such as Treatment Magazine. Treatment Magazine is distributed to a large number of addiction physicians and psychologists, making it a great potential referring source. When you look at advertising possibilities, really look at who will see them, who the subscribers are.

The internet is a great possibility as well. If you blog and blog often you’ll come up in searches more often. What can you blog about? Anything! Changes you’re making, the state of treatment in the country, philosophy, the economy, the fact that you’ve started a garden, your new chef, and particularly anything that gives a useful tip or information to a consumer or someone who can also help you in return.

You can also pay to advertise on the internet, but that can get expensive, unless you barter for space on your web site, or for services, etc. The internet is like life in some ways, the more active you are on there the more you get noticed. There are experts you can hire to help you with this.  A good SEO (search engine optimization) person can help get people to your website who are looking for your help. Also, take a good look at your website. Once people get there, is it convincing them to come? There’s an old adage in advertising that goes “telling isn’t selling.” Most websites merely inform rather than sell. They inform, but they don’t inspire further action like a phone call. Telling, in fact, isn’t selling, these are different languages.

If you have anything you can do that’s newsworthy, do it and get press for it. Hold an event, have a fund raiser for a charity, give a special gift to your community — and invite the press. You have to do something to get noticed, so get active.

There are a lot of ways to get out there. Really look at who your clients have been, where they have come from, where you might find others. Do you have a specialty that could appeal to a specific group of people? For example, if 90% of the people you’ve treated are steel workers, then that’s a specialty. If they’re Hungarian, that’s another specialty and you might want to address it in terms of language and your menu.  Use whatever you can to set yourself apart or appeal to a specific group. It’s easier if you have a specific target to hit rather than trying to go out to the general public at large.

If not us, who? If not now, when?

Now that you’ve gotten someone’s attention the real selling begins. Here the questions become more about what you’re selling, what the benefits are and how much it costs? In every instance it eventually comes down to a price verses value story.

When I started in advertising 30 years ago the first thing we learned was find your USP – your Unique Selling Proposition.  This is the same as a point of difference, or a competitive edge, whatever you want to call it. For some it’s the fact that they have horses, or equine therapy, for others it’s the lowest price point.

The places usually hit hardest in a bad economy are those just under the really expensive places. The really expensive places cater to a crowd that, often times, doesn’t feel an economic slowdown. But the so called upper middle class feels it and the middle class and so on down. In every other instance the price tag tends to get scrutinized a little harder in a bad economy — especially for some of the more luxurious places. When you have a very successful model like The Betty Ford Center that has had a host of celebs go through its doors yet shuns all the trappings of luxury it gets easier for people to tell themselves that the luxury stuff has nothing to do with getting sober. Of course, there will always be people who want the luxury, but there will be less of them in a bad economy.

Should you lower your price? Maybe. If you do, try to do it in a way that is either not obvious or is really obvious. In other words, you can lower your price by creating “specials” for a limited time. This can also help in terms of “converting sales” – in other words convincing people that now is the time to take advantage of your special offer. Or, you could make it an across the board price change and tie it to something specific, for example the economy, making an announcement like, “Starting today, we are discounting our price by the same percentage the national unemployment is at.” Which is to say, if the unemployment rate is 11%, you’ll be giving an 11% discount. If it goes up or down your discount will follow accordingly. You could further say that you’re also giving an additional percentage of income to food banks across the country. Get a cause going – it’s newsworthy. And people feel good about you.

Maybe you need a partner.

One thing you should always look for, but never more than in a bad economy, is relationships that can be mutually beneficial — even better if there’s an additional benefit for your clients.

I’ll give you the best example I know – Clarity Enterprises, Inc. Some thought we were crazy to launch in this economic climate. But, as a matter of fact, it’s probably the best time ever for us. Because, as a provider of neurofeedback services to recovery centers, we give you, the addiction treatment facility, a great point of difference.

Certainly, in this business, the biggest point of difference you can have is success. It somehow seems to be an intangible item in recovery scenarios, but certainly anyone spending any sum of money to stay in a residential center today is looking for the chances of success. What if you could have a success rate of 80% or better? That would be a huge point of difference. Especially if it were a claim you could validate.  There is one way to do that immediately. It’s with neurofeedback. Prolonged substance abuse and addiction result in brain damage. Neurofeedback training restores the brain functioning, reduces cravings, and helps the recovering addict control impulses and deal with the cravings that result in relapse.

Neurofeedback has been tested and proven time and again in all kinds of university conducted research.

Three studies of interest are:

Peniston, 1989 – a study done in conjunction with the Veterans Administration in Colorado. All subjects were Viet Nam veterans who had other forms of treatment unsuccessfully prior to the study. They were severe alcoholics who also suffered from post traumatic stress disorder (PTSD).

The outcome was that 80% of the subjects stayed sober and had no further issues with PTSD as of a follow-up study done three years after the treatments.

Diné (Navajos) – A study done with 19 alcoholic Native Americans in 1994. The treatments were culturally appropriate. Again the three-year follow-up showed that 80% of the subjects stayed sober.

Cri-Help – Cri-Help is a recovery center in North Hollywood, California. The study included 121 subjects (60 in the control group, 61 in the experimental group, or those that received the actual neurofeedback treatments). A three-year follow-up concluded that 77% of the experimental group remained sober (those that received the neurofeedback treatments) versus only 44% of the control group (those that did not receive the neurofeedback treatments).

The Cri-Help study also documented that the neurofeedback treatments significantly improved anxiety, depression, stress, sleep and other disorders, and the experimental group stayed in treatment 50% longer than the control group.

What we do makes what you do work better, faster and longer.

As stated, neurofeedback deals with cravings and relapse. It counters impulsivity. But, just as importantly, it makes the brain far more receptive to the treatments and therapies you’re already employing. So, the therapies and treatments you’re now using have far greater affect. Your success goes up. You have more successful clients who make recommendations to others on your behalf. And we can document your success rate because with our program your clients continue the neurofeedback sessions for a full year, even after they’ve left the residential facility. By the way, this also means you have a continuing revenue stream from each client after they’ve left your facility. Which leads to the next point…

Find or create other revenue streams.

Like the neurofeedback aftercare program I just mentioned. Or, we could also create an outpatient program for your facility. Or a highly specialized “executive” level program for people who are more on the go, or have too many obligations and can’t stay 30 days in a treatment facility. If you have more options available you have more chances of hearing a “yes” when speaking to a potential client.

Again, look for strategic partners that can gain a mutual benefit from working with you.

Staying ahead of the game.

Because the good times were so good for so long people naturally just let the business develop itself. These days you need to be informed of what’s happening in the industry, what’s happening in the country, how you can stay ahead of the competition. You should be looking not only at marketing for treatment facilities, but at marketing in general – you could find a great concept that could cross over to your situation. Subscribe to Marketing Week, for example, look at what types of promotions other industries are doing and what kind of press events people are doing. I once worked on a fabric maker’s business – their key accounts were lingerie manufacturers. They really couldn’t afford advertising, they didn’t have the budget. But they did have enough money and resources to make a huge bra that we put on the John Hancock Tower — which generated millions of dollars worth of press. So, get creative about getting out there. But, obviously, be appropriate to the business you’re in. We do good in this business. If you can combine it with other ways to do more good, you’ll most ocertainly have a winner.

And, by all means, check out neurofeedback. After all, I wrote this to promote what we do at Clarity. It’s part of our marketing strategy. See how that works?

For me personally, Reports and Record Keeping has been perhaps the least enjoyable core function to perform. Like most of you, I am a front line counselor and I create reports, write progress notes, correspond with third parties, and read others’ reports. All of this is for client care and program accountability. I’ve been in this field for 35+ years. After being trained by the Air Force as a Drug and Alcohol Abuse Control Officer (a fancy name for a substance abuse counselor), I was stationed at MacDill AFB in Tampa Florida. I recall that we kept client records in a six-section folder. What went into each section was detailed in our Manual of Standard Operating Procedures. Each page was two-hole punched and we. We recorded client information on forms while writing progress notes by hand. Sound familiar? In the a field, most of us still do this. At my agency, Parallels in Lincoln, NE, we’ve improved and now keep our records in a three-ring binder and frequently use word processing assistance to type and print information. Now, the process of Reports and Record Keeping is changing.

President Omaha has stated  “Computerize all health records within five years. The quality of health care for all Americans gets a big boost, and costs decline.” The age of electronic record keeping is upon us. Medical facilities are ahead of substance abuse and mental health facilities with implementing digital processes, but MyCaseRecords Case Management System by Eccentex brings us into this future now.

In November of 2008, I was named Vice-President of the Behavioral Health Division of Eccentex Corporation in Culver City, CA (www.eccentex.com). I offered my agency, Parallels, as a beta site for the development of an electronic case management system called MyCaseRecords. Eccentex recently launched MyCaseRecords (www.mycaserecords.com) and with this the launch, the field of substance abuse counselors comes into the 21st century. This article will describe how electronic record keeping can help substance abuse counselors and facilities to streamline the tasks involved in the core function of Reports and Record Keeping.

What is MyCaseRecords?

“MyCaseRecords Case Management System was especially designed for behavioral health agencies and professionals. It is a full featured, End-to-End Case Management Solution that is affordable and user-friendly use right out of the box. Manage services, cases, paperwork, staff, healthcare providers, claims, billing, plans, authorizations, schedules, and much more in one easy-to-use solution.

MyCaseRecords was designed by behavioral health professionals to address the case management needs of substance abuse treatment services programs”

The power of MyCaseRecords lies in its platform designed by software engineers and behavioral health experts. The system is evolving each week to improve task completion for front-line counselors and the professionals responsible for clinical care and agency operations.

As a counselor, I want a system that saves me time, eliminates redundant data entry, and makes my task of writing reports and keeping records easier.
As a clinical director, I want a system that easily allows me access any client chart anytime, anywhere. I need to ensure that my staff is doing the paperwork in a timely, efficient and effective manner.
As a facility owner, I want a system that provides me reports on my programs; tracks important client variables; improves the processes for program audits, and saves me money.
As a researcher, I see many applications of MyCaseRecords conducting on-going research on variables of interest. MyCaseRecords does all of that.

The paragraphs that follow will explain how an integrated electronic case management system makes all the other eleven core functions easier and relieves some counselor stress of performance in the core function of Reports and Record Keeping.

Screening: Most screening is done on the telephone and the person doing the screening gathers pertinent information about the client. MyCaseRecords gathers this information by having the counselor type demographic information such as the name, address and phone number into an electronic database. One can use the Screening form provided in MyCaseRecords or design one’s own. The pending client can then be scheduled for the next step, Intake, with a specific counselor using the Schedule function.

Intake: At the intake session a person becomes a client. The information already recorded in MyCaseRecords from Screening is available to auto-populate the many forms a facility requires a client to complete in this core function. No more redundant writing of information!  Your agency may still have forms that require a client to handwrite information; however, the goal is to minimize this. The Case Management System has the capability to scan forms such as the signed HIPAA forms and authorizations to obtain or release information into the electronic records and associate the scanned form with the client for easy retrieval when necessary. Documentation of the Intake is often accomplished by a counselor writing a progress note. With MyCaseRecords the Progress Note is documented in an electronic form auto-populated with the pertinent client information.

Orientation: If the core function of Orientation is performed at the same time as the Intake, this can be documented on the same Progress Note as the Intake. If performed at another time, simply document again using the Progress Note in MyCaseRecords. The signed Client’s Rights and Responsibilities form can also be scanned into the client’s electronic record.

Assessment: In my role as Vice-President for Behavioral Health at Eccentex I’ve been involved for the past year in developing a new assessment form. I’ve been honored by having the form named after me – the Herdman Assessment Form or HAF. I’ve used the Addiction Severity Index, the ASI, for many years and have found it necessary to supplement the questions of the ASI with additional questions. I’ve incorporated the information gathered by the ASI and enhanced the process of gathering bio-psycho-social data. I’ve written logic for each possible client answer on the HAF and developed a reader-friendly narrative report. My goal was to not have the narrative sound like it was computer generated, but to have a flow and feel of an individualized report. Although the narrative reports client bio-psycho-social history, the HAF allows the counselor to add additional detail as appropriate for a specific client through an easy word processing function within the HAF. Also, it remains the counselor’s professional responsibility to diagnose, summarize, determine an appropriate level of care (LOC) for the client, and to provide individualized recommendations consistent with all of the data collected in the core function of assessment. The HAF assists in doing a substance abuse assessment; it is not a diagnostic form.

Unique to the HAF is the addition of Supplemental forms or instruments to streamline and enhance the assessment and the report. As an option, if the client took a SASSI-3, the client’s raw scores can be recorded and the HAF automatically calculates the percentile and T-Score. Then the narrative is written identifying any significant or very significant scores on the scales of the SASSI-3.

Some agencies use the University of Rhode Island Change Assessment (URICA) to assess a client’s readiness to change. You have the option of having the client take the URICA on the HAF during your session or have the client complete a traditional paper version and then type the responses into the HAF. The HAF then uses the calculation table available for scoring the URICA and the narrative reports the client’s readiness for change stage.

Many states and insurance companies require the use of the ASAM Patient Placement Criteria (ASAM: PPC-2R) to assist in determining level of care. The HAF provides a Table for the counselor to rate the client in the six dimensions of the ASAM on a 0-4 scale. The counselor remains responsible for rating the client, based upon all the data collected on the client, i.e., from the client interview, collateral information, and assessment tools and finally recommending an appropriate level of care.

The HAF has a Diagnostic Impressions section. The counselor still must make the appropriate diagnosis; however, the HAF with it’s processing power makes it easy to record DSM-IV TR diagnoses without having to memorize codes or spell the full diagnosis.

The HAF has a section called Summary and another called Recommendations. No computer program can write those sections, so a counselor must still write this.

Once the HAF and its optional sections are completed, the counselor clicks the “Generate Narrative” button and the report is ready for proofing and adding any additional comments by the counselor. The HAF saves time and provides a professional and individualized report.

Treatment Planning: Currently, MyCaseRecords has a Treatment Plan Form that allows the counselor to do the client treatment plan. I’ve been asked to incorporate some information from the HAF assessment into the Treatment plan and I am in the process of doing just that.

Counseling: A frequent core function for a counselor is Counseling. Every client counseling session needs to have a progress note completed. Most often progress notes used are for individual and group sessions, but family and other sessions also need to be documented. Using the Scheduling function, once a client is scheduled for an individual or a group session, a “Pending” Activity Form is automatically generated for completion. As an agency owner and Clinical Director, I know how easy it is for a counselor to “forget” to complete required paperwork. I’ve never had a counselor leave my agency without finding out later that a discharge summary or other document was missed. Counselors are human beings and I’m amazed at how much paperwork front-line counselors need to complete. MyCaseRecords makes it easier to document and to avoid missed paperwork that could relate to not getting paid or getting “dinged” during an audit.

Case Management: MyCaseRecords makes it easy to add a note to document the many case management activities for a client. On your home page in the application there is a Dashboard that lists all active clients for a counselor. To the left of the client name is an option to “Add Note”. This is where a telephone call or other case management documentation is recorded. The note then becomes part of the client history available for electronic recall at any time.

Crisis Intervention: It is imperative to document all client crises. Again, use a Progress Note to document the elements of the crisis, steps taken to resolve the crisis and any recommendation plan to change the treatment plan or to take further action.

Client Education: Documenting this core function can be accomplished in a number of ways. The educational topic can be recorded in an individual Progress Note, on a Group Note, or on a Note. Each agency can set procedures for this for all the counselors.

Referral: A counselor can also document the core function of Referral in a number of ways. A letter can be written and scanned into MyCaseRecords; a Progress Note can be prepared; or a Note can be used.

Reports and Record Keeping: The Case Management System allows the counselor to efficiently and effectively complete reports, document client progress and electronically file the reports of others – all organized within a client case for easy access and use.

Consultation: This core function can be recorded on a Note form. At Parallels, I’ve developed an Initial, Intermediate and Discharge staffing form to use with MyCaseRecords. My counselors use these forms to document staffing and consultations for individual clients.

The future of electronic record keeping is now. Medical facilities are ahead of substance abuse and mental health facilities, but MyCaseRecords brings us into this future. I know that the software engineers at Eccentex are dedicated to providing the leading software for substance abuse and mental health counselors and facilities. The platform (AppBase) allows easy changes thus facilitating keeping pace for continuous quality improvement. Eccentex is working on a billing module to complete HICFA forms, individual and third-party billing compatible with accounting programs to avoid double entry, thus saving time and money. I am working on improving the Treatment Planning form and integrating that with the Assessment and with documenting individual and group progress notes. We will continue to enhance the HAF thus giving counselors and agencies additional options to include in client assessment.