August 10,2019

I try to write on themes that will have “legs,” that will, after a few years, still be relevant to the practice of clinical supervision, will age well.  I risk abandoning that standard for today’s blog, but can hazard a guess that some of my thoughts will have a bearing on clinical supervision a few years hence.

One thought is that the last state level project, permitted by the federal Centers for Medicaid and Medicare (CMS) as a “1915(b)(c) waiver,” and entitled  “Mental Health Reform” (implemented on or around October 2001) was marked by many problems including the following:

There were significant criticisms of state’s shift to privatization, including:

• Many highly trained mental health care workers – especially psychiatrists and C-suite managers -left the field as private providers took control of service delivery, reducing the professional public sector workforce.
• The fragmented system created through privatization had a tremendous negative impact on the quality of services provided to clients. Many times, important mental health services were no longer even available to clients.
• Private providers engaged in “cherry picking,” offering only the most profitable services, such as “community support” services. These services include basic assistance and mentoring, and such tasks as running errands for a client or helping with a child’s homework. They could be performed by low-paid, unlicensed personnel. Many providers focused on these highly profitable community support services and left seriously ill clients without the more costly care they needed.
• Initial reports of cost overruns estimated that the state wasted at least $400 million in community support services offered by private providers that were unnecessary for the client or not even performed. As a result of the treatment offered by the private providers, the number of North Carolinians with mental illness who ended up in emergency rooms or jails significantly increased.

I would balance this by noting the following:

• Many individuals who, under the previous system, would probably not enter the field, did enter the field.
• This included people of color as both owners of agencies and as licensed and certified line staff.
• The expansion of the schools of social work in North Carolina from a few to more than a dozen; and the expansion of substance abuse certification programs at the masters degree level.  How closely tied this is to the opportunity vs. the need is not clear, but since several of those new masters degree level social work programs are at Historically Black institutions and another is situated at Pembroke, a locus for the Lumbee Tribe, one can infer that there is a correlation if not causation.
• And, as a first tentative step towards addressing “Social Determinants of Health:”
• Modes of treatment such as Assertive Community Treatment began to flourish.
• Community Support changed into a professional service with both therapy and case management.

As far as clinical supervision, the result has been a mixed bag:

Some of the then prevalent, at times inappropriate psychodynamic passivity and 12 Step oriented passivity on part of clinicians began to wane, and more active and at times appropriate models emerged.  And please understand, I support those two models and regret that there now seems to be a lack of both in situations where those formulations and interventions would be appropriate (if applied by trained clinicians); but I am pleased that other tools are in our toolbox.

Those would be, on the short list (in alphabetical order): Cognitive Behavioral models for various specific disorders; Dialectical Behavior Therapy; EMDR; Motivational Interviewing; and Solution Focused therapy.

I’d like to remind and encourage those of you who live within driving distance of the Triangle that there are numerous opportunities to get advanced training:

• NC Society of Clinical Hypnosis & Wellness Consultants International
• UNC Satir Program (Virginia Satir Model Family Therapy)
• North Carolina Group Psychotherapy Association
• Psychoanalytic Center of the Carolinas
• Southeast Institute for Group and Family Therapy

I mention these post-masters level associations, programs and institutes for many reasons, but I will leave you with this thought:

Advanced training makes it easier and more enjoyable to do the work of therapy, whether you are working in the public sector (and its oncoming transformation) or the private sector; and if you want to work in the private sector, advanced training (specialization) is a key to referrals.

 

 

 

May 30,2019

Setting the stage for the assessment (in the patient’s home setting).

When you call to set up the appointment, you can “prep” the client.

Let them know that “I’ll have my ‘lab coat’ on; it’ll be like the doctor making a home visit, asking you very detailed and personal questions.”  “What kind of questions?  Anything from your birth to yesterday, from your best day at school to your worst day ever.  About money, friends, sex, success and sadness.”

• Tell them to have ALL medications on hand.
• A list of current and past doctors, psychiatrists, agencies, therapists with reasons for treatment at the time, dates, results, problems related to the treatment (side effects for medications, bad “fit” for therapy, treatment ended b/c it was ‘successful.’}
• A list they make up of their strengths and assets.
• They should begin to think about and write some notes about “how it all started.”
• And to be prepared for you to “pack in a lot of questions in the time we have scheduled.”

Ask that they set up a quiet place for the two of you to talk.

Ask that – if they have someone living with them, someone who is a support – that person can be there, but you need to do “as much with you alone as I need to – – – and get to talk to anyone who can help.”

Warn them ahead of time “If you are a talker, and 50% of people I see are talkers, I may be interrupting you frequently: I don’t mean any disrespect, I mean to do the best job I can for you; if you are not a talker, sometimes I’ll ask ‘leading questions’ – still no disrespect, still serving you best.”

Seeing a child?  Much the same telephone script with the parent, but always remember to ask permission to speak to the child via telephone.  Break the ice.  Let the child hear your voice.  Ask if the child has a favorite color or TV show or music (depends on age).  Something concrete.  Make note of that.  When you go to the appointment, consider (a) at the very least mention you thought about their favorite color, show, music – ask them to say a little more; (b) wearing something of that color, bringing a toy, humming a few bars of music (even if its not their favorite music – just to ‘say’ (metaphorically) ‘I like music too.’

This co-creates a transitional object between you and the child.  And the asking permission makes the parent an ally (most of the time).  They like being asked for permission.

Seeing a child?  Tell the parent you may want to see the two of them interact and for the parent to think of something that is mutually pleasant for the parent and the child.

Why?  (a) This “seeds” them to focus on ‘solutions’ not problems.  (b) If they experience success, great!  But if there is difficulty with this task?: it gives you a ‘heads up’ micro-assessment that there is some difficulty and either more or less activity is called for on your part.

You can also ask the parent if they are comfortable using their cellphone to audio or video record the child, especially if the concerning behavior is intermittent.

All these are micro-techniques – and mostly extensions of standard ones – for preparing people to be interviewed.  Which is often an embarrassing situation for the patient/family.  So give lots of prep and “prop” (Equation: Support, support, support….confront).

March 30,2019

A subject that regularly comes up in supervision – at least when clinicians are working under one of the agents of the North Carolina Department of Health and Human Services’ LME/MCOs -is the Comprehensive Clinical Assessment“How do I get it done in the time allotted?” is one of most common questions.  Another is “I guess I ended up doing therapy – it seemed the right thing to do – and now I see I missed a lot of detail.”

Assessment is a skilled interview.  A skilled conversation.  It is not filling in the blanks on a form.  It is about establishing a level of trust so that the patient will disclose aspects of themselves, information, history, events, and the like, which they might not disclose to others.  It is about your humanity and your “expertness,” including, as part of the latter, a willingness to tactfully probe areas that the patient has not yet decided to disclose, maybe even “wards off” unconsciously.  And a sensitivity on your part to know “when not to go there” but also make note of that “not gone into subject” in your documentation so the next clinician is fully informed of your decision, the scope of what you did not investigate, and why you did not.  This should be used rarely, and mainly due to lack of time or the issue is or seems to be peripheral to the main issue(s).

In addition a “skilled interview” means interview management.  Management of time, inducting the person into the role of “informant” vs “patient” (the interview may be therapeutic, but it is not therapy), the interviewer switching b/t open-ended questions and close-ended questions, giving rationale(s) for different stages of the interview, and sharing the results with the person (family).

An assessment is not a “Level of Care.”  I.e., it is not the ASAM, LOCUS, CALOCUS or equivalents.  You take the data from the assessment and integrate it into the Level of Care instrument to get an “intensity” of treatment recommendation (s).

An assessment is not in and of itself the use of “tools” such as the following, though these may be involved in the assessment process:

APA DSM-5 Cross-cutting Level 1 measures (adult child/parent versions); APA DSM-5 Level 2 measures; Mini-Mental Status Examination (various versions); Beck Depression Inventory (BDI-II); SASSI-3; PTSD Checklist; Burns Anxiety Inventory; Women’s Complex Trauma Screen; Multimodal Life History Inventory; Addiction Severity Index; Dissociative Experiences Scale (DES); Multidimensional Inventory of Dissociation (MID); Crisis Triage Rating Scale; and Structured Clinical Interview for DSM-IV® Dissociative Disorders (SCID-D-R).

Above all, the skilled assessor knows when to use “key questions” from the above tools or when to use the full tool and/or when to recommend that that full tool be used in a follow-up interview.

[FOR YOUR GENERAL INFORMATION:  The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) is the GOLD STANDARD diagnostic exam used to determine Axis I disorders (major mental disorders). The SCID-II is a diagnostic exam used to determine Axis II disorders (personality disorders). An Axis I SCID assessment with a psychiatric patient usually takes between 1 and 2 hours, depending on the complexity of the past psychiatric history and the subject’s ability to clearly describe episodes of current and past symptoms. A SCID with a non-psychiatric patient takes 1/2 hour to 1-1/2 hours. (See editions below.) A SCID-II personality assessment takes about 1/2 to 1 hour.]

General comments on writing the assessment and subsequent documentation: The Golden Thread:

• Chief complaint is usually a quote.
• The assessment is specific.
• The assessment, especially the diagnostic formulation, needs concrete examples
• Ex: You need 6 criteria for ADHD subtypes, therefore six examples.
• Simplify as much as possible without missing the point.
• No vagueness or lofty goals.
• Concrete language overall.
• Short punchy sentences whenever possible.
• Prune back sentences that have 2-3 verbs, extra adverbs and adjectives and multiple commas.
• Ask yourself:
• Am I using psychiatric/psychological terminology correctly?
• In all other ways – when psychiatric/psychological terminology is not needed:
• Would my patient (or patient’s parents) understand this easily OR with minimum explanation?
• Would they agree with the facts I have listed?
• And would it make sense to them (if not right away, after I gave a simple explanation).
• And will the doctor find it useful?
• And will another reviewer find it clear and understandable – an auditor, or, if we have a third party (another agency) request our documentation, that they will?

Summarizing.

 Formulating the case is allowed.  It  if you know how to do that using a specific model such as Cognitive Behavioral Therapy or Structural Family Therapy, etc.

Formulation is not your OPINIONS or guesses. Ex. “I think the patient…..”

Recommendations for treatment should be well justified.

If you are “just” the assessor and the case will be forwarded to others to handle the treatment, the final written product should remove any need for the outpatient therapist or teams to re-do your assessment EXCEPT where you have indicated a subject needed further investigation.

The final written product should be so clear that the clinician / QP for OPT, IIH, CST, etc can directly ‘cut and paste’ your observations/summaries etc into the Person Centered Plan and the Treatment Authorization Request.  NOTE: But that is about the limit for cutting and pasting, which should otherwise be avoided.

STANDARD ENGLISH:  Spelling, syntax and grammar count.  Changes in tense should be clear.  Build paragraphs with related material.

NARRATIVE:  When explaining any complex social interaction, the use of multiple “he” and “she” should not confuse the reader.  Otherwise, while it is cumbersome, you should use names:

Example (Confusing)   Sally (Pt) reports that she has trouble with her mother.  When she says “You’re not fair,” they get in an argument.  [Which she?  Mom or Sally?]

Example (Clear)   Sally reports that she has trouble with her mother, When Sally says “You’re not fair,” they get in an argument.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I’m going to start off by saying it’s difficult to put brief therapy – especially VERY BRIEF THERAPY, aka VBT –  into a short presentation.

After all, the current treatment “landscape” of brief therapies includes: Eye Movement and Desensitization and Reprogramming (EMDR); Clinical Hypnosis; Motivational Interviewing.  And what else?  Polyvagal, Hakomi, Transpersonal, Energy Psychology, Bodywork, Neuro-Linguistic Programming (NLP), etc.

So there are many versions of therapies that make some claim to significant behavior change or symptom relief or insight in ONE or a few sessions.  What are some factors that go into facilitating such therapies?

You and what ideas you allow to influence you:

Consider this: In the space of a few hours – at the most – a play or movie can take you through many emotional states.  And you could have an experience that changes you.  At least make you think.  If you consider this example, you realize there are some significant principles that are at work in brief therapy: conflict may be amplified; time and spatial relationships are deliberately distorted; drama unfolds; intensity is embraced.

And what theories and models and the history of theories and models do you expose yourself to become a Very Brief Therapist?

I want to zero in on two contributions, two seminal changes in the field.  The Crisis and War Therapies (for example, Erich Lindemann); and, starting with the work of Milton Erickson, those who extended his work such as the Mental Research Institute (MRI), Jay Haley, Bandler & Grinder (NLP) and Berg and De Shazer (SFBT)

What’s so important about these two nodes in the course of therapy practice?

One.  They started with the idea that you could resolve a psychological problem quickly.

Two.  By quickly they meant in a few sessions, perhaps even one, perhaps….gasp…even none!  Though none did not mean no intervention.

Three.  They used a developmental frame that focused on returning individuals to their highest level of prior functioning or on individuals accessing potentials – think strengths.

Four.  They were very focused on communications.  That is, both tactically and strategically using words in specific ways, and consciously deleting null communications.  For example, except for using this communication as a paradoxical intervention, it is doubtful a VBT therapist would say “You’re stuck,” because that is antithetical to VBT conceptualization.

Five.  While the Crisis and War Therapies worked with crisis thrust upon both the patient and the therapist as a given (trauma and combat), Milton Erickson and others considered the deliberate use of natural crisis OR therapeutic manipulation to create a crisis…..as allies in healing and growth.  Recall general systems theory and what you learned about unbalancing families’ homeostasis as the route to a recrystallization of improved family functioning.

Most of you are already doing short term therapy.  You are not inviting the patient to stretch out on the couch or defining the therapy as face-to-face at least once a week for a considerable length of time.  Probably the longest “short term therapy” anyone is practicing in the context of state funded therapies is adherent DBT.

So what are some core concepts the Very Brief Therapist considers?

“Cure.”  Now, this depends on how you conceptualize the problem, but essentially the complaint stops.

“Presenting problems are taken seriously (although not necessarily at face value).”  This position is the antithesis of psychodynamic formulations where the symptom is a screen for an unconscious conflict.  In VBT the problem might be a communication that is ‘outside of consciousness,’ but generally the patient’s complaint is the problem to be ameliorated.

“Time limited.”  Without getting into nuance, think of the patient in therapy for three or more years.  VBT is the opposite.

“…sometimes helpful and sometimes harmful.”  Short term therapies tend to mute the possibilities of therapy “casualties.”  A corollary of this is that “the least radical intervention” might result in the least harm aka the First Ethical Principle, “First Do No Harm.”

What are some basic interventional sequences in VBT?  First of all, you want to retain as much therapist maneuverability as possible.  Avoid taking a position early on.  Track that presenting problem.  Ask the patient what they think is the nature of the problem and its possible solution.  BTW, on that one, they may be right on; but they may also be tipping their hand that they have consciously or unconsciously staked out a “never change” or “stuck” position you need to avoid.

And certainly in the first session, you want to avoid being rushed.  Or at least appear to be rushed or pushed by the patient to rush.  If crisis is a bridge to change, productive anxiety is a key.  Allay or somewhat heighten anxiety at your direction.

Avoid taking sides.  You may need to conduct separate interviews with couples and families.  And you may need to quickly give directions.  Giving directions – when you are prepared to test your case conceptualization or implement you main intervention – is a central VBT concept.

Retain your ability to be directive.  As an example, instead of “How does that sound,” ask for “show me how that sounds” or “show me what you – or you two, or three, or four – do.”   Some of you may already know how to do this from family therapy.

When appropriate, take the one-down position.  Sincerely avoid the expert role when to do so enhances your leverage.

Avoid letting the patient set restrictive conditions.  You must initially retain the ability to invite who you need, communicate with who you need, have the number and frequency of sessions needed (it may surprise the patient you will not meet every week!), and avoid holding secrets.  In VBT do not get boxed into repeating the last therapist’s treatment – unless your formulation indicates that was an appropriate treatment (though likely not VBT).  I generally say something very one-down along the lines of “I might fail you if I agreed to that and leave you in the same position, possibly worse off.”

With this very brief introduction to very brief therapy, I leave you with a suggested bibliography:

Fisch, R., Weakland, J.H. and Segal, S.  (1985). The Tactics of Change: Doing Therapy Briefly

Hayley, Jay, Edit.  (1985). Conversations with Milton H. Erickson, M.D. Volume I-III

Hayley, Jay.  (1977). Problem Solving Therapy: New Strategies for Effective Family Therapy

Lankton, Stephen.  (1980). Practical Magic: A Translation of Basic Neuro-Linguistic Programming into Clinical Psychotherapy

Madanes, Cloe.  (1985). Behind the One Way Mirror: Advances in the Practice of Strategic Therapy