Reminders

Just a reminder that we have an upcoming training: Understanding and Working with Survivors of Trauma. It will take place on May 8th and will be taught by Professor Tana Bridge who was named the 2005 Trauma and Loss Consultant of the year by the national Institute for Trauma and Loss in Children.

The training has been approved for Social Work CE and CAC education hours. We would like to see everyone there. If possible, please clear your schedule and come. Breakfast and lunch will be provided.

That evening we also have a free first time home buyer workshop for the recovering community and Dawn Farm staff. (Flier here)

Learn how to transition from Recovering Renter to Recovering Homeowner

• Can I qualify for a home mortgage loan?
• How should I go about finding the right home?
• What is the best type of loan program for me?
• What does my credit report say and how will a mortgage banker look at it?
• FHA and VA Programs
• New no-money-down programs

TO REGISTER Call 734.929.9735. Ask for Pete Stegler or email at: pstegler@ffsimortgage.com

More on clients' preferences and empathy

Two responses (here and here) to the article I posted about earlier this week.

Change in Medical and Dependant Reimbursement Form

If you participate in medical and dependent care reimbursement, there is a new form and address for Kapnick Insurance. The new form is posted below, and can also be found on their website, www.kapnick.com.

FlexBenefitsReimRequest_4_07final.pdf

Understanding Empathy: Can You Feel My Pain?

Understanding Empathy: Can You Feel My Pain?

Is shared experience really necessary for a physician to understand or treat a patient? I wonder. After all, who would argue that a cardiologist would be more competent if he had had his own heart attack, or an oncologist more effective if he had had a brush with cancer?

Of course, a patient might feel more comfortable with a physician who has had personal experience with his medical illness, but that alone wouldn’t guarantee understanding, much less good treatment.

...

What is critical to understanding someone is not necessarily having had his or her experience; it is being able to imagine what it would be like to have it. Thus, I do not have to be black to empathize with the toxic effects of racial prejudice, or be a woman to know how I would feel about being denied promotion on the basis of sex.

...

In the right hands, empathy has tremendous positive therapeutic force and can narrow what looks like an unbridgeable gap between patients and therapists.

A few years back, I saw an elderly woman who had just lost her husband to cancer. “Oh, I hadn’t realized you were so young!” she exclaimed. “No offense, but maybe I need to see someone who’s a bit older.”

I asked her, “Are you worried that I can’t know what it feels like to lose someone you love and face life without him?”

True, I had never lost a partner, but it wasn’t hard to imagine her grief and anxiety about her future. That must have done the trick, because she stayed in treatment and never again mentioned my age.

Sometimes, though, patients should get exactly what they ask for in a therapist. One of my residents once saw a young woman from Africa who had survived hideous torture and rape and said that she didn’t think she could see a male therapist.

That struck me as entirely appropriate. Given her trauma, she simply could not have put her trust in a male therapist, no matter how empathic he might actually be.

What about patients whose demand for a particular therapist springs from nothing more than everyday prejudice? I remember a patient who once stormed into my office and demanded a white therapist to replace his therapist, who was black.

That’s a request I turned down, even knowing that this patient’s biased beliefs were an appropriate target for treatment. To do otherwise would have vindicated his prejudice and fundamentally compromised the therapy from the start.

In the end, empathy is what makes it possible for us to read each other. And it is the reason your doctor can understand your problem without actually having to live it.

I don't disagree with the writer's sentiment, obviously a worker does not have to live a client's experience to empathize with the client. However, he seems to take a very counselor-centric approach to the matter. Isn't it ultimately the client's decision who they work with? Don't we know that the therapeutic alliance and expectancy are critical to predicting outcomes? If I'm more comfortable with a female doctor should a male doctor assert that he's just as capable of treating me? It's only a preference, but does that make it unimportant?

I agree that it can be important to explore and challenge the client's thinking, but ultimately it's their decision--even if it's irrational. When expresses a preference for a recovering counselor (which is surprisingly infrequent), I make it clear that we don't believe it's important, but if it's important to them, we'll try to accommodate their preference. We all want to believe that we can be effective in serving just about anyone who lands in the chair in front of us, and that all clients should give us a chance to prove ourselves. Should they? Maybe. But we're not entitled to it.

Discharge Lessons--Responses

Responses to my post, Discharge Lesson. I thought you might like to see what your co-workers thought:
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I have a hard time applying the ideas about administrative discharge to Detox. When we discharge someone from Detox for "non-compliance," it seems very difficult to find a way to keep them in the Dawn Farm continuum of care, especially taking into consideration the volume of clients we have at Detox (and presumably more discharges), the lack of resources that many of our clients have, and the fact that most are, well, in need of Detox. It really feels like sending someone out into the cold sometimes when we discharge someone who has nowhere to go and no resources. We try to brainstorm with clients during discharge, usually other detox centers or possibly the shelter, and make it clear that they are welcome to return, if needed, in seven days. With limited resources, though, much of the time we are unsuccessful if helping clients find a safe place to go after discharge.

Is there something different that we could be doing at Detox in this regard?

My response: Detox has really been the organizational leader in finding ways to maintain meaningful connections with clients. Things like detox outreach, the big book study at the shelter and working on developing a recovery coaching program are all creative ways to stay connected and provide continuing support.

Administrative discharge is less an issue in detox and outpatient than it is in houses and residential. You guys pretty rarely discharge people.

The important thing is that we don't drift into thinking it's not our problem. That we keep looking for ways to hang on to more people and stay connected to them. It drives us to come up with small ideas, like recovery coaching and big ideas like expanding detox with something resembling a damp shelter and something resembling a recovery-focused shelter.

Thanks for responding.

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From a volunteer: <>
Not a fantasy, an enlightened and compassionate vision. (I hope some day it applies to your transitional housing too.) You guys have come a longgggg way despite many obstacles - hope your forward direction continues.
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I think that it would be helpful if we tried to publicize the severity of the addiction problem in our county and the severe lack of resources. I think that most people in this area believe that we are doing enough. this goes back to the e mail on discharge, I think that there are allot of great ideas floating around, the engagement center, recovery coaching etc.. but we need to implement them.
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I think this information is so important to review periodically and remind ourselves to rethink discharges. I suggested to Cassie that we review each point on the handout when we're considering discharge of a client, like a checklist.
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i think that, specifically, you hit the issue of accountability on the head. "Removing barriers to recovery" ideally encompasses presenting an alternative treatment system that is barrier-free.

When we discuss barrier removal, we are (I am) mainly considering the experience of the client. Equally critical: what barriers prevent clinical and administrative staff from presenting an all encompassing treatment continuum? What shift will truly help us to embody our ideal of non-punitive, empathic response?
money and housing issues aside, how do we visualize this program? Is it embodied by the Recovery Center laid out in the White Paper?

This would be a neat staff retreat didactic.
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I agree with the idea that clients should not be discharged for displaying symptoms of their diseases. I also agree with the idea that if one level of care is not working than we should offer another. I do not know enough about the details of this case to be able to help with a specific solution maybe another provider will offer him a setting that is more condusive for him and then we could help him with transitional? I believe that we should offer as many options as we have and that RECOVERY COACHING should be one of them. Treatment is not for everyone and we definitely should not work harder than our clients. Despite the fact that our clients are capable of living in allot of pain I believe that pain and consequences are a huge part of many peoples stories of recovery. We need to be there to provide hope and support, we also need to expose people to a solution. How do you think that we should have handled this case? What new programs would you like to see in the Dawn Farm Continuum?
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From Jim: Fun place to work, yes? I love having really smart, compassionate people around us…
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I agree! I love the 2nd way it could've been handled. It keeps us continuous with supporting them and lets them know that we do care about their recovery and well being. Sometimes just knowing that means everything to those who have been deprived of care for so long.
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I thought I'd reply but it''s more from a former-clients perspective. When I was in treatment, I was concerned by staff for withdrawing from the group. I was depressed, and pretty much unwilling to do any talking in group, and even do what my sponsor at the time was suggesting of me. Staff said that if I wanted to I could talk to them "one on one" (which of course I never took advantage of). I did however start doing what i didn't want to do. When I got to the apartments, that is when I really started to grow, as a resident and as an AA. I got more out of transitional housing than I did in any treatment center I had been to.

I'm not sure on the details of the client you were talking about, but it sounds to me like they were toxic to the entire group. I don't think treatment is for everyone, but maybe he would've done better at Huron Street, or transitional housing, or outpatient?

I definitely feel that staff should not be working harder than the client. Maybe a family session with the father who was paying for treatment?

Another discharge lesson

I have another discharge lesson that I wanted to share. This one's a little different than the last. We discharged a young women from residential for using twice in the house. (These are the discharges that pain me most--discharging someone for confirming her diagnosis. Again, we don't do it for the client, rather for the safety of the other clients.)

Some background on this case is that this woman had some serious co-occurring problems. She lasted quite a while in residential, but only with tremendous effort on the part of staff and other residents. Not only were her problems numerous, but they were intense. She had problems with self-harm and severe relational conflicts throughout her stay. Treatment was difficult, painful and characterized by one crisis after another.

Needless to say, the prospect of discharging her was difficult. Given the circumstances, detox didn't make sense, but we planned all sorts of ongoing support for her and encouraged her to come back in two weeks. Then we braced for the worst.

The worst hasn't happened to this point. When she left the treatment milieu she transformed into a shockingly capable person. We were scratching our heads. What was going on? How had all of us so shockingly underestimated this woman's resiliency? Why did we assume that our experience with her in residential was an accurate and complete reflection of how how she functions in the rest of the world? Was treatment actually harmful or limiting for her? Everything about this woman screamed the need for high intensity services, but she seems to be doing much better with lower intensity services.

We've talked about these kinds of cases before. How can we do a better job of identifying people who, while they may have multiple and severe problems, counter intuitively will benefit more from simple recovery support services than from treatment? How can we avoid slipping into thinking that treatment is the solution to every problem? How can we remind ourselves that we have a very limited view of their life and who they are.

I think that we remind ourselves of these things by having conversations like this.

New Hire

Isaac Williamson just completed his BSW field placement at the Farm and has been hired to fill in for Julie Boster when she goes on maternity leave next month. Congratulations Isaac!

Jim's a grandfather!

From Jim:

We are happy to announce that Gretchen gave birth to a beautiful baby girl at 6:54pm tonight after 15 hours of labor. Our new family member was 7 pounds, 12 ounces ­ and will be named tomorrow. Baby, parents and grandparents are all fine.
peace
Jim
:)

Discharge lesson

I just wanted to share an experience with all of you. We recently discharged a young man from residential treatment. He was unwilling to do the work necessary to justify the money that his father was paying for his treatment and his unwillingness to meet basic behavioral expectations was negatively affecting the group. We'd made several attempts over a period of weeks to change the direction of his treatment to no avail. We discharged him, wished him well, and encouraged him to consider returning to treatment in a couple of weeks. (We often hope that clients might develop more motivation and return to treatment.)

That night I felt a little uneasy about the whole thing. Not that we discharged him from residential--it wasn't working. I was uneasy that we treated his discharge from residential as a discharge from Dawn Farm. It didn't have to be.

Let me take a step back and explain that my fantasy for Dawn Farm is that we get to a point where we never have to discharge anyone. (See this article.) I'd like to see us develop a complete continuum of care that provides a place for everyone wherever they are on their journey to recovery and allows us to act as a consistent, dependable, continuous fellow traveler from active use into stable recovery.

Back to the case of the young man we discharged. Here's what I wish we would have done differently is this. We essentially sent the message that he was failing at treatment, we couldn't help him until he's ready, and that he should come back when he's ready. (And, hopefully, he'll be ready in 14 days.) I wish it would have gone more like this, "Residential isn't working right now. We can't justify keeping you here, it's expensive and your lack of commitment is affecting your peers in a way that's making it harder for them to recover. Since this isn't working, what might work for you right now? How can we help? We'd like to continue helping you, maybe outpatient treatment? If you decide that you want to give residential another shot we can look at that in a couple of weeks. Whatever you decide, we're unconditionally committed to your recovery."

In a lot of cases, this might feel like a token offering--the client may be homeless, there's no funding available and there are serious barriers to meaningful participation is a lower level of care. This case was different. He looked like he had a safe place to stay and access to funding for continuous treatment.

We've made a lot improvements in this area. Things like moving clients who relapse into detox and then back to transitional housing or residential treatment; hooking clients up Charles and Nancy for ongoing recovery support; moving clients who are tanking in residential to transitional housing. We've seen a lot of success and made a lot of progress, but we're still learning and we need to keep pushing ourselves.

I think that one important way we went wrong was by framing it as his problem and not ours. Accountability is important, but it has to run both ways. Holding ourselves accountable will keep pressure on us to take discharge seriously, continue to look for ways to fill gaps, and bundle services to meet the client's needs.

One more thing. I want to be clear that I'm not dumping on the staff involved. I was actively involved in this discharge. I suspect that it's something that happens in one form or another in all of our programs. On the subject, here's a handout from a presentation that Jim and I did last year.

What do you think?

--Jason

First time home buyer's seminar

A free workshop for the recovering community and Dawn Farm staff. (Flier here)

Learn how to transition from Recovering Renter to Recovering Homeowner

• Can I qualify for a home mortgage loan?
• How should I go about finding the right home?
• What is the best type of loan program for me?
• What does my credit report say and how will a mortgage banker look at it?
• FHA and VA Programs
• New no-money-down programs

TO REGISTER Call 734.929.9735. Ask for Pete Stegler or email at: pstegler@ffsimortgage.com

New Outpatient and Daybreak Coordinator

I'm pleased to announce (a little late) that we have a new Outpatient and Daybreak Program Coordinator. Debbie Snyder started on Monday, April 2nd. She's a psychologist with 19 years experience with addiction and adolescents. We're excited to have her on board. Welcome Debbie!

Volunteer of the Month - Corrected

Charles submitted the following correction:
Erica Doty is the April Volunteer of the Month. Erica has been the women’s Transitional House Manager for several months. Since taking over the huge responsibility of managing the houses, we have seen a tremendous turn around in retention at both of the houses. “The ladies are very happy to be there,” stated one of the residents. We continue to get very positive feedback from the ladies who reside in our women transitional house, expressing much gratitude for having her as a house manger. Keep up the good work, Erica!

Upcoming Training: Trauma

We have a training scheduled for May 8th on trauma. It will be presented by Tana Bridge, a Professor of Social Work at EMU and was named the 2005 Trauma and Loss Consultant of the year by the national Institute for Trauma and Loss in Children.

The training will be held in the barn at the Farm. Please clear your schedule and come. We will be offering Social Work CE credit and CAC CEUs.

Employee of the Month

Theresa Kilkenny is our April Employee of the Month. For 2 ½ weeks, Theresa kept the Finance Department running smoothly while Beverly was out sick. With a smile on her face, Theresa tackled new responsibilities in addition to her regular assignments and worked extra hours. Thank you, Theresa.