Economics and the Management of "Dual-Diagnosis" Alcohol-Drinking Clients: How Murky!

A patient is self-medicating if alcohol is used to reduce symptoms of emotional or physical pain regardless of whether the diagnosis of alcoholism exists. Unfortunately, this definition of self-medication often alters from one clinician to the next. And, of course, we know that some mental health professionals do this for the sake of economics, or maintaining their unshakable model of addiction, regardless of validity.

It is tempting to use "self-medicating" as an exclusionary term to decide the patient isn't simply an alcoholic or not an alcoholic at all. This helps justify the current course of therapy that may not meet the needs of the patient, especially if he or she continues drink. The incentive is usually preventing the loss of client or patient to a traditional course of treatment for addictive disease.

Alcoholics without dual-diagnoses drink to ward of withdrawal symptoms, however. So, as the AAMCO car transmission spokesman says on TV, "How can you tell which is what without mistaking one for the other?"

Why not use the National Council on Alcoholism and Drug Dependence and the American Society on Addiction Medicine's definition of alcoholism. No less that 20 or so authorities labored for a consensus and have amended the definition at least twice. 1990 was the last - 20 years ago. (Can't believe it, geez, time flies.) If you are not using it, why not? Goodness, I hope you know it! Click here!)

Digression: Many people were upset over the finality of the definition and deliberation of this well-credentialed group. Someone went as far to create a dummy website about the definition to load harmful viruses on people's computers who visit it. Talk about resistence. (Google has a warning on the Internet link to keep people away from it. You'll see it if you surf the web.)

A self-medicating patient is alcoholic if tolerance to alcohol as emerged during the course of the patient's drinking career and symptoms of withdrawal exist (even ones subtle enough to be certainly overlooked by non-medical professionals.)

Pathologic organ changes may be present or may coexist, and some of these may be undetectable without a meaningful liver functions work-up.

Obviously, based upon this description, you would need help in deciding for sure if the patient was only self-medicating, and not alcoholic, right? Definitely, especially if you were seeing adaptive and earliest stages of addictive disease.

Of course, it gets murkier.

There is the possibility that your patient is in the early stages of alcoholism. A dual-diagnosis might exist. (Dual-diagnosis was an behavioral health insurance-saving discovery rapidly popularized by mental health professionals, and very quickly, within few years of the explosive thrust to treat alcoholism as chronic disease in the early 70's.)

But here is the punchline: Regardless of why a patient drinks, abstinence is required to properly treat depression or any mental illness, especially if medication is involved, and even if it is a dual-diagnosis.

So this means the patient needs to acquire motivation and a sense of urgency to remain abstinent if he or she does not have it already. And what if you can't get that from your patient? Any non-alcoholic client wouldn't give it a second thought to acquire better mental health functioning. And, of course, an alcohol-using client wanting to stop drinking would be qualified for AA. (And you should use motivational counseling to help him or her do it.)

Consider the following:

• 1) Refer the patient or client to an addiction medicine (certified) physician for the differential diagnosis who will work with the official, and most rigorously formulated understanding of alcoholism that exists.
  
  
• 2) Do not accept without question or qualm the patient's explanation for why he or she drinks. I still can't believe how many professionals actually accept a patient's own well-intellectualized conclusions, even as they explain it with alcohol on their breath.
  
  It is natural to begin a diagnostic impression on what is conveyed by patients, but remember, alcoholics are well-practiced at explaining their drinking using the same misconceptions and misunderstandings as the general public. Some may even rely upon explanations provided to them by other health professionals who have attempted to treat in the past. The preferred definition of the actively drinking patient is always the one that will permit continued drinking or offer hope of doing so again one day.
  
  
• 3) Be prepared to feel anger and resistance at losing your client to traditional alcoholism treatment, because without sobriety, and a stretch of time to overcome protracted withdrawal symptoms and the normal symptoms of recovery (remember those?), you may not be able to determine what you have sitting in front of you in the clinical setting.

In the end, you may have to fight yourself, the law of economics, and your model of alcoholism at the same time.

A drug and alcohol training program with effective and non-confusing language for use in business and industry can be found here.

Something's Stirring with Psychologists

Sometimes it is a good idea to know what other occupational groups and professions are planning for the future.

Frequently these decisions are based upon well-researched needs and interests of customers. One such group are Psychologists. They have big plans for reaching out to business and industry in the future. Here's what the Ph.D.s have been focusing on and discussing at their conferences and reporting to their members:

• Workplace Resilience Training
• Workplace Psychological Well-being
• Military Stress and PTSD/Suicide Prevention (then on to other professions)
• Bullying prevention in workplace
• Presenteeism (employees sick at work and their impact on others/productivity)
• Erratic commuting stress and How It Undermines Productivity.
• Psychological health of untrained disaster responders (as opposed to trained responders)
• Improving personal communication on the job and creating healthier workplaces
• Employees with parental duties and productivity declining while at work, but beginning at the moment school lets out -- i.e. What is Johnny doing? Where's the babysitter?, Etc.
• The study and management of flexible work schedules, employee stress, and related issues.

Hey, wait a minute! I thought EAPs dealt with most of these issues? And, hey again, I read recently that there are more EAPs than ever! So, what gives?

One itsy, bitsy, small difference. Managed care now provide most EAPs. The CT (translation - authentic) programs are dwindling. Indeed, manager care 800#'s don't have any practical involvement with the issues discussed above.

Could it be that the decline in the number of solid, core technology-driven, personally visible, and integrated employee assistance programs is causing or allowing to become visible, unmet needs in the workplace? I think they are. I have been observing this trend ever since reading in an HR journal a few year ago that HR managers should start addressing more personal problems of employees when "EAPs" can't do it. Holy cow! You never heard that about the EAPs of the 70's, 80's, or early 90's.

So where do HR managers and customers (decision makers) turn to get these needs met? Themselves? Mental health? Of course, they are turning to mental health professionals. And psychologists are at the waiting--organized, focused, and with clout they have uniformly built for decades.

"We have an expert on that subject!"

Throughout the year the major media will visit health related subjects that have broad appeal to the public. They will also report on major calamities and news stories like the recent massacre at Fort Hood.

The media needs mental health experts when these events occur. Who do they call? The answer is whoever comes to mind. That could be you if you know what to do, and first step you should take is to believe that they want you instead of the same old warm body that calls them every time.

There is one national managed care organization that hogs the spotlight on these events. They have a well funded pubic relations arm and they consitently show up in the media, the New York Times, ann Washington Post. There is another large corporate EAP that does the same thing. I am amazed at their prowess, but they deserve the attention if no one else is seeking.

Hey, were talking about capitalizing on tragedy here. The Fort Hood massacre was beyond belief horrible, but the media will pursue experts to help the public cope with these events, and it might as well be you. This is especially important because the some organizations have completely misguided ideas about employees assistance programs and they don't have any resistance to sharing the view to match their economic pursuits, regardless of its grander impact on the profession.

You will notice that specific topics appear in the news periodically, but predictably. For example, you can predict that approximately once a year the topic of alcoholism will emerge. It might be a news event on the cause, a new drug to fight cravings, or some other related topic. Many other topics related social problems will emerge in the mass media.

Pay attention. You will see that this is the case. Your local television station is not the "major media" in our definition. We are referring to AP news wires, and other major media outlets that sell news to the major networks, principally ABC, CBS, and NBC. However, pay attention to enormously important local news, specifically news events that relate to a subject about which you are an expert.

Now, here is what you should do: Listen attentively to the news. When you hear news that relates to your field of expertise, immediately fax to the local television stations your biography (a half page) and call the news room to say that you are an expert on that subject, and that you are faxing a bio. This is a great way to get publicity and to get on TV or the radio. And, it will make you instantly visible to your potential clients and EAP customers. (It's also a rush.)

Television and news stations scramble to find experts on subjects when the news hits. You are doing them a big favor.

If it is national news, you will have a few hours to respond because it will take longer for local stations to run "local expert" interviews. And it could be day later. If it is local news, your window of opportunity is much shorter, about an hour. Obviously you need to prepare ahead of time by getting phone and fax numbers, and contacts lined up. Then, wait for the "big one"--well hopefully not THE big one, but you get the idea.

The scramble for an expert kicks into gear quickly. That's you. Be there.

Workers' Comp: Getting the EAP Involved

Most organizations of any appreciable size pay workers' compensation premiums, and for the biggest companies, they are self-insured. Companies want to keep their premiums as low and self-insureds try to reduce their costs, as well.

A CT-EAP (CT=Core Technology) can play a major cost-beneficial role in helping achieve these goals, but it takes education of human resource managers and those who control referrals after injury to pull the EAP into the picture.

This is a utilization improvement link EAPs.

Research supports the argument that empathic contact and support for injured employees received from the organization, plays a role in helping employees return to work more quickly. This saves money, and therefore a rationale exists to include the EAP in the continuum of care after injuries occur. Beyond coordinating the nuts and bolts of medical service and follow-up, figure out how to get your EAP into the care huddle and you will increase your EAP's utilization and influence by offering employees support for issues that nearly always associate themselves with injury and recovery.

Workers' comp claims are higher for addicts—five times that of non-addicted workers-is the commonly cited figure. NIAAA includes this in much of its literature, so there isn’t much argument about its validity. But this only a small piece of the EAP rationale. There is much more that EAPs can do vis-a-vis Workers' Comp.

While there has been solid promotion of EAPs using this alcoholic employee angle as a rationale to promote them, EAPs can also help injured workers no matter what the cause—alcohol, drugs, stress, absent mindedness, back luck, or mental distraction of any kind. After the injury occurs, employees often need support they aren't getting, and the EAP can fill the void.

Unfortunately NIAAA, and many other stakeholder organizations have not promoted EAPs in this way. If they had done so over the past 25 years, EAPs would be in a completely different place in their evolution. They would be household terms, and your mother would still not be calling an EAP an EPA.

Hundreds of property casualty insurers would be acquiring EAPs by now I think if this linkage were more well established. The direct role of EAPs in the workers comp cost-containment fight would have been identified and popularized.

Post-injury, some of the needs employee have to arrange are home health aides, companionship services, shopping assistance, transportation, and an empathic listening ear. Many injured workers need financial counseling and problem-solving for family problems and communication issues. EAPs are particularly adept at arranging the coordination of services or offer emotional support, and it is here they have no occupational match by another profession in the workplace. Few HR managers understand how to quickly obtain the resources above, and even fewer are want to get involved with these issues.

Workers' comp managed care firms can partner with EAPs for the intervention opportunities that exist with worker injuries. But they are not like to take the first step.

Work toward having your HR representatives or managed care companies that process workers' comp claims include EAP literature, the things EAPs can do, and other types of very direct communication with injured workers. Encourage the referral of the injured worker to the EAP for an assessment after the medical crisis and acute care period ends.

You will add points to your utilization rate by way of these referrals and improve your value as a service to employees and the organization's bottom line.

Part V of V - What If the Addict Says, "No!"

(Note, this post has four previous parts.) I will make all parts available in a downloadable document (grammatically proofed) at a later date.)

If the addict says no, intervention participants should be ready to act on the leverage they have previously decided to use. However, it is extremely effective to give a deadline for the addict to accept the offer of help if he or she says "no."

The recommendation is no more than one day. This gives the addict time to think about treatment and feel in control of the decision to accept it.

Many people argue only for an immediate transport to the treatment facility. I disagree from personal experience. Addicts babies. Don't treat them as such. You must guess that the addict is motivated and willing to follow through.

As a director of a 25-bed adolescent drug and alcohol treatment unit in 1982, I once convinced a teenager to enter treatment after attending an Ozzie Osbourne concert. This kid never would have entered treatment. I guessed I could make the deal. He shook on it and entered treatment two days later.

The desperate act of “forcing” the addict to decide upon admission within minutes of the intervention is linked to the intervention consultant’s role and the implication that the intervention can’t be repeated later when the interventionist does not come back.

Using an intervention consultants is almost entirely viewed as a “one shot” opportunity. It is a disservice to families and the patient to view interventions in this manner.

Virtually all interventions will succeed. That's a bold statement isn’t it? But if you understand the nature of addictive disease and its progression, you know that this statement is essentially true.

Helping intervention clients understand this reality is essential because it provides motivation to practice new behaviors that stop enabling and facilitate crises that can lead to admissions. The goal is for co-addicts (persons in relationships with addicts) to act in tireless and aggressive ways against disease until the addict accepts help at a future point, if not right now. That day will come with a new attitude and a watchful approach to stopping enabling. Alanon is extremely useful for this purpose, but the Alanon sponsor must not be a individual who sends the message of "do nothing", simply live detached. Alanon's message is powerful, but some individuals interpret Alanon principles as avoiding intervention--forever. So, be careful of this message.

There are essentially three reasons all interventions will eventually succeed, particularly if they are "family-managed” rather than intervention consultant-driven. (Family-managed means that the intervention becomes a process, not a one time shot event that is declared a failure on the first try if does not work.) Again, no intervention consultant is used with the family empowerment model.

Reason #1: The reality of the progression of incidental, serial crises until death or sobriety. As the disease worsens, crises continue unabated with only an unpredictable amount of time that separates them. Each one becomes an opportunity to initiate an intervention.

Reason #2: Denial and alibis of the addict diminish and this leads to a rapid progression of the illness’s symptoms. Addicts practice defensive mechanisms to avoid confrontation and consequences for their behavior. If an intervention at first does not succeed, drinking or drug use will increase, although there may be a short-term attempt to reduce consumption in a vein attempt to demonstrate control over the illness by practicing abstinence or moderation. As drinking continues or resumes, problems increase and interventionists (family and friends) need only await for the opportunity to try again. The mission: Make acceptance of treatment non-negotiable as before.

Reason #3: Addicts will sicken as their illness grows worse, making sudden medical crisis an eventual certainty if they do not kill themselves first either by accident, medical event, or suicide. This may take weeks or years, but medical symptoms will almost certainly emerge requiring sudden and acute intervention. Again, this is an incidental crisis as I have defined it earlier, and it is therefore another opportunity to make another move to intervene.

It is a medical fact that two-thirds of addicts die of the medical consequences of alcoholism left untreated. One-third die of calamities of one sort or another. Before death, intervention opportunities are numerous, not one shot. Obviously, no intervention consultant can return for a second, third, and fourth try at the intervention. Subsequent interventions do not require much planning. The addict is "directed" to treatment in the aftermath of each crisis.

Magic in Non-Disciplinary Corrective Letters

I have always been amazed at how supervisors chase employees to improve performance, stomp their feet to get them to work on time, or scold workers to curtail their inappropriate behavior. When none of the usual, emotional wrangling to to correct employee performance works, and a major incident occurs, out come the big guns - disciplinary action. What happened to the art and science of managing employees with an effective non-disciplinary corrective letter?

The missing piece of armament that very few supervisors seem to ever master well is the non-disciplinary corrective letter. A non-disciplinary corrective letter is a management tool and supportive measure to call an employee's attention unsatisfactory job performance and motivate him or her to make corrections to satisfy standards. These tools can salvage employees, reduce risk of behavioral issues and acting out, and help preserve a more effective relationship with the supervisor.

Effective corrective letters utilize potential reward and fear of loss to match the motivational psyche of the employee. (Some employees become motivated by reward. Other by fear of loss. It is the equivalent of being either left handed or right handed. And, of course some employees are both -- call it "motivation-ally ambidextrous."

Here is a "classic" non-disciplinary corrective letter. Print this model, because it can be a good one in your desk draw to share with supervisors in your one-on-one consults with them.
=============================

To: Sally Smith, Machinist
From: John Doe, Supervisor
Subj: Attendance and Performance Problems
Date: 1-1-2006

Last week I reviewed the sick leave records and discovered that you have taken nine days of sick leave in the past year. Each of these days occurred on a Tuesday following a holiday weekend, or on a Friday preceding a three-day holiday weekend. I discussed my concern about this pattern with you last August 12, 2005. Since then, I have grown increasingly concerned. Your last such absence was on Dec. 27, 2005.

As you know, sick leave is a benefit to be used when necessary. The frequency of your sick leave is too high and affects your ability to perform essential functions. On February 15, several overdue widget projects caused a loss of their sale the day you were out. This cost the company $50,000. Your absences also negatively affect clerical staff. I would like to see your performance improve and your absences reduce.

You have excellent skills, and are a valued worker on the assembly line. But, if your use of sick leave remains high I will take additional steps to intervene, which could include administrative or disciplinary action.

Please provide verification of any future illness in which you lose work time. Please see me if you have any questions with regard to this request or the contents in this memo.

Thank you for your attention to this matter. As you know, the EAP is always available to assist you in the event a personal problem is contributing to your attendance problem. You can reach the EAP confidentially at 555-1234. I will review your use of sick leave in one month on Tuesday, February 1, 2006. Please plan to meet with me at 3:00 PM on that day.

cc: next level supervisor

Workplace Violence and Problematic Relationships with Supervisors

I wanted to talk with you about workplace violence and supervisor relationships.

EAPs routinely help resolve problematic relationships that employees have with their supervisors. If you haven't worked with this type of issue yet, you will.

I believe this intervention activity that HR managers, EAPs, and even OD people sometimes tackle has the most potential to improve productivity, reduce risk of violence, and help insulate the company from lawsuits -- big ones. The role EAPs play in helping resolve employee-supervisor conflict should get more attention in the literature.

I have always believed that effective EAP models reduce the number of potentially violent acts that, as a result, never happen. The question is, do companies appreciate this enormous benefit that can't be easily proven?

Many of these cases begin with employees who have problems with supervisors. These problems don't just create conflict and distraction. They can lead to death by a violent act. The subject of violence and improving relationships with supervisors is so critical to safety that I always include articles about it during the year when writing WorkExcel.com\'s newsletters. I so badly want to produce 7-9 minute Flash movie on "Best Tips for Reducing Supervisory Conflict with Subordinates" I think this would prevent violent acts more than the usual "know the nearest exit to your office if your employee explodes."

Employees love tips for improving their relationships with supervisors. There are huge payoffs for providing them, and top management will love you for doing so. That's because management can't rally employees to improve their relationships with their supervisors. The dynamics of paycheck-driven relationships simply makes it impossible. Your newsletter is a perfect medium for doing it.

Here are a few topics to consider for your next newsletter and those down the road. Chase after your newsletter company to write about these topics. If you are in a pinch, have them send me an e-mail and I will reply with my thoughts. They shouldn't have any problem if the writers possess an EAP background, of course.

Topic ideas

* Improving channels of communication and increasing frequency of
communicationSpeaking with your boss freely about concerns early on, before
problems arise
* Asking for advice about problems that you are experiencing on the job
* Writing down your concerns and sharing them; helping plan your evaluation goals
* Asking for feedback -- going to the boss and not waiting for it
* Considering your boss's perspective -- not just your own; how to do it and why
* Using tact when discussing differences
* Figuring out what your boss really wants from you, without asking
* Understanding that your supervisor is probably not "out to get you"

Don't just make a newsletter entertaining for employees. Make it a loss-prevention tool for the company. These tips will reduce conflict, improve program utilization, and increase top management's awareness for your true value.

Employee Newsletters for EAPs and Workforce Productivity