User login
How to discuss Vivitrol with the ambivalent patient
As our nation faces an unprecedented opioid epidemic, mental health clinicians must communicate to patients options for treatment for opioid use disorders (OUDs). A small subset of patients who suffer from an OUD will be consistently motivated in their willingness to accept and fully engage in medically assisted treatment (MAT). However, most patients will display fluctuating degrees of intrinsic motivation in their perceived abilities, needs, and desires for MAT. As of 2017, the MAT agents that are approved for use in OUD by the Food and Drug Administration are methadone, buprenorphine, and naltrexone.
An obvious first step in treating these patients is to forge a therapeutic alliance that allows the patient to feel comfortable expressing myriad emotions, including shame, sadness, fear, anger, guilt, relief, hopefulness, and hopelessness. It is important for the clinician to have a nonjudgmental, kind, open, and empathic approach. We also must be able to specifically empathize with the ambivalence many patients feel regarding MAT. This column will review common questions and concerns that patients voice when contemplating the use of the long-acting injectable naltrexone (Vivitrol). In addition, this article will attempt to provide clinicians with possible responses to these questions, and aim to increase the likelihood that patients will be willing to accept treatment with Vivitrol.
Patient: “If I’m sober, then I should be completely sober, and that includes abstaining from Vivitrol.”
Here, this patient has expressed his/her point of view on what it means to be sober. This view is not uncommon. The clinician should explore the origin of this belief. This particular response may be internalized from an experience in a 12-step program. Or it may be a personal feeling. Engage in a conversation about what sobriety means to the patient, his or her personal goals, and thoughts related to how opiates might interfere with these goals. Clinicians should resist the urge to persuade a patient to use Vivitrol, regardless of how strongly the clinician feels about its effectiveness, in order to address the patient’s ambivalence. Join in with the patient to acknowledge and shed light on his or her perspective and ultimately support a well-informed decision that incorporates a patient’s individual values.
Patient: “Others will judge me and say that I can’t handle life without Vivitrol and I need a crutch.”
The truth is, others may think this. Clinicians should acknowledge that the influential people in the lives of our patients may very well be judgmental. But it is a potential barrier for this patient to be too concerned with others’ reaction to Vivitrol. Stay with the patient’s concern about being judged in order to move into a discussion about ways to tolerate that response. Maybe this is a time to ask whether it would be helpful to educate family members about Vivitrol or to problem-solve ways to handle interactions with others when they say this. It also might be a time to explore questions such as “Why is needing a crutch a sign of weakness to you?” Take a moment to understand the patient’s feelings about using “crutches.” This may open up the dialogue and the potential for seeing Vivitrol as a helpful resource rather than a sign of weakness.
Patient: “If I am doing so well, why introduce another medication?”
That is a valid question, especially if the patient has experienced real change and doesn’t see a need to mix things up. You can tell them that they may be right. However, this also is an opportunity to engage in a meaningful discussion with the patient about the nature of addiction and the nature of motivation. It may be helpful to review the triggers and patterns of use for this particular patient. Remind him or her that motivation to stay sober is fluid. People in the process of change typically are in regular dialogue with themselves about what they want, why they want it, and what they need to do. It is a natural part of the process to sometimes favor sobriety, while other times want to use. Vivitrol is ONE way to manage the relationship between these fluctuations and the desire to act on urges. This may be an appropriate time to tell the patient about other patients’ experiences with Vivitrol and how they experienced relief from not having to work through the costs and benefits of using on a constant basis.
Patient: “I feel controlled by Vivitrol, and it brings up a lot of emotions for me.”
For the most part, Vivitrol will remove the person’s day-to-day participation in their decision to use drugs. This is unsettling for many of our patients who find that using a substance of their own volition makes them feel more in control than does taking a prescribed medicine. The decision to use Vivitrol to treat their addiction is asking patients to think ahead and face what comes up day to day in ways they may not have. Clients can experience fear and sadness when attempting to manage life without the “escape hatch.” It’s natural to want to fight against any feelings of being controlled. To work through ambivalence, allow the patient to air these concerns, acknowledge that feeling controlled understandably is an uncomfortable experience, and then move into ways the patient may see Vivitrol as giving them more control. It is in this kind of conversation about the pros and cons that we can help a patient recognize what feels “wise” in the long term.
Patient: “If I take Vivitrol, I could imagine using many more opioids to override the blockade.”
This thought is a kind of hopeless, automatic one, such as “This won’t work for me,” or “I will just use on it.” We can remind our patient that a thought is simply a thought. Mindfulness can be used to help this patient identify and label his/her thoughts. The task is then to figure out whether it is wise to act on those thoughts. It is crucial to be able to monitor and track this kind of thinking to help a patient identify and manage cravings. These thoughts will happen, but the behavior does not have to follow. In dialectical behavior therapy, we help patients identify thoughts that come mostly from emotions, which are, for the most part, about having short-term relief rather than thoughts that are more balanced by emotion and reason. We call the latter kinds of thoughts “wise mind”; they are more focused on long-term goals. Clinicians should help the patient discern the difference between these different types of thoughts. Remember, if the patients are sitting in your office, there must have been some “wise mind thinking” that led them there, and you should highlight and explore why they made that choice in the first place.
Patient: “I want to have the ability to use opioids if things get really bad.”
Opioids can become a source of security and a reliable resource that doesn’t fail the patient when he or she is struggling. Most of the time, patients have gotten to a place in which opioids are the only coping skill they have to manage life’s difficulties. These clients need to relearn alternative coping skills. Using Vivitrol gives them the ability to be sober enough to practice distress tolerance skills and realize the benefits of not using opioids. Learning how to distract, soothe, and use relaxation strategies are the only ways they are going to be able to build a satisfying life again without substance use. If we can hold up the dilemma facing this person by saying “On the one hand, you are scared not to have your usual go-to; and on the other hand, you want things to change.” It may be helpful to have an in-depth discussion of what patients imagine might happen if they don’t have opioids to fall back on. This discussion may uncover the patients’ lack of confidence about being able to cope and a way to introduce some of the alternative coping strategies. It also may leave them with some concrete ways to manage the difficult feelings they are experiencing.
Patient: “What if I get in an accident and really need opioids?”
Some patients who have developed a dependence on opioids did so as a result of a past prescription for pain medication. They know very well the relationship between opioids and pain relief and the concern that they won’t have this option may be a real obstacle for them. Clinicians are in a position here to explain that, in most cases, patients can be treated with alternatives to opiate medication such as regional analgesia, nonopioid analgesics, and general anesthesia. In an emergency situation, a trained anesthesia provider is able to reverse the Vivitrol blockade so that the client can receive adequate pain management.
Patient: “I’m worried about side effects … ”
The most common side effects of Vivitrol are headache, nausea, somnolence, and vomiting. A serious but very rare complication is hepatocellular injury, but this is really only seen at extremely high doses of naltrexone (five times the approved dosage). If the patient is pregnant or planning pregnancy, she should consider alternative relapse-prevention medications, such as buprenorphine or methadone. If the patient has a proven allergy to naltrexone, polylactide-co-glycolide, carboxymethylcellulose, or any other component of the injection, Vivitrol should be avoided. As for the injection site, the client may experience some pain, tenderness, swelling, bruising. In very few cases, the site reaction can be severe. Again, here is an opportunity for a valuation of pros and cons of both continued opioid use and a Vivitrol trial.
Dr. Ascher is a board-certified general and addiction psychiatrist who serves as a clinical assistant professor in psychiatry at the University of Pennsylvania, Philadelphia, and is in private practice. Dr. Rosof is a clinical psychologist in Philadelphia with a specialty in addiction and extensive training in motivational approaches. Dr. Schack is a clinical psychologist who serves as an expert consultant with the Center for Motivation and Change and is private practice in Philadelphia and New York City. None of them have conflicts of interest to disclose.
As our nation faces an unprecedented opioid epidemic, mental health clinicians must communicate to patients options for treatment for opioid use disorders (OUDs). A small subset of patients who suffer from an OUD will be consistently motivated in their willingness to accept and fully engage in medically assisted treatment (MAT). However, most patients will display fluctuating degrees of intrinsic motivation in their perceived abilities, needs, and desires for MAT. As of 2017, the MAT agents that are approved for use in OUD by the Food and Drug Administration are methadone, buprenorphine, and naltrexone.
An obvious first step in treating these patients is to forge a therapeutic alliance that allows the patient to feel comfortable expressing myriad emotions, including shame, sadness, fear, anger, guilt, relief, hopefulness, and hopelessness. It is important for the clinician to have a nonjudgmental, kind, open, and empathic approach. We also must be able to specifically empathize with the ambivalence many patients feel regarding MAT. This column will review common questions and concerns that patients voice when contemplating the use of the long-acting injectable naltrexone (Vivitrol). In addition, this article will attempt to provide clinicians with possible responses to these questions, and aim to increase the likelihood that patients will be willing to accept treatment with Vivitrol.
Patient: “If I’m sober, then I should be completely sober, and that includes abstaining from Vivitrol.”
Here, this patient has expressed his/her point of view on what it means to be sober. This view is not uncommon. The clinician should explore the origin of this belief. This particular response may be internalized from an experience in a 12-step program. Or it may be a personal feeling. Engage in a conversation about what sobriety means to the patient, his or her personal goals, and thoughts related to how opiates might interfere with these goals. Clinicians should resist the urge to persuade a patient to use Vivitrol, regardless of how strongly the clinician feels about its effectiveness, in order to address the patient’s ambivalence. Join in with the patient to acknowledge and shed light on his or her perspective and ultimately support a well-informed decision that incorporates a patient’s individual values.
Patient: “Others will judge me and say that I can’t handle life without Vivitrol and I need a crutch.”
The truth is, others may think this. Clinicians should acknowledge that the influential people in the lives of our patients may very well be judgmental. But it is a potential barrier for this patient to be too concerned with others’ reaction to Vivitrol. Stay with the patient’s concern about being judged in order to move into a discussion about ways to tolerate that response. Maybe this is a time to ask whether it would be helpful to educate family members about Vivitrol or to problem-solve ways to handle interactions with others when they say this. It also might be a time to explore questions such as “Why is needing a crutch a sign of weakness to you?” Take a moment to understand the patient’s feelings about using “crutches.” This may open up the dialogue and the potential for seeing Vivitrol as a helpful resource rather than a sign of weakness.
Patient: “If I am doing so well, why introduce another medication?”
That is a valid question, especially if the patient has experienced real change and doesn’t see a need to mix things up. You can tell them that they may be right. However, this also is an opportunity to engage in a meaningful discussion with the patient about the nature of addiction and the nature of motivation. It may be helpful to review the triggers and patterns of use for this particular patient. Remind him or her that motivation to stay sober is fluid. People in the process of change typically are in regular dialogue with themselves about what they want, why they want it, and what they need to do. It is a natural part of the process to sometimes favor sobriety, while other times want to use. Vivitrol is ONE way to manage the relationship between these fluctuations and the desire to act on urges. This may be an appropriate time to tell the patient about other patients’ experiences with Vivitrol and how they experienced relief from not having to work through the costs and benefits of using on a constant basis.
Patient: “I feel controlled by Vivitrol, and it brings up a lot of emotions for me.”
For the most part, Vivitrol will remove the person’s day-to-day participation in their decision to use drugs. This is unsettling for many of our patients who find that using a substance of their own volition makes them feel more in control than does taking a prescribed medicine. The decision to use Vivitrol to treat their addiction is asking patients to think ahead and face what comes up day to day in ways they may not have. Clients can experience fear and sadness when attempting to manage life without the “escape hatch.” It’s natural to want to fight against any feelings of being controlled. To work through ambivalence, allow the patient to air these concerns, acknowledge that feeling controlled understandably is an uncomfortable experience, and then move into ways the patient may see Vivitrol as giving them more control. It is in this kind of conversation about the pros and cons that we can help a patient recognize what feels “wise” in the long term.
Patient: “If I take Vivitrol, I could imagine using many more opioids to override the blockade.”
This thought is a kind of hopeless, automatic one, such as “This won’t work for me,” or “I will just use on it.” We can remind our patient that a thought is simply a thought. Mindfulness can be used to help this patient identify and label his/her thoughts. The task is then to figure out whether it is wise to act on those thoughts. It is crucial to be able to monitor and track this kind of thinking to help a patient identify and manage cravings. These thoughts will happen, but the behavior does not have to follow. In dialectical behavior therapy, we help patients identify thoughts that come mostly from emotions, which are, for the most part, about having short-term relief rather than thoughts that are more balanced by emotion and reason. We call the latter kinds of thoughts “wise mind”; they are more focused on long-term goals. Clinicians should help the patient discern the difference between these different types of thoughts. Remember, if the patients are sitting in your office, there must have been some “wise mind thinking” that led them there, and you should highlight and explore why they made that choice in the first place.
Patient: “I want to have the ability to use opioids if things get really bad.”
Opioids can become a source of security and a reliable resource that doesn’t fail the patient when he or she is struggling. Most of the time, patients have gotten to a place in which opioids are the only coping skill they have to manage life’s difficulties. These clients need to relearn alternative coping skills. Using Vivitrol gives them the ability to be sober enough to practice distress tolerance skills and realize the benefits of not using opioids. Learning how to distract, soothe, and use relaxation strategies are the only ways they are going to be able to build a satisfying life again without substance use. If we can hold up the dilemma facing this person by saying “On the one hand, you are scared not to have your usual go-to; and on the other hand, you want things to change.” It may be helpful to have an in-depth discussion of what patients imagine might happen if they don’t have opioids to fall back on. This discussion may uncover the patients’ lack of confidence about being able to cope and a way to introduce some of the alternative coping strategies. It also may leave them with some concrete ways to manage the difficult feelings they are experiencing.
Patient: “What if I get in an accident and really need opioids?”
Some patients who have developed a dependence on opioids did so as a result of a past prescription for pain medication. They know very well the relationship between opioids and pain relief and the concern that they won’t have this option may be a real obstacle for them. Clinicians are in a position here to explain that, in most cases, patients can be treated with alternatives to opiate medication such as regional analgesia, nonopioid analgesics, and general anesthesia. In an emergency situation, a trained anesthesia provider is able to reverse the Vivitrol blockade so that the client can receive adequate pain management.
Patient: “I’m worried about side effects … ”
The most common side effects of Vivitrol are headache, nausea, somnolence, and vomiting. A serious but very rare complication is hepatocellular injury, but this is really only seen at extremely high doses of naltrexone (five times the approved dosage). If the patient is pregnant or planning pregnancy, she should consider alternative relapse-prevention medications, such as buprenorphine or methadone. If the patient has a proven allergy to naltrexone, polylactide-co-glycolide, carboxymethylcellulose, or any other component of the injection, Vivitrol should be avoided. As for the injection site, the client may experience some pain, tenderness, swelling, bruising. In very few cases, the site reaction can be severe. Again, here is an opportunity for a valuation of pros and cons of both continued opioid use and a Vivitrol trial.
Dr. Ascher is a board-certified general and addiction psychiatrist who serves as a clinical assistant professor in psychiatry at the University of Pennsylvania, Philadelphia, and is in private practice. Dr. Rosof is a clinical psychologist in Philadelphia with a specialty in addiction and extensive training in motivational approaches. Dr. Schack is a clinical psychologist who serves as an expert consultant with the Center for Motivation and Change and is private practice in Philadelphia and New York City. None of them have conflicts of interest to disclose.
As our nation faces an unprecedented opioid epidemic, mental health clinicians must communicate to patients options for treatment for opioid use disorders (OUDs). A small subset of patients who suffer from an OUD will be consistently motivated in their willingness to accept and fully engage in medically assisted treatment (MAT). However, most patients will display fluctuating degrees of intrinsic motivation in their perceived abilities, needs, and desires for MAT. As of 2017, the MAT agents that are approved for use in OUD by the Food and Drug Administration are methadone, buprenorphine, and naltrexone.
An obvious first step in treating these patients is to forge a therapeutic alliance that allows the patient to feel comfortable expressing myriad emotions, including shame, sadness, fear, anger, guilt, relief, hopefulness, and hopelessness. It is important for the clinician to have a nonjudgmental, kind, open, and empathic approach. We also must be able to specifically empathize with the ambivalence many patients feel regarding MAT. This column will review common questions and concerns that patients voice when contemplating the use of the long-acting injectable naltrexone (Vivitrol). In addition, this article will attempt to provide clinicians with possible responses to these questions, and aim to increase the likelihood that patients will be willing to accept treatment with Vivitrol.
Patient: “If I’m sober, then I should be completely sober, and that includes abstaining from Vivitrol.”
Here, this patient has expressed his/her point of view on what it means to be sober. This view is not uncommon. The clinician should explore the origin of this belief. This particular response may be internalized from an experience in a 12-step program. Or it may be a personal feeling. Engage in a conversation about what sobriety means to the patient, his or her personal goals, and thoughts related to how opiates might interfere with these goals. Clinicians should resist the urge to persuade a patient to use Vivitrol, regardless of how strongly the clinician feels about its effectiveness, in order to address the patient’s ambivalence. Join in with the patient to acknowledge and shed light on his or her perspective and ultimately support a well-informed decision that incorporates a patient’s individual values.
Patient: “Others will judge me and say that I can’t handle life without Vivitrol and I need a crutch.”
The truth is, others may think this. Clinicians should acknowledge that the influential people in the lives of our patients may very well be judgmental. But it is a potential barrier for this patient to be too concerned with others’ reaction to Vivitrol. Stay with the patient’s concern about being judged in order to move into a discussion about ways to tolerate that response. Maybe this is a time to ask whether it would be helpful to educate family members about Vivitrol or to problem-solve ways to handle interactions with others when they say this. It also might be a time to explore questions such as “Why is needing a crutch a sign of weakness to you?” Take a moment to understand the patient’s feelings about using “crutches.” This may open up the dialogue and the potential for seeing Vivitrol as a helpful resource rather than a sign of weakness.
Patient: “If I am doing so well, why introduce another medication?”
That is a valid question, especially if the patient has experienced real change and doesn’t see a need to mix things up. You can tell them that they may be right. However, this also is an opportunity to engage in a meaningful discussion with the patient about the nature of addiction and the nature of motivation. It may be helpful to review the triggers and patterns of use for this particular patient. Remind him or her that motivation to stay sober is fluid. People in the process of change typically are in regular dialogue with themselves about what they want, why they want it, and what they need to do. It is a natural part of the process to sometimes favor sobriety, while other times want to use. Vivitrol is ONE way to manage the relationship between these fluctuations and the desire to act on urges. This may be an appropriate time to tell the patient about other patients’ experiences with Vivitrol and how they experienced relief from not having to work through the costs and benefits of using on a constant basis.
Patient: “I feel controlled by Vivitrol, and it brings up a lot of emotions for me.”
For the most part, Vivitrol will remove the person’s day-to-day participation in their decision to use drugs. This is unsettling for many of our patients who find that using a substance of their own volition makes them feel more in control than does taking a prescribed medicine. The decision to use Vivitrol to treat their addiction is asking patients to think ahead and face what comes up day to day in ways they may not have. Clients can experience fear and sadness when attempting to manage life without the “escape hatch.” It’s natural to want to fight against any feelings of being controlled. To work through ambivalence, allow the patient to air these concerns, acknowledge that feeling controlled understandably is an uncomfortable experience, and then move into ways the patient may see Vivitrol as giving them more control. It is in this kind of conversation about the pros and cons that we can help a patient recognize what feels “wise” in the long term.
Patient: “If I take Vivitrol, I could imagine using many more opioids to override the blockade.”
This thought is a kind of hopeless, automatic one, such as “This won’t work for me,” or “I will just use on it.” We can remind our patient that a thought is simply a thought. Mindfulness can be used to help this patient identify and label his/her thoughts. The task is then to figure out whether it is wise to act on those thoughts. It is crucial to be able to monitor and track this kind of thinking to help a patient identify and manage cravings. These thoughts will happen, but the behavior does not have to follow. In dialectical behavior therapy, we help patients identify thoughts that come mostly from emotions, which are, for the most part, about having short-term relief rather than thoughts that are more balanced by emotion and reason. We call the latter kinds of thoughts “wise mind”; they are more focused on long-term goals. Clinicians should help the patient discern the difference between these different types of thoughts. Remember, if the patients are sitting in your office, there must have been some “wise mind thinking” that led them there, and you should highlight and explore why they made that choice in the first place.
Patient: “I want to have the ability to use opioids if things get really bad.”
Opioids can become a source of security and a reliable resource that doesn’t fail the patient when he or she is struggling. Most of the time, patients have gotten to a place in which opioids are the only coping skill they have to manage life’s difficulties. These clients need to relearn alternative coping skills. Using Vivitrol gives them the ability to be sober enough to practice distress tolerance skills and realize the benefits of not using opioids. Learning how to distract, soothe, and use relaxation strategies are the only ways they are going to be able to build a satisfying life again without substance use. If we can hold up the dilemma facing this person by saying “On the one hand, you are scared not to have your usual go-to; and on the other hand, you want things to change.” It may be helpful to have an in-depth discussion of what patients imagine might happen if they don’t have opioids to fall back on. This discussion may uncover the patients’ lack of confidence about being able to cope and a way to introduce some of the alternative coping strategies. It also may leave them with some concrete ways to manage the difficult feelings they are experiencing.
Patient: “What if I get in an accident and really need opioids?”
Some patients who have developed a dependence on opioids did so as a result of a past prescription for pain medication. They know very well the relationship between opioids and pain relief and the concern that they won’t have this option may be a real obstacle for them. Clinicians are in a position here to explain that, in most cases, patients can be treated with alternatives to opiate medication such as regional analgesia, nonopioid analgesics, and general anesthesia. In an emergency situation, a trained anesthesia provider is able to reverse the Vivitrol blockade so that the client can receive adequate pain management.
Patient: “I’m worried about side effects … ”
The most common side effects of Vivitrol are headache, nausea, somnolence, and vomiting. A serious but very rare complication is hepatocellular injury, but this is really only seen at extremely high doses of naltrexone (five times the approved dosage). If the patient is pregnant or planning pregnancy, she should consider alternative relapse-prevention medications, such as buprenorphine or methadone. If the patient has a proven allergy to naltrexone, polylactide-co-glycolide, carboxymethylcellulose, or any other component of the injection, Vivitrol should be avoided. As for the injection site, the client may experience some pain, tenderness, swelling, bruising. In very few cases, the site reaction can be severe. Again, here is an opportunity for a valuation of pros and cons of both continued opioid use and a Vivitrol trial.
Dr. Ascher is a board-certified general and addiction psychiatrist who serves as a clinical assistant professor in psychiatry at the University of Pennsylvania, Philadelphia, and is in private practice. Dr. Rosof is a clinical psychologist in Philadelphia with a specialty in addiction and extensive training in motivational approaches. Dr. Schack is a clinical psychologist who serves as an expert consultant with the Center for Motivation and Change and is private practice in Philadelphia and New York City. None of them have conflicts of interest to disclose.
Treatment courts for veterans deserve our support
Over the last 5 years, Veterans Treatment Courts have been established across the country to address the unique challenges posed by our nation’s veterans who suffer from addiction, psychiatric illness, and/or co-occurring disorders, and who also run afoul of the law.
One study of almost 250,000 veterans who had returned from Iraq and Afghanistan and were under Veterans Affairs care found that 35% of them had received mental health diagnoses, including adjustment disorder, depression, and substance use disorders. The most prevalent mental health diagnosis was posttraumatic stress disorder (J. Gen. Intern. Med. 2010;25:18-24).
Meanwhile, a Bureau of Justice Statistics Special Report found that 9.3% of people incarcerated in jails are veterans and the majority of those serving time were for nonviolent crimes. More than 29% of the violent offenses among offenders who were in military correctional facilities came under the categories of rape and "other sexual assault." The report estimates that at least 90,000 of the 9 million inmates annually released from U.S. jails are veterans and that 82% are eligible for VA services.
Reintegrating into civilian life can be profoundly challenging for veterans, particularly when they also suffer from psychiatric illness, substance use disorders, and/or traumatic brain injury. Veterans often return to a life lacking in adequate support, which may result in unemployment, limited social connectedness, and housing problems. The physical and emotional scars that many veterans acquire during active duty also can be the catalyst for progressive mental health decline. Returning service members are at increased risk of engaging in unsafe risk-taking behaviors, such as reckless driving and heavy drinking (Drug Court Rev. 2011;3:171-208). Furthermore, many veterans live in rural areas with limited access to mental health care. To make matters worse, there continues to be a stigma among veterans that is associated with mental health treatment. Veterans Treatment Courts (VTCs) help to divert veteran defendants into community-based treatments where they are offered access to a comprehensive package of medical and mental health resources through the VA, as well as peer support services.
VTCs grew out of the drug court movement. The first VTC was formed in Buffalo, N.Y., in 2008 by Judge Robert Russell, who grew frustrated with the number of nonviolent veteran offenders forced to enter the criminal justice system after being arrested for crimes related to substance and mental health problems. Opponents of VTCs argue that all citizens, regardless of veteran status, should be afforded equal protection under the law and treated the same. However, while there have been no elegant outcome studies done thus far, state reports indicate that VTCs save taxpayers money and contribute to lower rates of recidivism.
Because of the many complexities of treating veterans, clinicians should embrace a culture of recovery. In particular, contingency management and the use of positive-reinforcement systems should be a standard and central practice in all treatment settings. Servicemen and -women have experienced trauma in order to protect our freedoms and ensure our safety, and it is our collective job to support a compassionate system that makes every effort to help our veterans avoid incarceration, which can be a retraumatizing experience. Many patients who are eligible for VA services are not connected to those services and clinicians should make appropriate referrals if necessary.
Dr. Ascher is a postdoctoral fellow at the Philadelphia VA Medical Center and clinical instructor in psychiatry at the University of Pennsylvania, Philadelphia.
Over the last 5 years, Veterans Treatment Courts have been established across the country to address the unique challenges posed by our nation’s veterans who suffer from addiction, psychiatric illness, and/or co-occurring disorders, and who also run afoul of the law.
One study of almost 250,000 veterans who had returned from Iraq and Afghanistan and were under Veterans Affairs care found that 35% of them had received mental health diagnoses, including adjustment disorder, depression, and substance use disorders. The most prevalent mental health diagnosis was posttraumatic stress disorder (J. Gen. Intern. Med. 2010;25:18-24).
Meanwhile, a Bureau of Justice Statistics Special Report found that 9.3% of people incarcerated in jails are veterans and the majority of those serving time were for nonviolent crimes. More than 29% of the violent offenses among offenders who were in military correctional facilities came under the categories of rape and "other sexual assault." The report estimates that at least 90,000 of the 9 million inmates annually released from U.S. jails are veterans and that 82% are eligible for VA services.
Reintegrating into civilian life can be profoundly challenging for veterans, particularly when they also suffer from psychiatric illness, substance use disorders, and/or traumatic brain injury. Veterans often return to a life lacking in adequate support, which may result in unemployment, limited social connectedness, and housing problems. The physical and emotional scars that many veterans acquire during active duty also can be the catalyst for progressive mental health decline. Returning service members are at increased risk of engaging in unsafe risk-taking behaviors, such as reckless driving and heavy drinking (Drug Court Rev. 2011;3:171-208). Furthermore, many veterans live in rural areas with limited access to mental health care. To make matters worse, there continues to be a stigma among veterans that is associated with mental health treatment. Veterans Treatment Courts (VTCs) help to divert veteran defendants into community-based treatments where they are offered access to a comprehensive package of medical and mental health resources through the VA, as well as peer support services.
VTCs grew out of the drug court movement. The first VTC was formed in Buffalo, N.Y., in 2008 by Judge Robert Russell, who grew frustrated with the number of nonviolent veteran offenders forced to enter the criminal justice system after being arrested for crimes related to substance and mental health problems. Opponents of VTCs argue that all citizens, regardless of veteran status, should be afforded equal protection under the law and treated the same. However, while there have been no elegant outcome studies done thus far, state reports indicate that VTCs save taxpayers money and contribute to lower rates of recidivism.
Because of the many complexities of treating veterans, clinicians should embrace a culture of recovery. In particular, contingency management and the use of positive-reinforcement systems should be a standard and central practice in all treatment settings. Servicemen and -women have experienced trauma in order to protect our freedoms and ensure our safety, and it is our collective job to support a compassionate system that makes every effort to help our veterans avoid incarceration, which can be a retraumatizing experience. Many patients who are eligible for VA services are not connected to those services and clinicians should make appropriate referrals if necessary.
Dr. Ascher is a postdoctoral fellow at the Philadelphia VA Medical Center and clinical instructor in psychiatry at the University of Pennsylvania, Philadelphia.
Over the last 5 years, Veterans Treatment Courts have been established across the country to address the unique challenges posed by our nation’s veterans who suffer from addiction, psychiatric illness, and/or co-occurring disorders, and who also run afoul of the law.
One study of almost 250,000 veterans who had returned from Iraq and Afghanistan and were under Veterans Affairs care found that 35% of them had received mental health diagnoses, including adjustment disorder, depression, and substance use disorders. The most prevalent mental health diagnosis was posttraumatic stress disorder (J. Gen. Intern. Med. 2010;25:18-24).
Meanwhile, a Bureau of Justice Statistics Special Report found that 9.3% of people incarcerated in jails are veterans and the majority of those serving time were for nonviolent crimes. More than 29% of the violent offenses among offenders who were in military correctional facilities came under the categories of rape and "other sexual assault." The report estimates that at least 90,000 of the 9 million inmates annually released from U.S. jails are veterans and that 82% are eligible for VA services.
Reintegrating into civilian life can be profoundly challenging for veterans, particularly when they also suffer from psychiatric illness, substance use disorders, and/or traumatic brain injury. Veterans often return to a life lacking in adequate support, which may result in unemployment, limited social connectedness, and housing problems. The physical and emotional scars that many veterans acquire during active duty also can be the catalyst for progressive mental health decline. Returning service members are at increased risk of engaging in unsafe risk-taking behaviors, such as reckless driving and heavy drinking (Drug Court Rev. 2011;3:171-208). Furthermore, many veterans live in rural areas with limited access to mental health care. To make matters worse, there continues to be a stigma among veterans that is associated with mental health treatment. Veterans Treatment Courts (VTCs) help to divert veteran defendants into community-based treatments where they are offered access to a comprehensive package of medical and mental health resources through the VA, as well as peer support services.
VTCs grew out of the drug court movement. The first VTC was formed in Buffalo, N.Y., in 2008 by Judge Robert Russell, who grew frustrated with the number of nonviolent veteran offenders forced to enter the criminal justice system after being arrested for crimes related to substance and mental health problems. Opponents of VTCs argue that all citizens, regardless of veteran status, should be afforded equal protection under the law and treated the same. However, while there have been no elegant outcome studies done thus far, state reports indicate that VTCs save taxpayers money and contribute to lower rates of recidivism.
Because of the many complexities of treating veterans, clinicians should embrace a culture of recovery. In particular, contingency management and the use of positive-reinforcement systems should be a standard and central practice in all treatment settings. Servicemen and -women have experienced trauma in order to protect our freedoms and ensure our safety, and it is our collective job to support a compassionate system that makes every effort to help our veterans avoid incarceration, which can be a retraumatizing experience. Many patients who are eligible for VA services are not connected to those services and clinicians should make appropriate referrals if necessary.
Dr. Ascher is a postdoctoral fellow at the Philadelphia VA Medical Center and clinical instructor in psychiatry at the University of Pennsylvania, Philadelphia.
Treatment courts for veterans deserve our support
Over the last 5 years, Veterans Treatment Courts have been established across the country to address the unique challenges posed by our nation’s veterans who suffer from addiction, psychiatric illness, and/or co-occurring disorders, and who also run afoul of the law.
One study of almost 250,000 veterans who had returned from Iraq and Afghanistan and were under Veterans Affairs care found that 35% of them had received mental health diagnoses, including adjustment disorder, depression, and substance use disorders. The most prevalent mental health diagnosis was posttraumatic stress disorder (J. Gen. Intern. Med. 2010;25:18-24).
Meanwhile, a Bureau of Justice Statistics Special Report found that 9.3% of people incarcerated in jails are veterans and the majority of those serving time were for nonviolent crimes. More than 29% of the violent offenses among offenders who were in military correctional facilities came under the categories of rape and "other sexual assault." The report estimates that at least 90,000 of the 9 million inmates annually released from U.S. jails are veterans and that 82% are eligible for VA services.
Reintegrating into civilian life can be profoundly challenging for veterans, particularly when they also suffer from psychiatric illness, substance use disorders, and/or traumatic brain injury. Veterans often return to a life lacking in adequate support, which may result in unemployment, limited social connectedness, and housing problems. The physical and emotional scars that many veterans acquire during active duty also can be the catalyst for progressive mental health decline. Returning service members are at increased risk of engaging in unsafe risk-taking behaviors, such as reckless driving and heavy drinking (Drug Court Rev. 2011;3:171-208). Furthermore, many veterans live in rural areas with limited access to mental health care. To make matters worse, there continues to be a stigma among veterans that is associated with mental health treatment. Veterans Treatment Courts (VTCs) help to divert veteran defendants into community-based treatments where they are offered access to a comprehensive package of medical and mental health resources through the VA, as well as peer support services.
VTCs grew out of the drug court movement. The first VTC was formed in Buffalo, N.Y., in 2008 by Judge Robert Russell, who grew frustrated with the number of nonviolent veteran offenders forced to enter the criminal justice system after being arrested for crimes related to substance and mental health problems. Opponents of VTCs argue that all citizens, regardless of veteran status, should be afforded equal protection under the law and treated the same. However, while there have been no elegant outcome studies done thus far, state reports indicate that VTCs save taxpayers money and contribute to lower rates of recidivism.
Because of the many complexities of treating veterans, clinicians should embrace a culture of recovery. In particular, contingency management and the use of positive-reinforcement systems should be a standard and central practice in all treatment settings. Servicemen and -women have experienced trauma in order to protect our freedoms and ensure our safety, and it is our collective job to support a compassionate system that makes every effort to help our veterans avoid incarceration, which can be a retraumatizing experience. Many patients who are eligible for VA services are not connected to those services and clinicians should make appropriate referrals if necessary.
Dr. Ascher is a postdoctoral fellow at the Philadelphia VA Medical Center and clinical instructor in psychiatry at the University of Pennsylvania, Philadelphia.
Over the last 5 years, Veterans Treatment Courts have been established across the country to address the unique challenges posed by our nation’s veterans who suffer from addiction, psychiatric illness, and/or co-occurring disorders, and who also run afoul of the law.
One study of almost 250,000 veterans who had returned from Iraq and Afghanistan and were under Veterans Affairs care found that 35% of them had received mental health diagnoses, including adjustment disorder, depression, and substance use disorders. The most prevalent mental health diagnosis was posttraumatic stress disorder (J. Gen. Intern. Med. 2010;25:18-24).
Meanwhile, a Bureau of Justice Statistics Special Report found that 9.3% of people incarcerated in jails are veterans and the majority of those serving time were for nonviolent crimes. More than 29% of the violent offenses among offenders who were in military correctional facilities came under the categories of rape and "other sexual assault." The report estimates that at least 90,000 of the 9 million inmates annually released from U.S. jails are veterans and that 82% are eligible for VA services.
Reintegrating into civilian life can be profoundly challenging for veterans, particularly when they also suffer from psychiatric illness, substance use disorders, and/or traumatic brain injury. Veterans often return to a life lacking in adequate support, which may result in unemployment, limited social connectedness, and housing problems. The physical and emotional scars that many veterans acquire during active duty also can be the catalyst for progressive mental health decline. Returning service members are at increased risk of engaging in unsafe risk-taking behaviors, such as reckless driving and heavy drinking (Drug Court Rev. 2011;3:171-208). Furthermore, many veterans live in rural areas with limited access to mental health care. To make matters worse, there continues to be a stigma among veterans that is associated with mental health treatment. Veterans Treatment Courts (VTCs) help to divert veteran defendants into community-based treatments where they are offered access to a comprehensive package of medical and mental health resources through the VA, as well as peer support services.
VTCs grew out of the drug court movement. The first VTC was formed in Buffalo, N.Y., in 2008 by Judge Robert Russell, who grew frustrated with the number of nonviolent veteran offenders forced to enter the criminal justice system after being arrested for crimes related to substance and mental health problems. Opponents of VTCs argue that all citizens, regardless of veteran status, should be afforded equal protection under the law and treated the same. However, while there have been no elegant outcome studies done thus far, state reports indicate that VTCs save taxpayers money and contribute to lower rates of recidivism.
Because of the many complexities of treating veterans, clinicians should embrace a culture of recovery. In particular, contingency management and the use of positive-reinforcement systems should be a standard and central practice in all treatment settings. Servicemen and -women have experienced trauma in order to protect our freedoms and ensure our safety, and it is our collective job to support a compassionate system that makes every effort to help our veterans avoid incarceration, which can be a retraumatizing experience. Many patients who are eligible for VA services are not connected to those services and clinicians should make appropriate referrals if necessary.
Dr. Ascher is a postdoctoral fellow at the Philadelphia VA Medical Center and clinical instructor in psychiatry at the University of Pennsylvania, Philadelphia.
Over the last 5 years, Veterans Treatment Courts have been established across the country to address the unique challenges posed by our nation’s veterans who suffer from addiction, psychiatric illness, and/or co-occurring disorders, and who also run afoul of the law.
One study of almost 250,000 veterans who had returned from Iraq and Afghanistan and were under Veterans Affairs care found that 35% of them had received mental health diagnoses, including adjustment disorder, depression, and substance use disorders. The most prevalent mental health diagnosis was posttraumatic stress disorder (J. Gen. Intern. Med. 2010;25:18-24).
Meanwhile, a Bureau of Justice Statistics Special Report found that 9.3% of people incarcerated in jails are veterans and the majority of those serving time were for nonviolent crimes. More than 29% of the violent offenses among offenders who were in military correctional facilities came under the categories of rape and "other sexual assault." The report estimates that at least 90,000 of the 9 million inmates annually released from U.S. jails are veterans and that 82% are eligible for VA services.
Reintegrating into civilian life can be profoundly challenging for veterans, particularly when they also suffer from psychiatric illness, substance use disorders, and/or traumatic brain injury. Veterans often return to a life lacking in adequate support, which may result in unemployment, limited social connectedness, and housing problems. The physical and emotional scars that many veterans acquire during active duty also can be the catalyst for progressive mental health decline. Returning service members are at increased risk of engaging in unsafe risk-taking behaviors, such as reckless driving and heavy drinking (Drug Court Rev. 2011;3:171-208). Furthermore, many veterans live in rural areas with limited access to mental health care. To make matters worse, there continues to be a stigma among veterans that is associated with mental health treatment. Veterans Treatment Courts (VTCs) help to divert veteran defendants into community-based treatments where they are offered access to a comprehensive package of medical and mental health resources through the VA, as well as peer support services.
VTCs grew out of the drug court movement. The first VTC was formed in Buffalo, N.Y., in 2008 by Judge Robert Russell, who grew frustrated with the number of nonviolent veteran offenders forced to enter the criminal justice system after being arrested for crimes related to substance and mental health problems. Opponents of VTCs argue that all citizens, regardless of veteran status, should be afforded equal protection under the law and treated the same. However, while there have been no elegant outcome studies done thus far, state reports indicate that VTCs save taxpayers money and contribute to lower rates of recidivism.
Because of the many complexities of treating veterans, clinicians should embrace a culture of recovery. In particular, contingency management and the use of positive-reinforcement systems should be a standard and central practice in all treatment settings. Servicemen and -women have experienced trauma in order to protect our freedoms and ensure our safety, and it is our collective job to support a compassionate system that makes every effort to help our veterans avoid incarceration, which can be a retraumatizing experience. Many patients who are eligible for VA services are not connected to those services and clinicians should make appropriate referrals if necessary.
Dr. Ascher is a postdoctoral fellow at the Philadelphia VA Medical Center and clinical instructor in psychiatry at the University of Pennsylvania, Philadelphia.
Using CBT to decipher dreams
Ms. B is a 23-year-old white, married woman who first sought mental health treatment after experiencing depressive symptoms for 4 weeks following the birth of her first child. She endured guilt, hopelessness, anxiety, ruminative thoughts, and irrational fears of impending doom. Fortunately, her symptoms remitted soon after a trial of low-dose selective serotonin reuptake inhibitors (SSRIs). As the therapeutic relationship grew and Ms. B felt more comfortable with her psychiatrist, she acknowledged that she had endured years of low-grade anxiety and frequently experienced maladaptive thoughts that affected her self-esteem. Ms. B reports that she always had a "fear of failing in life." These beliefs were so entrenched and longstanding that she left college early, married, and started a family. Ms. B feels that her medication "puts her mind more at rest." She has a happier relationship with her husband and feels a greater sense of attachment to her baby. However, Ms. B expresses distress as a result of vivid dreams that began soon after she began treatment with SSRIs.
Ms. B is unable to recall the details of her dreams but is very bothered by them. We provided her with psychoeducation about the relationship between SSRIs and disruptive dreams. We informed her that most dreams that occur shortly before awakening are non-REM dreams, which are typical side effects of SSRIs and differ from REM dreams. She was relieved to learn that her reaction to medication is not unique, just as she was relieved to learn that postpartum depression affects up to 15% of new mothers (MMWR 2008;57:361-6)
We inquired as to whether the dreams are mostly visual or narrative, explaining that non-REM dreams typically tell stories in words rather than images. Non-REM dreams are more like novels than movies or comics. Ms. B maintains that she has little recall of those dreams, apart from the negative emotions that they evoke. She adds that she does not want to begin a "lengthy psychoanalysis" to understand her dreams, since her child care responsibilities leave her with barely enough time for brief 15- to 20-minute psychiatry visits.
We reassured Ms. B that even brief exploration of her dreams might have a therapeutic function. We suggested that she keep an old-fashioned telephone notepad at her bedside, with long, narrow strips that are just wide enough to write a name and number on. The goal is for her to jot down a word or two about her dreams – but nothing more – so that she can fall back asleep quickly. During the day, those few words will likely help jar her memory enough for her to expand upon her recollections. We recommended against her using her smartphone notepad, because the phone’s bright light could make her more alert and obstruct a quick return to sleep.
When Ms. B looked quizzical, we reminded her that this technique of dream note taking is favored by creative people who capture fleeting nighttime images and ideas for projects. Many patients enjoy learning that Romantic Movement poets such as Samuel Coleridge, as well as many Surrealist artists, turned their dreams into art ("Dreams in Myth, Medicine, and Movies," Westport, Conn.: Praeger, 2002).
Ms. B was able to capture the essence or "spirit" of her most disturbing dreams using this technique. She was both proud and embarrassed when she first brought in her notebook – proud, because she completed her assignment but embarrassed because of the dreams’ content. After being reassured that non-REM dreams tend to be bizarre and are not necessarily representative of the dreamer’s personal attitudes, she admitted that she dreamt about child sacrifice. She stressed that she would never harm her child. Nor did she experience similar daytime fantasies. Having observed her interactions with her infant, we were not concerned with an imminent risk of danger to her child. We used this information to normalize Ms. B’s experience while maintaining a nonjudgmental and supportive therapeutic space.
To reassure Ms. B that her unconscious was not the first to coin such unfathomable concepts, we reminded her that the motif of child sacrifice recurs in myth and religion ("The New Golden Bough: A New Abridgement of the Classic Work by Sir James Frazer," New York: Criterion, 1956). For example, Abraham almost sacrificed his son Isaac. The Bible mentions child sacrifice among Near Eastern goddess cults. This made sense to Ms. B, who had studied the Bible in religious school. She also acknowledged that she had wanted to major in anthropology prior to dropping out of college. She linked her ambivalence about bearing a child to her lapsed college studies, correctly perceiving that this conflict predisposed her to postpartum depression.
Had Ms. B expressed interest in exploratory therapy – or if we had doubts about her commitment to her child and ability to be a responsible caretaker – we would have referred her to additional resources. However, we sensed that she could be lost to treatment altogether if we demanded more treatment than she was ready to embrace. We drew inspiration from "High-Yield Cognitive-Behavior Therapy for Brief Sessions" (Arlington, Va.: American Psychiatric Publishing, 2010) and used the limited time available to ask targeted questions. Specifically, how did she react to tragic news about untreated postpartum depression?
We were not surprised to learn of Ms. B’s secret fears that her depression and dreams could progress to the level of Andrea Yates, the Texas woman with untreated psychosis who responded to delusions and hallucinations by murdering her five children in 2001. Again, we reassured Ms. B that many people share such fears, and that was one reason why the Yates case garnered such media attention. We pointed out differences between Ms. Yates’s life and that of Ms. B, stressing that Ms. B’s decision to seek timely treatment (instead of avoiding it), coupled with her husband’s support and the absence of psychosis dramatically distinguished her situation from Ms. Yates’s.
Ms. B accepted this explanation. Her distress subsided, and she gained a greater sense of self-efficacy. She remained in treatment, attending monthly appointments, and expressing joy about her baby. Ms. B revealed to us that she planned to return to college part time when her baby starts preschool.
Dr. Packer is an assistant clinical professor of psychiatry and behavioral sciences at Albert Einstein College of Medicine, New York, and is in private practice. Her most recent book is "Cinemas Sinister Psychiatrists: From Caligari to Hannibal" (Jefferson, N.C.: McFarland, 2012). Dr. Ascher is a postdoctoral fellow in addiction psychiatry at the University of Pennsylvania Perelman School of Medicine, Philadelphia, and a candidate at the New York University postdoctoral program in psychotherapy and psychoanalysis. He is a new Clinical Psychiatry News editorial advisory board member.
Ms. B is a 23-year-old white, married woman who first sought mental health treatment after experiencing depressive symptoms for 4 weeks following the birth of her first child. She endured guilt, hopelessness, anxiety, ruminative thoughts, and irrational fears of impending doom. Fortunately, her symptoms remitted soon after a trial of low-dose selective serotonin reuptake inhibitors (SSRIs). As the therapeutic relationship grew and Ms. B felt more comfortable with her psychiatrist, she acknowledged that she had endured years of low-grade anxiety and frequently experienced maladaptive thoughts that affected her self-esteem. Ms. B reports that she always had a "fear of failing in life." These beliefs were so entrenched and longstanding that she left college early, married, and started a family. Ms. B feels that her medication "puts her mind more at rest." She has a happier relationship with her husband and feels a greater sense of attachment to her baby. However, Ms. B expresses distress as a result of vivid dreams that began soon after she began treatment with SSRIs.
Ms. B is unable to recall the details of her dreams but is very bothered by them. We provided her with psychoeducation about the relationship between SSRIs and disruptive dreams. We informed her that most dreams that occur shortly before awakening are non-REM dreams, which are typical side effects of SSRIs and differ from REM dreams. She was relieved to learn that her reaction to medication is not unique, just as she was relieved to learn that postpartum depression affects up to 15% of new mothers (MMWR 2008;57:361-6)
We inquired as to whether the dreams are mostly visual or narrative, explaining that non-REM dreams typically tell stories in words rather than images. Non-REM dreams are more like novels than movies or comics. Ms. B maintains that she has little recall of those dreams, apart from the negative emotions that they evoke. She adds that she does not want to begin a "lengthy psychoanalysis" to understand her dreams, since her child care responsibilities leave her with barely enough time for brief 15- to 20-minute psychiatry visits.
We reassured Ms. B that even brief exploration of her dreams might have a therapeutic function. We suggested that she keep an old-fashioned telephone notepad at her bedside, with long, narrow strips that are just wide enough to write a name and number on. The goal is for her to jot down a word or two about her dreams – but nothing more – so that she can fall back asleep quickly. During the day, those few words will likely help jar her memory enough for her to expand upon her recollections. We recommended against her using her smartphone notepad, because the phone’s bright light could make her more alert and obstruct a quick return to sleep.
When Ms. B looked quizzical, we reminded her that this technique of dream note taking is favored by creative people who capture fleeting nighttime images and ideas for projects. Many patients enjoy learning that Romantic Movement poets such as Samuel Coleridge, as well as many Surrealist artists, turned their dreams into art ("Dreams in Myth, Medicine, and Movies," Westport, Conn.: Praeger, 2002).
Ms. B was able to capture the essence or "spirit" of her most disturbing dreams using this technique. She was both proud and embarrassed when she first brought in her notebook – proud, because she completed her assignment but embarrassed because of the dreams’ content. After being reassured that non-REM dreams tend to be bizarre and are not necessarily representative of the dreamer’s personal attitudes, she admitted that she dreamt about child sacrifice. She stressed that she would never harm her child. Nor did she experience similar daytime fantasies. Having observed her interactions with her infant, we were not concerned with an imminent risk of danger to her child. We used this information to normalize Ms. B’s experience while maintaining a nonjudgmental and supportive therapeutic space.
To reassure Ms. B that her unconscious was not the first to coin such unfathomable concepts, we reminded her that the motif of child sacrifice recurs in myth and religion ("The New Golden Bough: A New Abridgement of the Classic Work by Sir James Frazer," New York: Criterion, 1956). For example, Abraham almost sacrificed his son Isaac. The Bible mentions child sacrifice among Near Eastern goddess cults. This made sense to Ms. B, who had studied the Bible in religious school. She also acknowledged that she had wanted to major in anthropology prior to dropping out of college. She linked her ambivalence about bearing a child to her lapsed college studies, correctly perceiving that this conflict predisposed her to postpartum depression.
Had Ms. B expressed interest in exploratory therapy – or if we had doubts about her commitment to her child and ability to be a responsible caretaker – we would have referred her to additional resources. However, we sensed that she could be lost to treatment altogether if we demanded more treatment than she was ready to embrace. We drew inspiration from "High-Yield Cognitive-Behavior Therapy for Brief Sessions" (Arlington, Va.: American Psychiatric Publishing, 2010) and used the limited time available to ask targeted questions. Specifically, how did she react to tragic news about untreated postpartum depression?
We were not surprised to learn of Ms. B’s secret fears that her depression and dreams could progress to the level of Andrea Yates, the Texas woman with untreated psychosis who responded to delusions and hallucinations by murdering her five children in 2001. Again, we reassured Ms. B that many people share such fears, and that was one reason why the Yates case garnered such media attention. We pointed out differences between Ms. Yates’s life and that of Ms. B, stressing that Ms. B’s decision to seek timely treatment (instead of avoiding it), coupled with her husband’s support and the absence of psychosis dramatically distinguished her situation from Ms. Yates’s.
Ms. B accepted this explanation. Her distress subsided, and she gained a greater sense of self-efficacy. She remained in treatment, attending monthly appointments, and expressing joy about her baby. Ms. B revealed to us that she planned to return to college part time when her baby starts preschool.
Dr. Packer is an assistant clinical professor of psychiatry and behavioral sciences at Albert Einstein College of Medicine, New York, and is in private practice. Her most recent book is "Cinemas Sinister Psychiatrists: From Caligari to Hannibal" (Jefferson, N.C.: McFarland, 2012). Dr. Ascher is a postdoctoral fellow in addiction psychiatry at the University of Pennsylvania Perelman School of Medicine, Philadelphia, and a candidate at the New York University postdoctoral program in psychotherapy and psychoanalysis. He is a new Clinical Psychiatry News editorial advisory board member.
Ms. B is a 23-year-old white, married woman who first sought mental health treatment after experiencing depressive symptoms for 4 weeks following the birth of her first child. She endured guilt, hopelessness, anxiety, ruminative thoughts, and irrational fears of impending doom. Fortunately, her symptoms remitted soon after a trial of low-dose selective serotonin reuptake inhibitors (SSRIs). As the therapeutic relationship grew and Ms. B felt more comfortable with her psychiatrist, she acknowledged that she had endured years of low-grade anxiety and frequently experienced maladaptive thoughts that affected her self-esteem. Ms. B reports that she always had a "fear of failing in life." These beliefs were so entrenched and longstanding that she left college early, married, and started a family. Ms. B feels that her medication "puts her mind more at rest." She has a happier relationship with her husband and feels a greater sense of attachment to her baby. However, Ms. B expresses distress as a result of vivid dreams that began soon after she began treatment with SSRIs.
Ms. B is unable to recall the details of her dreams but is very bothered by them. We provided her with psychoeducation about the relationship between SSRIs and disruptive dreams. We informed her that most dreams that occur shortly before awakening are non-REM dreams, which are typical side effects of SSRIs and differ from REM dreams. She was relieved to learn that her reaction to medication is not unique, just as she was relieved to learn that postpartum depression affects up to 15% of new mothers (MMWR 2008;57:361-6)
We inquired as to whether the dreams are mostly visual or narrative, explaining that non-REM dreams typically tell stories in words rather than images. Non-REM dreams are more like novels than movies or comics. Ms. B maintains that she has little recall of those dreams, apart from the negative emotions that they evoke. She adds that she does not want to begin a "lengthy psychoanalysis" to understand her dreams, since her child care responsibilities leave her with barely enough time for brief 15- to 20-minute psychiatry visits.
We reassured Ms. B that even brief exploration of her dreams might have a therapeutic function. We suggested that she keep an old-fashioned telephone notepad at her bedside, with long, narrow strips that are just wide enough to write a name and number on. The goal is for her to jot down a word or two about her dreams – but nothing more – so that she can fall back asleep quickly. During the day, those few words will likely help jar her memory enough for her to expand upon her recollections. We recommended against her using her smartphone notepad, because the phone’s bright light could make her more alert and obstruct a quick return to sleep.
When Ms. B looked quizzical, we reminded her that this technique of dream note taking is favored by creative people who capture fleeting nighttime images and ideas for projects. Many patients enjoy learning that Romantic Movement poets such as Samuel Coleridge, as well as many Surrealist artists, turned their dreams into art ("Dreams in Myth, Medicine, and Movies," Westport, Conn.: Praeger, 2002).
Ms. B was able to capture the essence or "spirit" of her most disturbing dreams using this technique. She was both proud and embarrassed when she first brought in her notebook – proud, because she completed her assignment but embarrassed because of the dreams’ content. After being reassured that non-REM dreams tend to be bizarre and are not necessarily representative of the dreamer’s personal attitudes, she admitted that she dreamt about child sacrifice. She stressed that she would never harm her child. Nor did she experience similar daytime fantasies. Having observed her interactions with her infant, we were not concerned with an imminent risk of danger to her child. We used this information to normalize Ms. B’s experience while maintaining a nonjudgmental and supportive therapeutic space.
To reassure Ms. B that her unconscious was not the first to coin such unfathomable concepts, we reminded her that the motif of child sacrifice recurs in myth and religion ("The New Golden Bough: A New Abridgement of the Classic Work by Sir James Frazer," New York: Criterion, 1956). For example, Abraham almost sacrificed his son Isaac. The Bible mentions child sacrifice among Near Eastern goddess cults. This made sense to Ms. B, who had studied the Bible in religious school. She also acknowledged that she had wanted to major in anthropology prior to dropping out of college. She linked her ambivalence about bearing a child to her lapsed college studies, correctly perceiving that this conflict predisposed her to postpartum depression.
Had Ms. B expressed interest in exploratory therapy – or if we had doubts about her commitment to her child and ability to be a responsible caretaker – we would have referred her to additional resources. However, we sensed that she could be lost to treatment altogether if we demanded more treatment than she was ready to embrace. We drew inspiration from "High-Yield Cognitive-Behavior Therapy for Brief Sessions" (Arlington, Va.: American Psychiatric Publishing, 2010) and used the limited time available to ask targeted questions. Specifically, how did she react to tragic news about untreated postpartum depression?
We were not surprised to learn of Ms. B’s secret fears that her depression and dreams could progress to the level of Andrea Yates, the Texas woman with untreated psychosis who responded to delusions and hallucinations by murdering her five children in 2001. Again, we reassured Ms. B that many people share such fears, and that was one reason why the Yates case garnered such media attention. We pointed out differences between Ms. Yates’s life and that of Ms. B, stressing that Ms. B’s decision to seek timely treatment (instead of avoiding it), coupled with her husband’s support and the absence of psychosis dramatically distinguished her situation from Ms. Yates’s.
Ms. B accepted this explanation. Her distress subsided, and she gained a greater sense of self-efficacy. She remained in treatment, attending monthly appointments, and expressing joy about her baby. Ms. B revealed to us that she planned to return to college part time when her baby starts preschool.
Dr. Packer is an assistant clinical professor of psychiatry and behavioral sciences at Albert Einstein College of Medicine, New York, and is in private practice. Her most recent book is "Cinemas Sinister Psychiatrists: From Caligari to Hannibal" (Jefferson, N.C.: McFarland, 2012). Dr. Ascher is a postdoctoral fellow in addiction psychiatry at the University of Pennsylvania Perelman School of Medicine, Philadelphia, and a candidate at the New York University postdoctoral program in psychotherapy and psychoanalysis. He is a new Clinical Psychiatry News editorial advisory board member.
Familiarizing yourself with Alcoholics Anonymous dictums
From “90 minutes in 90 days,” to “people, places, and things,” to “cucumbers and pickles,” Alcoholics Anonymous (AA) slogans have been influencing the public’s understanding of the addictive process for almost a century. Regrettably, these terms have, inadvertently, alienated the scientific community. The translation and subsequent use of AA slogans has been a valuable tool in engaging science experts with mutual-help fellowships such as AA.
Recent advances in the neurobiology and neurochemistry of addiction have validated several of the memorable sayings of AA.1 As a result, physicians and scientists are now more willing to explore AA’s mottos.
Here are five well-known AA slogans that we have translated into medical terms and then briefly assessed in terms of their validity and relevance in today’s treatment of alcohol addiction:
1. “90 meetings in 90 days”
TRUE! Clinically, the first three months of sobriety constitute the most severe part of prolonged withdrawal syndrome and pose the most dangerous opportunities for a relapse.
2. “Keep it simple”
NOT TRUE! Clinical research and everyday practice of addiction treatment show that combination approaches—with medications, group psychotherapy, individual psychotherapy, involvement in mutual-help groups, family therapy, primary care, and treatment of psychiatric comorbidities—typically result in better outcomes than singular approaches.2
3. “Denial is not just a river in Egypt”
NOT TRUE! Since motivational inter-viewing was introduced in the treatment of addiction, we have learned how to effectively work with patients who are in complete denial and have absolutely no interest in changing anything about their life.3
4. “Beware of people, places, and things”
TRUE! Otherwise known as “cues” in psychology literature, triggers of relapse have been implicated in both the basic understanding of the addictive process and its treatment. “Classical conditioning” and “operant conditioning” models of behavior incorporate triggers. Additionally, cognitive behavior therapy helps extensively with maintaining sobriety. Even the DSM-5 gives a nod to “people, places, and things” by introducing “cravings” as a bona fide criterion of a substance use disorder.
5. “A cucumber that has become a pickle cannot become a cucumber again”
EQUIVOCAL. It is not clear, and highly debatable, whether an alcoholic who has been sober for more than 20 years still has a heightened vulnerability to reverting to alcoholism after consumption of alcohol. What is evident is that, even if the neuroadaptations responsible for hijacking the pleasure-reward pathways of the brain one day return to a normal, pre-addiction state, this healing process takes a long time—probably measured in decades, not years.
Click here for another Pearl on alternatives to 12-step groups.
Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Volkow ND, Baler RD. Addiction science: Uncovering neurobiological complexity. Neuropharmacology. 2013; (13)217-7.
2. Nunes EV, Selzer J, Levounis P, et al. Substance dependence and co-occurring psychiatric disorders: Best practices for diagnosis and clinical treatment. New York, NY: Civic Research Institute, 2010.
3. Levounis, P, Arnaout B. Handbook of motivation and change: A practical guide for clinicians. Arlington, VA: American Psychiatric Publishing, Inc.; 2010.
From “90 minutes in 90 days,” to “people, places, and things,” to “cucumbers and pickles,” Alcoholics Anonymous (AA) slogans have been influencing the public’s understanding of the addictive process for almost a century. Regrettably, these terms have, inadvertently, alienated the scientific community. The translation and subsequent use of AA slogans has been a valuable tool in engaging science experts with mutual-help fellowships such as AA.
Recent advances in the neurobiology and neurochemistry of addiction have validated several of the memorable sayings of AA.1 As a result, physicians and scientists are now more willing to explore AA’s mottos.
Here are five well-known AA slogans that we have translated into medical terms and then briefly assessed in terms of their validity and relevance in today’s treatment of alcohol addiction:
1. “90 meetings in 90 days”
TRUE! Clinically, the first three months of sobriety constitute the most severe part of prolonged withdrawal syndrome and pose the most dangerous opportunities for a relapse.
2. “Keep it simple”
NOT TRUE! Clinical research and everyday practice of addiction treatment show that combination approaches—with medications, group psychotherapy, individual psychotherapy, involvement in mutual-help groups, family therapy, primary care, and treatment of psychiatric comorbidities—typically result in better outcomes than singular approaches.2
3. “Denial is not just a river in Egypt”
NOT TRUE! Since motivational inter-viewing was introduced in the treatment of addiction, we have learned how to effectively work with patients who are in complete denial and have absolutely no interest in changing anything about their life.3
4. “Beware of people, places, and things”
TRUE! Otherwise known as “cues” in psychology literature, triggers of relapse have been implicated in both the basic understanding of the addictive process and its treatment. “Classical conditioning” and “operant conditioning” models of behavior incorporate triggers. Additionally, cognitive behavior therapy helps extensively with maintaining sobriety. Even the DSM-5 gives a nod to “people, places, and things” by introducing “cravings” as a bona fide criterion of a substance use disorder.
5. “A cucumber that has become a pickle cannot become a cucumber again”
EQUIVOCAL. It is not clear, and highly debatable, whether an alcoholic who has been sober for more than 20 years still has a heightened vulnerability to reverting to alcoholism after consumption of alcohol. What is evident is that, even if the neuroadaptations responsible for hijacking the pleasure-reward pathways of the brain one day return to a normal, pre-addiction state, this healing process takes a long time—probably measured in decades, not years.
Click here for another Pearl on alternatives to 12-step groups.
Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
From “90 minutes in 90 days,” to “people, places, and things,” to “cucumbers and pickles,” Alcoholics Anonymous (AA) slogans have been influencing the public’s understanding of the addictive process for almost a century. Regrettably, these terms have, inadvertently, alienated the scientific community. The translation and subsequent use of AA slogans has been a valuable tool in engaging science experts with mutual-help fellowships such as AA.
Recent advances in the neurobiology and neurochemistry of addiction have validated several of the memorable sayings of AA.1 As a result, physicians and scientists are now more willing to explore AA’s mottos.
Here are five well-known AA slogans that we have translated into medical terms and then briefly assessed in terms of their validity and relevance in today’s treatment of alcohol addiction:
1. “90 meetings in 90 days”
TRUE! Clinically, the first three months of sobriety constitute the most severe part of prolonged withdrawal syndrome and pose the most dangerous opportunities for a relapse.
2. “Keep it simple”
NOT TRUE! Clinical research and everyday practice of addiction treatment show that combination approaches—with medications, group psychotherapy, individual psychotherapy, involvement in mutual-help groups, family therapy, primary care, and treatment of psychiatric comorbidities—typically result in better outcomes than singular approaches.2
3. “Denial is not just a river in Egypt”
NOT TRUE! Since motivational inter-viewing was introduced in the treatment of addiction, we have learned how to effectively work with patients who are in complete denial and have absolutely no interest in changing anything about their life.3
4. “Beware of people, places, and things”
TRUE! Otherwise known as “cues” in psychology literature, triggers of relapse have been implicated in both the basic understanding of the addictive process and its treatment. “Classical conditioning” and “operant conditioning” models of behavior incorporate triggers. Additionally, cognitive behavior therapy helps extensively with maintaining sobriety. Even the DSM-5 gives a nod to “people, places, and things” by introducing “cravings” as a bona fide criterion of a substance use disorder.
5. “A cucumber that has become a pickle cannot become a cucumber again”
EQUIVOCAL. It is not clear, and highly debatable, whether an alcoholic who has been sober for more than 20 years still has a heightened vulnerability to reverting to alcoholism after consumption of alcohol. What is evident is that, even if the neuroadaptations responsible for hijacking the pleasure-reward pathways of the brain one day return to a normal, pre-addiction state, this healing process takes a long time—probably measured in decades, not years.
Click here for another Pearl on alternatives to 12-step groups.
Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Volkow ND, Baler RD. Addiction science: Uncovering neurobiological complexity. Neuropharmacology. 2013; (13)217-7.
2. Nunes EV, Selzer J, Levounis P, et al. Substance dependence and co-occurring psychiatric disorders: Best practices for diagnosis and clinical treatment. New York, NY: Civic Research Institute, 2010.
3. Levounis, P, Arnaout B. Handbook of motivation and change: A practical guide for clinicians. Arlington, VA: American Psychiatric Publishing, Inc.; 2010.
1. Volkow ND, Baler RD. Addiction science: Uncovering neurobiological complexity. Neuropharmacology. 2013; (13)217-7.
2. Nunes EV, Selzer J, Levounis P, et al. Substance dependence and co-occurring psychiatric disorders: Best practices for diagnosis and clinical treatment. New York, NY: Civic Research Institute, 2010.
3. Levounis, P, Arnaout B. Handbook of motivation and change: A practical guide for clinicians. Arlington, VA: American Psychiatric Publishing, Inc.; 2010.
Alternatives to 12-step groups
Persons addicted to drugs often are among the most marginalized psychiatric patients, but are in need of the most support.1 Many of these patients have comorbid medical and psychiatric problems, including difficult-to-treat pathologies that may have developed because of a traumatic experience or an attachment disorder that dominates their emotional lives.2 These patients value clinicians who engage them in an open, nonjudgmental, and empathetic way.
Eliciting a patient’s reasons for change and introducing him (her) to a variety of peer-led recovery group options that complement and support psychotherapy and pharmacotherapy can be valuable. Although most clinicians are aware of the traditional 12-step group model that embraces spirituality, many might know less about other groups that can play an instrumental role in engaging patients and placing them on the path to recovery.
SMART (Self-Management and Recovery Training) Recovery5 is a nonprofit organization that does not employ the 12-step model; instead, it uses evidence-based, non-confrontational, motivational, behavioral, and cognitive approaches to achieve abstinence.
Women for Sobriety6 helps women achieve abstinence.
LifeRing Secular Recovery7 works on empowering the “sober self” through groups that de-emphasize drug and alcohol use in personal histories.
Rational Recovery8 uses the Addictive Voice Recognition Technique to empower people overcoming addictions. This technique trains individuals to recognize the “addictive voice.” It does not support the theory of continuous recovery, or even recovery groups, but enables the user to achieve sobriety independently. This program greatly limits interaction between people overcoming addiction and physicians and counselors—save for periods of serious withdrawal.
The Community Reinforcement Approach (CRA)9 is an evidence-based program that focuses primarily on environmental and social factors influencing sobriety. This behavioral approach emphasizes the role of contingencies that can encourage or discourage sobriety. CRA has been studied in outpatients—predominantly homeless persons—and inpatients, and in a range of abused substances.
Click here for another Pearl on familiarizing yourself with Alcoholics Anonymous dictums.
Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Kreek MJ. Extreme marginalization: addiction and other mental health disorders, stigma, and imprisonment. Ann N Y Acad Sci. 2011;1231:65-72.
2. Wu NS, Schairer LC, Dellor E, et al. Childhood trauma and health outcomes in adults with comorbid substance abuse and mental health disorders. Addict Behav. 2010;35(1):68-71.
3. Moderation Management. http://www.moderation.org. Accessed April 12, 2013.
4. Moderation Management. What is moderation management? http://www.moderation.org/whatisMM.shtml. Accessed August 6, 2013.
5. SMART (Self Management and Recovery Training) Recovery. http://www.smartrecovery.org. Accessed April 12, 2013.
6. Women for Sobriety. http://www.womenforsobriety.org. Accessed April 12, 2013.
7. LifeRing. http://lifering.org. Accessed April 12, 2013.
8. Rational Recovery. http://www.rational.org. Published October 25, 1995. Accessed April 12, 2013.
9. Miller WR, Meyers RJ, Hiller-Sturmhofel S. The community-reinforcement approach. http://pubs.niaaa.nih.gov/publications/arh23-2/116-121.pdf. Accessed August 6, 2013.
Persons addicted to drugs often are among the most marginalized psychiatric patients, but are in need of the most support.1 Many of these patients have comorbid medical and psychiatric problems, including difficult-to-treat pathologies that may have developed because of a traumatic experience or an attachment disorder that dominates their emotional lives.2 These patients value clinicians who engage them in an open, nonjudgmental, and empathetic way.
Eliciting a patient’s reasons for change and introducing him (her) to a variety of peer-led recovery group options that complement and support psychotherapy and pharmacotherapy can be valuable. Although most clinicians are aware of the traditional 12-step group model that embraces spirituality, many might know less about other groups that can play an instrumental role in engaging patients and placing them on the path to recovery.
SMART (Self-Management and Recovery Training) Recovery5 is a nonprofit organization that does not employ the 12-step model; instead, it uses evidence-based, non-confrontational, motivational, behavioral, and cognitive approaches to achieve abstinence.
Women for Sobriety6 helps women achieve abstinence.
LifeRing Secular Recovery7 works on empowering the “sober self” through groups that de-emphasize drug and alcohol use in personal histories.
Rational Recovery8 uses the Addictive Voice Recognition Technique to empower people overcoming addictions. This technique trains individuals to recognize the “addictive voice.” It does not support the theory of continuous recovery, or even recovery groups, but enables the user to achieve sobriety independently. This program greatly limits interaction between people overcoming addiction and physicians and counselors—save for periods of serious withdrawal.
The Community Reinforcement Approach (CRA)9 is an evidence-based program that focuses primarily on environmental and social factors influencing sobriety. This behavioral approach emphasizes the role of contingencies that can encourage or discourage sobriety. CRA has been studied in outpatients—predominantly homeless persons—and inpatients, and in a range of abused substances.
Click here for another Pearl on familiarizing yourself with Alcoholics Anonymous dictums.
Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
Persons addicted to drugs often are among the most marginalized psychiatric patients, but are in need of the most support.1 Many of these patients have comorbid medical and psychiatric problems, including difficult-to-treat pathologies that may have developed because of a traumatic experience or an attachment disorder that dominates their emotional lives.2 These patients value clinicians who engage them in an open, nonjudgmental, and empathetic way.
Eliciting a patient’s reasons for change and introducing him (her) to a variety of peer-led recovery group options that complement and support psychotherapy and pharmacotherapy can be valuable. Although most clinicians are aware of the traditional 12-step group model that embraces spirituality, many might know less about other groups that can play an instrumental role in engaging patients and placing them on the path to recovery.
SMART (Self-Management and Recovery Training) Recovery5 is a nonprofit organization that does not employ the 12-step model; instead, it uses evidence-based, non-confrontational, motivational, behavioral, and cognitive approaches to achieve abstinence.
Women for Sobriety6 helps women achieve abstinence.
LifeRing Secular Recovery7 works on empowering the “sober self” through groups that de-emphasize drug and alcohol use in personal histories.
Rational Recovery8 uses the Addictive Voice Recognition Technique to empower people overcoming addictions. This technique trains individuals to recognize the “addictive voice.” It does not support the theory of continuous recovery, or even recovery groups, but enables the user to achieve sobriety independently. This program greatly limits interaction between people overcoming addiction and physicians and counselors—save for periods of serious withdrawal.
The Community Reinforcement Approach (CRA)9 is an evidence-based program that focuses primarily on environmental and social factors influencing sobriety. This behavioral approach emphasizes the role of contingencies that can encourage or discourage sobriety. CRA has been studied in outpatients—predominantly homeless persons—and inpatients, and in a range of abused substances.
Click here for another Pearl on familiarizing yourself with Alcoholics Anonymous dictums.
Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Kreek MJ. Extreme marginalization: addiction and other mental health disorders, stigma, and imprisonment. Ann N Y Acad Sci. 2011;1231:65-72.
2. Wu NS, Schairer LC, Dellor E, et al. Childhood trauma and health outcomes in adults with comorbid substance abuse and mental health disorders. Addict Behav. 2010;35(1):68-71.
3. Moderation Management. http://www.moderation.org. Accessed April 12, 2013.
4. Moderation Management. What is moderation management? http://www.moderation.org/whatisMM.shtml. Accessed August 6, 2013.
5. SMART (Self Management and Recovery Training) Recovery. http://www.smartrecovery.org. Accessed April 12, 2013.
6. Women for Sobriety. http://www.womenforsobriety.org. Accessed April 12, 2013.
7. LifeRing. http://lifering.org. Accessed April 12, 2013.
8. Rational Recovery. http://www.rational.org. Published October 25, 1995. Accessed April 12, 2013.
9. Miller WR, Meyers RJ, Hiller-Sturmhofel S. The community-reinforcement approach. http://pubs.niaaa.nih.gov/publications/arh23-2/116-121.pdf. Accessed August 6, 2013.
1. Kreek MJ. Extreme marginalization: addiction and other mental health disorders, stigma, and imprisonment. Ann N Y Acad Sci. 2011;1231:65-72.
2. Wu NS, Schairer LC, Dellor E, et al. Childhood trauma and health outcomes in adults with comorbid substance abuse and mental health disorders. Addict Behav. 2010;35(1):68-71.
3. Moderation Management. http://www.moderation.org. Accessed April 12, 2013.
4. Moderation Management. What is moderation management? http://www.moderation.org/whatisMM.shtml. Accessed August 6, 2013.
5. SMART (Self Management and Recovery Training) Recovery. http://www.smartrecovery.org. Accessed April 12, 2013.
6. Women for Sobriety. http://www.womenforsobriety.org. Accessed April 12, 2013.
7. LifeRing. http://lifering.org. Accessed April 12, 2013.
8. Rational Recovery. http://www.rational.org. Published October 25, 1995. Accessed April 12, 2013.
9. Miller WR, Meyers RJ, Hiller-Sturmhofel S. The community-reinforcement approach. http://pubs.niaaa.nih.gov/publications/arh23-2/116-121.pdf. Accessed August 6, 2013.
The clinician's role in the face of domestic violence
Patients often use the clinical encounter to divulge intimate and sometimes frightening details about their domestic lives. Family secrets, especially those as serious as intimate partner violence, are highly charged and thus are challenging for us to contain. Clinicians must receive, process, and respond to this information in an optimal way while simultaneously honoring and promoting their patients’ autonomy. Even the most experienced clinician might have trouble addressing situations in which a patient is at risk of significant physical and emotional harm.
Higher rates of domestic violence are experienced by psychiatric patients, compared with nonpsychiatric patients. However, violence is often underdetected, even in clinical settings (Psychol. Med. 2010 40;881-93). Women are victims of forced sex or sexual assault by an intimate partner seven times more often than men, but men, too, can be victims of domestic violence.
Domestic violence can include physical, sexual, emotional, and psychological abuse. When conceptualized as a disorder of power and control, domestic violence also can include coercive social, financial, and vocational control. It is associated with long-term physical and psychological consequences. Common injuries in domestic abuse include bruising, internal injuries, head trauma, broken bones, and gynecologic problems. Additionally, anxiety, depression, posttraumatic stress disorder, and self-harm behaviors are widespread among victims of domestic violence.
What keeps individuals in abusive relationships, despite the psychological and physical harm perpetrated against them, is multiply determined. Domestic trauma can cause significant neurobiological changes in the brain, decreasing an individual’s ability to use higher cortical functions, resulting in difficulty with impulse control and emotion regulation (British J. Psychiatry 2002;181:102-10 and Am. J. Psychiatry 2005;162:1961-3). When emotion-driven judgment prevails over-rational thinking, attachment frequently trumps the fear of further violence (Can. J. Psychiatry 1995;40:234-40), and taking effective action may prove too overwhelming.
Domestic violence – which thrives in the secrecy and isolation of the violent couple or family – also can contribute to feelings of shame, embarrassment, denial, and self-blame – all of which make it difficult for patients to find the perspective and resolve required to end an abusive relationship or even to make a disclosure of intimate partner violence.
Patients are often hesitant to disclose abuse because of wide-ranging fears, including fears related to social service involvement, retaliation, disruption of family life, and the possibility of not being believed (Brit. J. Psychiatry 2011;198:189-94). Patients are more likely to disclose abuse when asked directly about domestic violence, but may need to be asked more than once before they are ready to disclose.
For clinicians, the experience of being on the receiving end of the disclosure can bring up feelings such as helplessness, anger, and sadness. It can be difficult to keep in mind that even at the point of disclosure, patients are at varying stages of readiness to take any action. It can be tempting to give the patient advice, but it is more therapeutically effective to create a safe, supportive, and nonjudgmental environment.
In a trusting relationship, patients can feel empowered to explore their options and the complexities of their particular situation with the clinician. Clearly, in cases where minor children are witnesses or recipients of abuse, appropriate authorities such as Child Protective Services must be contacted. In the case of elder abuse, Adult Protective Services must be notified.
The clinician plays an important role in fostering an open and safe dialogue about domestic violence. Having a strong working alliance and a solid understanding of domestic violence will enable clinicians to feel more confident and competent in discussions with their patients. Research suggests that clinicians are often hesitant to engage in discussions about domestic violence because of personal discomfort, lack of confidence, and/or lack of knowledge and expertise, which suggests that further training in this area might help facilitate these discussions.
Clinicians interested in learning more about domestic violence can contact the National Center for PTSD. The center provides free, online training on PTSD and on the use of psychiatric medications in PTSD; assessment; Cognitive Processing Therapy (CPT); and related topics. Patients who want more information about referrals in their area can contact the National Domestic Violence Hotline or call 1-800-799-SAFE.
Dr. Briggie is a staff psychologist at the Center for Motivation and Change, New York. Dr. Ascher is a postdoctoral fellow in Addiction Psychiatry at the University of Pennsylvania, Philadelphia. The authors would like to thank Anna Kreiter, a research assistant at the Family Center for Bipolar at Beth Israel Medical Center, New York, for her contributions to this Commentary.
Patients often use the clinical encounter to divulge intimate and sometimes frightening details about their domestic lives. Family secrets, especially those as serious as intimate partner violence, are highly charged and thus are challenging for us to contain. Clinicians must receive, process, and respond to this information in an optimal way while simultaneously honoring and promoting their patients’ autonomy. Even the most experienced clinician might have trouble addressing situations in which a patient is at risk of significant physical and emotional harm.
Higher rates of domestic violence are experienced by psychiatric patients, compared with nonpsychiatric patients. However, violence is often underdetected, even in clinical settings (Psychol. Med. 2010 40;881-93). Women are victims of forced sex or sexual assault by an intimate partner seven times more often than men, but men, too, can be victims of domestic violence.
Domestic violence can include physical, sexual, emotional, and psychological abuse. When conceptualized as a disorder of power and control, domestic violence also can include coercive social, financial, and vocational control. It is associated with long-term physical and psychological consequences. Common injuries in domestic abuse include bruising, internal injuries, head trauma, broken bones, and gynecologic problems. Additionally, anxiety, depression, posttraumatic stress disorder, and self-harm behaviors are widespread among victims of domestic violence.
What keeps individuals in abusive relationships, despite the psychological and physical harm perpetrated against them, is multiply determined. Domestic trauma can cause significant neurobiological changes in the brain, decreasing an individual’s ability to use higher cortical functions, resulting in difficulty with impulse control and emotion regulation (British J. Psychiatry 2002;181:102-10 and Am. J. Psychiatry 2005;162:1961-3). When emotion-driven judgment prevails over-rational thinking, attachment frequently trumps the fear of further violence (Can. J. Psychiatry 1995;40:234-40), and taking effective action may prove too overwhelming.
Domestic violence – which thrives in the secrecy and isolation of the violent couple or family – also can contribute to feelings of shame, embarrassment, denial, and self-blame – all of which make it difficult for patients to find the perspective and resolve required to end an abusive relationship or even to make a disclosure of intimate partner violence.
Patients are often hesitant to disclose abuse because of wide-ranging fears, including fears related to social service involvement, retaliation, disruption of family life, and the possibility of not being believed (Brit. J. Psychiatry 2011;198:189-94). Patients are more likely to disclose abuse when asked directly about domestic violence, but may need to be asked more than once before they are ready to disclose.
For clinicians, the experience of being on the receiving end of the disclosure can bring up feelings such as helplessness, anger, and sadness. It can be difficult to keep in mind that even at the point of disclosure, patients are at varying stages of readiness to take any action. It can be tempting to give the patient advice, but it is more therapeutically effective to create a safe, supportive, and nonjudgmental environment.
In a trusting relationship, patients can feel empowered to explore their options and the complexities of their particular situation with the clinician. Clearly, in cases where minor children are witnesses or recipients of abuse, appropriate authorities such as Child Protective Services must be contacted. In the case of elder abuse, Adult Protective Services must be notified.
The clinician plays an important role in fostering an open and safe dialogue about domestic violence. Having a strong working alliance and a solid understanding of domestic violence will enable clinicians to feel more confident and competent in discussions with their patients. Research suggests that clinicians are often hesitant to engage in discussions about domestic violence because of personal discomfort, lack of confidence, and/or lack of knowledge and expertise, which suggests that further training in this area might help facilitate these discussions.
Clinicians interested in learning more about domestic violence can contact the National Center for PTSD. The center provides free, online training on PTSD and on the use of psychiatric medications in PTSD; assessment; Cognitive Processing Therapy (CPT); and related topics. Patients who want more information about referrals in their area can contact the National Domestic Violence Hotline or call 1-800-799-SAFE.
Dr. Briggie is a staff psychologist at the Center for Motivation and Change, New York. Dr. Ascher is a postdoctoral fellow in Addiction Psychiatry at the University of Pennsylvania, Philadelphia. The authors would like to thank Anna Kreiter, a research assistant at the Family Center for Bipolar at Beth Israel Medical Center, New York, for her contributions to this Commentary.
Patients often use the clinical encounter to divulge intimate and sometimes frightening details about their domestic lives. Family secrets, especially those as serious as intimate partner violence, are highly charged and thus are challenging for us to contain. Clinicians must receive, process, and respond to this information in an optimal way while simultaneously honoring and promoting their patients’ autonomy. Even the most experienced clinician might have trouble addressing situations in which a patient is at risk of significant physical and emotional harm.
Higher rates of domestic violence are experienced by psychiatric patients, compared with nonpsychiatric patients. However, violence is often underdetected, even in clinical settings (Psychol. Med. 2010 40;881-93). Women are victims of forced sex or sexual assault by an intimate partner seven times more often than men, but men, too, can be victims of domestic violence.
Domestic violence can include physical, sexual, emotional, and psychological abuse. When conceptualized as a disorder of power and control, domestic violence also can include coercive social, financial, and vocational control. It is associated with long-term physical and psychological consequences. Common injuries in domestic abuse include bruising, internal injuries, head trauma, broken bones, and gynecologic problems. Additionally, anxiety, depression, posttraumatic stress disorder, and self-harm behaviors are widespread among victims of domestic violence.
What keeps individuals in abusive relationships, despite the psychological and physical harm perpetrated against them, is multiply determined. Domestic trauma can cause significant neurobiological changes in the brain, decreasing an individual’s ability to use higher cortical functions, resulting in difficulty with impulse control and emotion regulation (British J. Psychiatry 2002;181:102-10 and Am. J. Psychiatry 2005;162:1961-3). When emotion-driven judgment prevails over-rational thinking, attachment frequently trumps the fear of further violence (Can. J. Psychiatry 1995;40:234-40), and taking effective action may prove too overwhelming.
Domestic violence – which thrives in the secrecy and isolation of the violent couple or family – also can contribute to feelings of shame, embarrassment, denial, and self-blame – all of which make it difficult for patients to find the perspective and resolve required to end an abusive relationship or even to make a disclosure of intimate partner violence.
Patients are often hesitant to disclose abuse because of wide-ranging fears, including fears related to social service involvement, retaliation, disruption of family life, and the possibility of not being believed (Brit. J. Psychiatry 2011;198:189-94). Patients are more likely to disclose abuse when asked directly about domestic violence, but may need to be asked more than once before they are ready to disclose.
For clinicians, the experience of being on the receiving end of the disclosure can bring up feelings such as helplessness, anger, and sadness. It can be difficult to keep in mind that even at the point of disclosure, patients are at varying stages of readiness to take any action. It can be tempting to give the patient advice, but it is more therapeutically effective to create a safe, supportive, and nonjudgmental environment.
In a trusting relationship, patients can feel empowered to explore their options and the complexities of their particular situation with the clinician. Clearly, in cases where minor children are witnesses or recipients of abuse, appropriate authorities such as Child Protective Services must be contacted. In the case of elder abuse, Adult Protective Services must be notified.
The clinician plays an important role in fostering an open and safe dialogue about domestic violence. Having a strong working alliance and a solid understanding of domestic violence will enable clinicians to feel more confident and competent in discussions with their patients. Research suggests that clinicians are often hesitant to engage in discussions about domestic violence because of personal discomfort, lack of confidence, and/or lack of knowledge and expertise, which suggests that further training in this area might help facilitate these discussions.
Clinicians interested in learning more about domestic violence can contact the National Center for PTSD. The center provides free, online training on PTSD and on the use of psychiatric medications in PTSD; assessment; Cognitive Processing Therapy (CPT); and related topics. Patients who want more information about referrals in their area can contact the National Domestic Violence Hotline or call 1-800-799-SAFE.
Dr. Briggie is a staff psychologist at the Center for Motivation and Change, New York. Dr. Ascher is a postdoctoral fellow in Addiction Psychiatry at the University of Pennsylvania, Philadelphia. The authors would like to thank Anna Kreiter, a research assistant at the Family Center for Bipolar at Beth Israel Medical Center, New York, for her contributions to this Commentary.
Therapy helps visually impaired patient with depression
Ms. A is a 51-year-old woman with a longstanding history of anxiety and recent loss of functioning because of polyneuropathy and progressive visual loss from years of uncontrolled diabetes. She is highly intelligent and well spoken, and enjoys reading novels, writing poems, and painting. Although Ms. A is no longer able to run her graphic design business, she has been unable to gather the strength to dissolve the business properly. She lives with her elderly aunt and has a home attendant 5 days per week. During her most recent medication management visit, she tearfully states that she feels very lonely and angry and that life seems hopeless.
Helping patients alleviate suffering associated with the loss of social, occupational, and psychological functioning is fundamental to the work we do as clinicians. Understanding and supporting the needs of visually impaired patients are an underappreciated topic deserving more awareness, especially since depression strikes persons with visual loss nearly twice as often as it does the general population (JAMA Ophthalmol. 2013;131:573-81). There is much more discussion about the needs of hearing-impaired patients, partly because of medicolegal concerns surrounding sign language interpreters.
Clinicians need to do a better job of effectively cultivating a greater sense of well-being and agency for patients suffering from visual loss.
In the case described above, Ms. A experienced a variety of emotions – guilt, anger, sadness, and hopelessness – in response to the realization that she had neglected her health for years, resulting in irreparable damage to her eyesight. Over the course of many sessions, Ms. A was given space to grieve the loss. She was open to exploring the negative cognitions that kept her in a state of inertia, putting her at risk of greater harm.
During this process, we elicited the patient’s motivations for enriching her life while problem solving around potential barriers. Using psychoeducation, we explained how unremitted depression amplified her guilt, and how guilt contributes to beliefs that treatment is undeserved. Those cognitions, in turn, can prompt avoidance of treatment altogether. To assuage her feelings of weakness about feeling depressed, we explained the research linking depression and visual loss.
Because Ms. A receives psychopharmacological treatment for depression, along with meds from many other prescribers, we addressed potential pitfalls. Pharmacies do not automatically provide verbal or large print instructions, so we contacted other prescribers and encouraged them to write "low vision" on prescriptions. Knowing that depressed or disabled persons may be reluctant to advocate for themselves, we telephoned her pharmacist in advance. We informed Ms. A that generics are often substituted for one another, so pills change size and shape. For visually impaired persons who rely on tactile cues to distinguish pills, such misidentification can prove deadly!
As a recipient of government-subsidized health insurance, Ms. A was eligible for visiting nursing services to arrange her meds. Patients with commercial insurance or no insurance can access related services through an ophthalmologist’s "low vision evaluation." In our experience, these referrals are not automatic, so contacting relative treaters directly is recommended.
Ms. A. was made aware of The Lighthouse, where volunteers read to the visually impaired, adding a human connection to "talking books." As a self-employed person, she did not need contact with federal Americans with Disabilities services, where visually impaired attorneys offer telephone advice (and inspiration). We deferred referral to Vocational and Educational Services for Individuals with Disabilities for vocational training before she fully mourned her visual loss.
Ms. A. did not volunteer mythical, cultural, or religious beliefs associated with her vision loss, so we inquired directly, since these factors can influence self-acceptance. Oedipus is arguably psychiatry’s best-known myth overall but is hardly the only classical myth about blindness.
"Bulfinchs Mythology" lists several mortals and deities who lost vision, with some gaining extra "insight" after losing sight and being credited with superhuman or prophetic abilities rather than discredited for their deficits. Because Deuteronomy links blindness (and madness) to punishment for sin (Deuteronomy 28:15-68), while the Gospels credit Jesus with healing the blind (Mark 8:22-6; Matthew 9:27-31), we queried her religious beliefs, either current or deep seated, and prepared her for a resurgence of long-forgotten Sunday school teachings under stress.
Ms. A’s interest in the visual arts caused concern in light of her condition, making us wonder whether she would benefit from redirecting her aesthetic interests to music. Appreciating music without sight is easy. There is a long list of renowned visually impaired musicians, including Stevie Wonder, Ray Charles, Art Tatum, Blind Willie McTell, and The Blind Boys of Alabama for starters. However, we chose to focus on established interests before encouraging alternative interests. We alerted her to museums that host "touchable" art shows or arrange annotated gallery tours for the visually challenged.
Soho’s Museum of Comic and Cartoon Art was one such museum, which coincidentally showcased images of blinded superheroes (Dr. Mid-Nite and Daredevil) who developed other skills after losing physical sight (Superheroes and Superegos: Analyzing the Minds Behind the Masks; Santa Barbara, Calif.: ABC-CLIO-Praeger, 2009). Such excursions into fantasy encourage brainstorming about creative ways to cultivate new skills, while broaching reality testing about what is possible in today’s world.
Ms. A has continued to make slow, but steady progress, and is less dysphoric and more hopeful. The therapeutic alliance is strong, and Ms. A is setting new goals for herself and making use of the resources we provided to her.
Dr. Packer is an assistant clinical professor of psychiatry and behavioral sciences at Albert Einstein College of Medicine, New York, and is in private practice. Her most recent book is Cinemas Sinister Psychiatrists: From Caligari to Hannibal (Jefferson, N.C.: McFarland, 2012). Dr. Ascher is a senior resident in psychiatry at Beth Israel Medical Center, New York.
Ms. A is a 51-year-old woman with a longstanding history of anxiety and recent loss of functioning because of polyneuropathy and progressive visual loss from years of uncontrolled diabetes. She is highly intelligent and well spoken, and enjoys reading novels, writing poems, and painting. Although Ms. A is no longer able to run her graphic design business, she has been unable to gather the strength to dissolve the business properly. She lives with her elderly aunt and has a home attendant 5 days per week. During her most recent medication management visit, she tearfully states that she feels very lonely and angry and that life seems hopeless.
Helping patients alleviate suffering associated with the loss of social, occupational, and psychological functioning is fundamental to the work we do as clinicians. Understanding and supporting the needs of visually impaired patients are an underappreciated topic deserving more awareness, especially since depression strikes persons with visual loss nearly twice as often as it does the general population (JAMA Ophthalmol. 2013;131:573-81). There is much more discussion about the needs of hearing-impaired patients, partly because of medicolegal concerns surrounding sign language interpreters.
Clinicians need to do a better job of effectively cultivating a greater sense of well-being and agency for patients suffering from visual loss.
In the case described above, Ms. A experienced a variety of emotions – guilt, anger, sadness, and hopelessness – in response to the realization that she had neglected her health for years, resulting in irreparable damage to her eyesight. Over the course of many sessions, Ms. A was given space to grieve the loss. She was open to exploring the negative cognitions that kept her in a state of inertia, putting her at risk of greater harm.
During this process, we elicited the patient’s motivations for enriching her life while problem solving around potential barriers. Using psychoeducation, we explained how unremitted depression amplified her guilt, and how guilt contributes to beliefs that treatment is undeserved. Those cognitions, in turn, can prompt avoidance of treatment altogether. To assuage her feelings of weakness about feeling depressed, we explained the research linking depression and visual loss.
Because Ms. A receives psychopharmacological treatment for depression, along with meds from many other prescribers, we addressed potential pitfalls. Pharmacies do not automatically provide verbal or large print instructions, so we contacted other prescribers and encouraged them to write "low vision" on prescriptions. Knowing that depressed or disabled persons may be reluctant to advocate for themselves, we telephoned her pharmacist in advance. We informed Ms. A that generics are often substituted for one another, so pills change size and shape. For visually impaired persons who rely on tactile cues to distinguish pills, such misidentification can prove deadly!
As a recipient of government-subsidized health insurance, Ms. A was eligible for visiting nursing services to arrange her meds. Patients with commercial insurance or no insurance can access related services through an ophthalmologist’s "low vision evaluation." In our experience, these referrals are not automatic, so contacting relative treaters directly is recommended.
Ms. A. was made aware of The Lighthouse, where volunteers read to the visually impaired, adding a human connection to "talking books." As a self-employed person, she did not need contact with federal Americans with Disabilities services, where visually impaired attorneys offer telephone advice (and inspiration). We deferred referral to Vocational and Educational Services for Individuals with Disabilities for vocational training before she fully mourned her visual loss.
Ms. A. did not volunteer mythical, cultural, or religious beliefs associated with her vision loss, so we inquired directly, since these factors can influence self-acceptance. Oedipus is arguably psychiatry’s best-known myth overall but is hardly the only classical myth about blindness.
"Bulfinchs Mythology" lists several mortals and deities who lost vision, with some gaining extra "insight" after losing sight and being credited with superhuman or prophetic abilities rather than discredited for their deficits. Because Deuteronomy links blindness (and madness) to punishment for sin (Deuteronomy 28:15-68), while the Gospels credit Jesus with healing the blind (Mark 8:22-6; Matthew 9:27-31), we queried her religious beliefs, either current or deep seated, and prepared her for a resurgence of long-forgotten Sunday school teachings under stress.
Ms. A’s interest in the visual arts caused concern in light of her condition, making us wonder whether she would benefit from redirecting her aesthetic interests to music. Appreciating music without sight is easy. There is a long list of renowned visually impaired musicians, including Stevie Wonder, Ray Charles, Art Tatum, Blind Willie McTell, and The Blind Boys of Alabama for starters. However, we chose to focus on established interests before encouraging alternative interests. We alerted her to museums that host "touchable" art shows or arrange annotated gallery tours for the visually challenged.
Soho’s Museum of Comic and Cartoon Art was one such museum, which coincidentally showcased images of blinded superheroes (Dr. Mid-Nite and Daredevil) who developed other skills after losing physical sight (Superheroes and Superegos: Analyzing the Minds Behind the Masks; Santa Barbara, Calif.: ABC-CLIO-Praeger, 2009). Such excursions into fantasy encourage brainstorming about creative ways to cultivate new skills, while broaching reality testing about what is possible in today’s world.
Ms. A has continued to make slow, but steady progress, and is less dysphoric and more hopeful. The therapeutic alliance is strong, and Ms. A is setting new goals for herself and making use of the resources we provided to her.
Dr. Packer is an assistant clinical professor of psychiatry and behavioral sciences at Albert Einstein College of Medicine, New York, and is in private practice. Her most recent book is Cinemas Sinister Psychiatrists: From Caligari to Hannibal (Jefferson, N.C.: McFarland, 2012). Dr. Ascher is a senior resident in psychiatry at Beth Israel Medical Center, New York.
Ms. A is a 51-year-old woman with a longstanding history of anxiety and recent loss of functioning because of polyneuropathy and progressive visual loss from years of uncontrolled diabetes. She is highly intelligent and well spoken, and enjoys reading novels, writing poems, and painting. Although Ms. A is no longer able to run her graphic design business, she has been unable to gather the strength to dissolve the business properly. She lives with her elderly aunt and has a home attendant 5 days per week. During her most recent medication management visit, she tearfully states that she feels very lonely and angry and that life seems hopeless.
Helping patients alleviate suffering associated with the loss of social, occupational, and psychological functioning is fundamental to the work we do as clinicians. Understanding and supporting the needs of visually impaired patients are an underappreciated topic deserving more awareness, especially since depression strikes persons with visual loss nearly twice as often as it does the general population (JAMA Ophthalmol. 2013;131:573-81). There is much more discussion about the needs of hearing-impaired patients, partly because of medicolegal concerns surrounding sign language interpreters.
Clinicians need to do a better job of effectively cultivating a greater sense of well-being and agency for patients suffering from visual loss.
In the case described above, Ms. A experienced a variety of emotions – guilt, anger, sadness, and hopelessness – in response to the realization that she had neglected her health for years, resulting in irreparable damage to her eyesight. Over the course of many sessions, Ms. A was given space to grieve the loss. She was open to exploring the negative cognitions that kept her in a state of inertia, putting her at risk of greater harm.
During this process, we elicited the patient’s motivations for enriching her life while problem solving around potential barriers. Using psychoeducation, we explained how unremitted depression amplified her guilt, and how guilt contributes to beliefs that treatment is undeserved. Those cognitions, in turn, can prompt avoidance of treatment altogether. To assuage her feelings of weakness about feeling depressed, we explained the research linking depression and visual loss.
Because Ms. A receives psychopharmacological treatment for depression, along with meds from many other prescribers, we addressed potential pitfalls. Pharmacies do not automatically provide verbal or large print instructions, so we contacted other prescribers and encouraged them to write "low vision" on prescriptions. Knowing that depressed or disabled persons may be reluctant to advocate for themselves, we telephoned her pharmacist in advance. We informed Ms. A that generics are often substituted for one another, so pills change size and shape. For visually impaired persons who rely on tactile cues to distinguish pills, such misidentification can prove deadly!
As a recipient of government-subsidized health insurance, Ms. A was eligible for visiting nursing services to arrange her meds. Patients with commercial insurance or no insurance can access related services through an ophthalmologist’s "low vision evaluation." In our experience, these referrals are not automatic, so contacting relative treaters directly is recommended.
Ms. A. was made aware of The Lighthouse, where volunteers read to the visually impaired, adding a human connection to "talking books." As a self-employed person, she did not need contact with federal Americans with Disabilities services, where visually impaired attorneys offer telephone advice (and inspiration). We deferred referral to Vocational and Educational Services for Individuals with Disabilities for vocational training before she fully mourned her visual loss.
Ms. A. did not volunteer mythical, cultural, or religious beliefs associated with her vision loss, so we inquired directly, since these factors can influence self-acceptance. Oedipus is arguably psychiatry’s best-known myth overall but is hardly the only classical myth about blindness.
"Bulfinchs Mythology" lists several mortals and deities who lost vision, with some gaining extra "insight" after losing sight and being credited with superhuman or prophetic abilities rather than discredited for their deficits. Because Deuteronomy links blindness (and madness) to punishment for sin (Deuteronomy 28:15-68), while the Gospels credit Jesus with healing the blind (Mark 8:22-6; Matthew 9:27-31), we queried her religious beliefs, either current or deep seated, and prepared her for a resurgence of long-forgotten Sunday school teachings under stress.
Ms. A’s interest in the visual arts caused concern in light of her condition, making us wonder whether she would benefit from redirecting her aesthetic interests to music. Appreciating music without sight is easy. There is a long list of renowned visually impaired musicians, including Stevie Wonder, Ray Charles, Art Tatum, Blind Willie McTell, and The Blind Boys of Alabama for starters. However, we chose to focus on established interests before encouraging alternative interests. We alerted her to museums that host "touchable" art shows or arrange annotated gallery tours for the visually challenged.
Soho’s Museum of Comic and Cartoon Art was one such museum, which coincidentally showcased images of blinded superheroes (Dr. Mid-Nite and Daredevil) who developed other skills after losing physical sight (Superheroes and Superegos: Analyzing the Minds Behind the Masks; Santa Barbara, Calif.: ABC-CLIO-Praeger, 2009). Such excursions into fantasy encourage brainstorming about creative ways to cultivate new skills, while broaching reality testing about what is possible in today’s world.
Ms. A has continued to make slow, but steady progress, and is less dysphoric and more hopeful. The therapeutic alliance is strong, and Ms. A is setting new goals for herself and making use of the resources we provided to her.
Dr. Packer is an assistant clinical professor of psychiatry and behavioral sciences at Albert Einstein College of Medicine, New York, and is in private practice. Her most recent book is Cinemas Sinister Psychiatrists: From Caligari to Hannibal (Jefferson, N.C.: McFarland, 2012). Dr. Ascher is a senior resident in psychiatry at Beth Israel Medical Center, New York.
'Prescribing' companion animals for patients with mental illness
Roughly 78 million, or 62% of households in the United States, have a pet, according to the American Pet Products Association. It is estimated that Americans will spend $55.53 billion on their pets in the year 2013 alone.
Over the last decade, the mental health profession has been placing an increased emphasis on the potential healing benefits of this animal companionship. In light of these trends, animal companionship can play an important role in our work with patients with mental illness and their families.
Froma Walsh, Ph.D., has examined both existing research and the history of animal companionship in a two-part review (Fam. Process 2009;48:462-80 and Fam. Process 2009;48:481-99). Dr. Walsh found that animals can assist in the family education of authority, boundaries, and communication. They also can become the subject of affection and attachment that provide the family with a common bond, according to Dr. Walsh, codirector and cofounder of the Chicago Center for Family Health, and the Mose and Sylvia Firestone Professor Emerita in the school of social service administration and department of psychiatry at the University of Chicago.
In addition, research has shown that a relationship exists between pets and improved outcomes within serious mental health diagnoses, such as bipolar disorder, schizophrenia, and schizoaffective disorder. For example, researchers at the New York State Psychiatric Institute found that pets provide outlets for empathy, connection, self-efficacy, and support for adults with serious illness. Their conclusion was based on surveys from 177 health maintenance organization members who had participated in the Study of Transitions and Recovery Strategies study (Am. J. Orthopsychiatry 2009;79:430-6). Interestingly, participants who owned pets were found to have a greater avoidance of isolating behaviors by providing a social outlet that helped them to connect with others.
We need to be aware of potential resources for using animal companions that can be tapped to help our patients. Within the canine species, three types of therapeutic dogs are shown to provide benefits to psychiatric patients: Emotional Support Dogs (ESDs), Mental Healthy/Psychiatric Service Dogs, and Therapy Dogs.
An ESD is a therapeutic dog that can be used to assist an elderly person or an individual with disabilities. The primary purpose of an ESD is to provide the owner with affection, companionship, and improved motivation to fulfill important tasks of daily living, such as getting a basic amount of exercise and going outside. ESDs do not qualify as service dogs under the Americans with Disabilities Act, but they are covered under the Fair Housing Amendment Act and the Amended Air Carrier Access Act. Therefore, ESDs can live in certain types of housing that have "no pet rules" and must be allowed to sit with their owners in the cabin of an aircraft.
Mental Health/Psychiatric Service Dogs undergo rigorous and specialized training in basic and advanced obedience, public access, and task performance. These dogs are found to be especially effective in the lives of people who suffer from anxiety disorders, including posttraumatic stress disorder. They can perform such tasks as providing a buffer for the handler in crowded areas by creating a physical barrier, standing behind the owner and others to increase feelings of security, and helping reduce hypervigilance on the part of their owners. They also can be trained to remind owners to take medication.
Therapy Dogs are available to provide affection and comfort for people in nursing homes, hospitals, hospices, and community centers. To be registered as a therapy dog or cat, the pet must be very social and enjoy human companionship. The dog should know basic obedience cues and be able to sit down, stay, heel, leave it, and come when called. Animals and their handlers must be registered and pass a certification exam that are offered by organizations such as Pet Partners.
The National Alliance on Mental Illness provides free, ongoing groups that offer peer support and therapeutic interaction with professionally trained pet therapy dogs. In addition, many animal shelters often look for volunteers to spend time caring for and engaging with animals. In our clinical experience, we have found that patients gain a greater sense of independence, self-worth, and purpose by not only interacting with therapy dogs but also by engaging in this type of volunteer work with their own pets.
Another useful resource, Puppies Behind Bars, is an organization that helps inmates train service dogs for veterans with PTSD. Paws and Stripes provides veterans who suffer from PTSD with a shelter dog and interactive training at no cost. Heeling Allies privately trains both mental health service dogs and ESDs to enrich the lives of individuals living with psychological, neurologic, and developmental impairments such as PTSD, depressive and anxiety disorders, autism spectrum disorders, and Tourette syndrome.
Given the shifting focus of psychiatry to a more comprehensive recovery model, evidence that animals can function not only as social companions, but also as therapy pets is gaining attention. With further research, we might be able to determine a mental health need presented by a patient and subsequently "prescribe" the kind of animal that would be best suited to "treat" the need.
In the meantime, clinicians should keep in mind the benefits of pet companionship. Discussions involving the meaning of pets in patients’ lives might increase the therapeutic alliance and make patients feel more connected, understood, and engaged in their treatment.
Dr. Wittenauer is a resident in the department of psychiatry and behavioral sciences, Emory University, Atlanta. Dr. Ascher is a resident in the department of psychiatry and behavioral sciences, Beth Israel Medical Center, New York.
Roughly 78 million, or 62% of households in the United States, have a pet, according to the American Pet Products Association. It is estimated that Americans will spend $55.53 billion on their pets in the year 2013 alone.
Over the last decade, the mental health profession has been placing an increased emphasis on the potential healing benefits of this animal companionship. In light of these trends, animal companionship can play an important role in our work with patients with mental illness and their families.
Froma Walsh, Ph.D., has examined both existing research and the history of animal companionship in a two-part review (Fam. Process 2009;48:462-80 and Fam. Process 2009;48:481-99). Dr. Walsh found that animals can assist in the family education of authority, boundaries, and communication. They also can become the subject of affection and attachment that provide the family with a common bond, according to Dr. Walsh, codirector and cofounder of the Chicago Center for Family Health, and the Mose and Sylvia Firestone Professor Emerita in the school of social service administration and department of psychiatry at the University of Chicago.
In addition, research has shown that a relationship exists between pets and improved outcomes within serious mental health diagnoses, such as bipolar disorder, schizophrenia, and schizoaffective disorder. For example, researchers at the New York State Psychiatric Institute found that pets provide outlets for empathy, connection, self-efficacy, and support for adults with serious illness. Their conclusion was based on surveys from 177 health maintenance organization members who had participated in the Study of Transitions and Recovery Strategies study (Am. J. Orthopsychiatry 2009;79:430-6). Interestingly, participants who owned pets were found to have a greater avoidance of isolating behaviors by providing a social outlet that helped them to connect with others.
We need to be aware of potential resources for using animal companions that can be tapped to help our patients. Within the canine species, three types of therapeutic dogs are shown to provide benefits to psychiatric patients: Emotional Support Dogs (ESDs), Mental Healthy/Psychiatric Service Dogs, and Therapy Dogs.
An ESD is a therapeutic dog that can be used to assist an elderly person or an individual with disabilities. The primary purpose of an ESD is to provide the owner with affection, companionship, and improved motivation to fulfill important tasks of daily living, such as getting a basic amount of exercise and going outside. ESDs do not qualify as service dogs under the Americans with Disabilities Act, but they are covered under the Fair Housing Amendment Act and the Amended Air Carrier Access Act. Therefore, ESDs can live in certain types of housing that have "no pet rules" and must be allowed to sit with their owners in the cabin of an aircraft.
Mental Health/Psychiatric Service Dogs undergo rigorous and specialized training in basic and advanced obedience, public access, and task performance. These dogs are found to be especially effective in the lives of people who suffer from anxiety disorders, including posttraumatic stress disorder. They can perform such tasks as providing a buffer for the handler in crowded areas by creating a physical barrier, standing behind the owner and others to increase feelings of security, and helping reduce hypervigilance on the part of their owners. They also can be trained to remind owners to take medication.
Therapy Dogs are available to provide affection and comfort for people in nursing homes, hospitals, hospices, and community centers. To be registered as a therapy dog or cat, the pet must be very social and enjoy human companionship. The dog should know basic obedience cues and be able to sit down, stay, heel, leave it, and come when called. Animals and their handlers must be registered and pass a certification exam that are offered by organizations such as Pet Partners.
The National Alliance on Mental Illness provides free, ongoing groups that offer peer support and therapeutic interaction with professionally trained pet therapy dogs. In addition, many animal shelters often look for volunteers to spend time caring for and engaging with animals. In our clinical experience, we have found that patients gain a greater sense of independence, self-worth, and purpose by not only interacting with therapy dogs but also by engaging in this type of volunteer work with their own pets.
Another useful resource, Puppies Behind Bars, is an organization that helps inmates train service dogs for veterans with PTSD. Paws and Stripes provides veterans who suffer from PTSD with a shelter dog and interactive training at no cost. Heeling Allies privately trains both mental health service dogs and ESDs to enrich the lives of individuals living with psychological, neurologic, and developmental impairments such as PTSD, depressive and anxiety disorders, autism spectrum disorders, and Tourette syndrome.
Given the shifting focus of psychiatry to a more comprehensive recovery model, evidence that animals can function not only as social companions, but also as therapy pets is gaining attention. With further research, we might be able to determine a mental health need presented by a patient and subsequently "prescribe" the kind of animal that would be best suited to "treat" the need.
In the meantime, clinicians should keep in mind the benefits of pet companionship. Discussions involving the meaning of pets in patients’ lives might increase the therapeutic alliance and make patients feel more connected, understood, and engaged in their treatment.
Dr. Wittenauer is a resident in the department of psychiatry and behavioral sciences, Emory University, Atlanta. Dr. Ascher is a resident in the department of psychiatry and behavioral sciences, Beth Israel Medical Center, New York.
Roughly 78 million, or 62% of households in the United States, have a pet, according to the American Pet Products Association. It is estimated that Americans will spend $55.53 billion on their pets in the year 2013 alone.
Over the last decade, the mental health profession has been placing an increased emphasis on the potential healing benefits of this animal companionship. In light of these trends, animal companionship can play an important role in our work with patients with mental illness and their families.
Froma Walsh, Ph.D., has examined both existing research and the history of animal companionship in a two-part review (Fam. Process 2009;48:462-80 and Fam. Process 2009;48:481-99). Dr. Walsh found that animals can assist in the family education of authority, boundaries, and communication. They also can become the subject of affection and attachment that provide the family with a common bond, according to Dr. Walsh, codirector and cofounder of the Chicago Center for Family Health, and the Mose and Sylvia Firestone Professor Emerita in the school of social service administration and department of psychiatry at the University of Chicago.
In addition, research has shown that a relationship exists between pets and improved outcomes within serious mental health diagnoses, such as bipolar disorder, schizophrenia, and schizoaffective disorder. For example, researchers at the New York State Psychiatric Institute found that pets provide outlets for empathy, connection, self-efficacy, and support for adults with serious illness. Their conclusion was based on surveys from 177 health maintenance organization members who had participated in the Study of Transitions and Recovery Strategies study (Am. J. Orthopsychiatry 2009;79:430-6). Interestingly, participants who owned pets were found to have a greater avoidance of isolating behaviors by providing a social outlet that helped them to connect with others.
We need to be aware of potential resources for using animal companions that can be tapped to help our patients. Within the canine species, three types of therapeutic dogs are shown to provide benefits to psychiatric patients: Emotional Support Dogs (ESDs), Mental Healthy/Psychiatric Service Dogs, and Therapy Dogs.
An ESD is a therapeutic dog that can be used to assist an elderly person or an individual with disabilities. The primary purpose of an ESD is to provide the owner with affection, companionship, and improved motivation to fulfill important tasks of daily living, such as getting a basic amount of exercise and going outside. ESDs do not qualify as service dogs under the Americans with Disabilities Act, but they are covered under the Fair Housing Amendment Act and the Amended Air Carrier Access Act. Therefore, ESDs can live in certain types of housing that have "no pet rules" and must be allowed to sit with their owners in the cabin of an aircraft.
Mental Health/Psychiatric Service Dogs undergo rigorous and specialized training in basic and advanced obedience, public access, and task performance. These dogs are found to be especially effective in the lives of people who suffer from anxiety disorders, including posttraumatic stress disorder. They can perform such tasks as providing a buffer for the handler in crowded areas by creating a physical barrier, standing behind the owner and others to increase feelings of security, and helping reduce hypervigilance on the part of their owners. They also can be trained to remind owners to take medication.
Therapy Dogs are available to provide affection and comfort for people in nursing homes, hospitals, hospices, and community centers. To be registered as a therapy dog or cat, the pet must be very social and enjoy human companionship. The dog should know basic obedience cues and be able to sit down, stay, heel, leave it, and come when called. Animals and their handlers must be registered and pass a certification exam that are offered by organizations such as Pet Partners.
The National Alliance on Mental Illness provides free, ongoing groups that offer peer support and therapeutic interaction with professionally trained pet therapy dogs. In addition, many animal shelters often look for volunteers to spend time caring for and engaging with animals. In our clinical experience, we have found that patients gain a greater sense of independence, self-worth, and purpose by not only interacting with therapy dogs but also by engaging in this type of volunteer work with their own pets.
Another useful resource, Puppies Behind Bars, is an organization that helps inmates train service dogs for veterans with PTSD. Paws and Stripes provides veterans who suffer from PTSD with a shelter dog and interactive training at no cost. Heeling Allies privately trains both mental health service dogs and ESDs to enrich the lives of individuals living with psychological, neurologic, and developmental impairments such as PTSD, depressive and anxiety disorders, autism spectrum disorders, and Tourette syndrome.
Given the shifting focus of psychiatry to a more comprehensive recovery model, evidence that animals can function not only as social companions, but also as therapy pets is gaining attention. With further research, we might be able to determine a mental health need presented by a patient and subsequently "prescribe" the kind of animal that would be best suited to "treat" the need.
In the meantime, clinicians should keep in mind the benefits of pet companionship. Discussions involving the meaning of pets in patients’ lives might increase the therapeutic alliance and make patients feel more connected, understood, and engaged in their treatment.
Dr. Wittenauer is a resident in the department of psychiatry and behavioral sciences, Emory University, Atlanta. Dr. Ascher is a resident in the department of psychiatry and behavioral sciences, Beth Israel Medical Center, New York.
New edition can benefit psychiatrists in all settings
It has been more than a decade since Dr. William R. Miller and Dr. Stephen Rollnick unveiled the last edition of their bestselling book, "Motivational Interviewing: Helping People Change." In that time, more than 200 randomized clinical trials have been published, and the understanding and practice of motivational interviewing (MI) has continued to evolve.
MI is a collaborative conversation between a patient and clinician that addresses ambivalence about change through attention to the language of change. MI is designed to help patients mobilize their strength, commitment, and personal resources for transformation. In addition, MI embodies acceptance and compassion, and has been described as a "way of being" that can break down barriers and establish open lines of communication between patients, clinicians, and supervisors in a profound way.
This new edition of "Motivational Interviewing" (New York: The Guilford Press, 2012), provides clinicians with an updated guide to help understand and use the principles of MI. Specifically, clinicians are taught the four confluent processes of MI: engaging, focusing, evoking, and planning. They also are taught the five communication skills, which are open questioning, affirming, reflecting, summarizing, and informing. These principles are instrumental to fostering change and promoting integrity in the lives of patients.
The authors contend that MI is about "evoking that which is already present, not installing what is missing." The authors emphasize that MI is done "for" and "with" a person as opposed to "on someone." The book does a fine job of dispelling commonly held myths associated with MI as being "a panacea" or "a gimmicky technique."
Another common myth that has persisted since the first edition of "Motivational Interviewing" is that the patient-centered approach is a passive psychotherapy, during which the therapist never reveals her or his agenda, never disagrees with the patient, and—God forbid!—never gives advice. In fact, first and foremost, MI is a collaboration and, as such, sharing information and coming up with suggestions from both sides of the therapeutic dyad is welcome and encouraged.
This text is filled with exemplary phrases that psychiatrists can incorporate into their lexicons. The authors delineate the importance of using empathic reflections and garnering respect for a patient’s autonomy while eliciting the patient’s core values. Clinicians are encouraged to acknowledge autonomy and emphasize personal choice, even when patients directly ask the clinician what to do: "I could suggest some things that have worked for other people, but the most important thing is to find what will work for you, and you’re the best judge of that. Would you like to hear some ideas?" (p. 148). Clinicians are encouraged to provide patients with "a menu of options" and continually convey compassion, respect, and hope.
MI is compatible with evidence-based clinical skills and a variety of psychotherapy perspectives, including psychodynamic psychotherapy, cognitive-behavioral therapy, experiential therapy, and family systems theory. The book illustrates clinical case examples to prepare psychiatrists who work in all different types of settings. For example, clinicians will learn how to incorporate MI into the brief medicine management visit, and the standard intake interview and assessment. MI can increase a clinician’s capacity to tolerate uncertainty while potentially decreasing clinician burnout.
The authors underscore the importance of direct feedback, coaching, and observed practice to develop proficiency in MI. The process of developing MI skill is a lifelong endeavor. In sum, this is a user-friendly, engaging, and comprehensive text that should be required reading for all practicing clinicians.
Dr. Ascher is a senior resident in psychiatry at Beth Israel Medical Center, New York, and a member of the Motivational Interviewing Network of Trainers (MINT). Dr. Levounis is chair of the department of psychiatry at the New Jersey Medical School, Newark, and also the coauthor of the book "Handbook of Motivation and Change: A Practical Guide for Clinicians" (Washington: American Psychiatric Publishing Inc., 2010).
It has been more than a decade since Dr. William R. Miller and Dr. Stephen Rollnick unveiled the last edition of their bestselling book, "Motivational Interviewing: Helping People Change." In that time, more than 200 randomized clinical trials have been published, and the understanding and practice of motivational interviewing (MI) has continued to evolve.
MI is a collaborative conversation between a patient and clinician that addresses ambivalence about change through attention to the language of change. MI is designed to help patients mobilize their strength, commitment, and personal resources for transformation. In addition, MI embodies acceptance and compassion, and has been described as a "way of being" that can break down barriers and establish open lines of communication between patients, clinicians, and supervisors in a profound way.
This new edition of "Motivational Interviewing" (New York: The Guilford Press, 2012), provides clinicians with an updated guide to help understand and use the principles of MI. Specifically, clinicians are taught the four confluent processes of MI: engaging, focusing, evoking, and planning. They also are taught the five communication skills, which are open questioning, affirming, reflecting, summarizing, and informing. These principles are instrumental to fostering change and promoting integrity in the lives of patients.
The authors contend that MI is about "evoking that which is already present, not installing what is missing." The authors emphasize that MI is done "for" and "with" a person as opposed to "on someone." The book does a fine job of dispelling commonly held myths associated with MI as being "a panacea" or "a gimmicky technique."
Another common myth that has persisted since the first edition of "Motivational Interviewing" is that the patient-centered approach is a passive psychotherapy, during which the therapist never reveals her or his agenda, never disagrees with the patient, and—God forbid!—never gives advice. In fact, first and foremost, MI is a collaboration and, as such, sharing information and coming up with suggestions from both sides of the therapeutic dyad is welcome and encouraged.
This text is filled with exemplary phrases that psychiatrists can incorporate into their lexicons. The authors delineate the importance of using empathic reflections and garnering respect for a patient’s autonomy while eliciting the patient’s core values. Clinicians are encouraged to acknowledge autonomy and emphasize personal choice, even when patients directly ask the clinician what to do: "I could suggest some things that have worked for other people, but the most important thing is to find what will work for you, and you’re the best judge of that. Would you like to hear some ideas?" (p. 148). Clinicians are encouraged to provide patients with "a menu of options" and continually convey compassion, respect, and hope.
MI is compatible with evidence-based clinical skills and a variety of psychotherapy perspectives, including psychodynamic psychotherapy, cognitive-behavioral therapy, experiential therapy, and family systems theory. The book illustrates clinical case examples to prepare psychiatrists who work in all different types of settings. For example, clinicians will learn how to incorporate MI into the brief medicine management visit, and the standard intake interview and assessment. MI can increase a clinician’s capacity to tolerate uncertainty while potentially decreasing clinician burnout.
The authors underscore the importance of direct feedback, coaching, and observed practice to develop proficiency in MI. The process of developing MI skill is a lifelong endeavor. In sum, this is a user-friendly, engaging, and comprehensive text that should be required reading for all practicing clinicians.
Dr. Ascher is a senior resident in psychiatry at Beth Israel Medical Center, New York, and a member of the Motivational Interviewing Network of Trainers (MINT). Dr. Levounis is chair of the department of psychiatry at the New Jersey Medical School, Newark, and also the coauthor of the book "Handbook of Motivation and Change: A Practical Guide for Clinicians" (Washington: American Psychiatric Publishing Inc., 2010).
It has been more than a decade since Dr. William R. Miller and Dr. Stephen Rollnick unveiled the last edition of their bestselling book, "Motivational Interviewing: Helping People Change." In that time, more than 200 randomized clinical trials have been published, and the understanding and practice of motivational interviewing (MI) has continued to evolve.
MI is a collaborative conversation between a patient and clinician that addresses ambivalence about change through attention to the language of change. MI is designed to help patients mobilize their strength, commitment, and personal resources for transformation. In addition, MI embodies acceptance and compassion, and has been described as a "way of being" that can break down barriers and establish open lines of communication between patients, clinicians, and supervisors in a profound way.
This new edition of "Motivational Interviewing" (New York: The Guilford Press, 2012), provides clinicians with an updated guide to help understand and use the principles of MI. Specifically, clinicians are taught the four confluent processes of MI: engaging, focusing, evoking, and planning. They also are taught the five communication skills, which are open questioning, affirming, reflecting, summarizing, and informing. These principles are instrumental to fostering change and promoting integrity in the lives of patients.
The authors contend that MI is about "evoking that which is already present, not installing what is missing." The authors emphasize that MI is done "for" and "with" a person as opposed to "on someone." The book does a fine job of dispelling commonly held myths associated with MI as being "a panacea" or "a gimmicky technique."
Another common myth that has persisted since the first edition of "Motivational Interviewing" is that the patient-centered approach is a passive psychotherapy, during which the therapist never reveals her or his agenda, never disagrees with the patient, and—God forbid!—never gives advice. In fact, first and foremost, MI is a collaboration and, as such, sharing information and coming up with suggestions from both sides of the therapeutic dyad is welcome and encouraged.
This text is filled with exemplary phrases that psychiatrists can incorporate into their lexicons. The authors delineate the importance of using empathic reflections and garnering respect for a patient’s autonomy while eliciting the patient’s core values. Clinicians are encouraged to acknowledge autonomy and emphasize personal choice, even when patients directly ask the clinician what to do: "I could suggest some things that have worked for other people, but the most important thing is to find what will work for you, and you’re the best judge of that. Would you like to hear some ideas?" (p. 148). Clinicians are encouraged to provide patients with "a menu of options" and continually convey compassion, respect, and hope.
MI is compatible with evidence-based clinical skills and a variety of psychotherapy perspectives, including psychodynamic psychotherapy, cognitive-behavioral therapy, experiential therapy, and family systems theory. The book illustrates clinical case examples to prepare psychiatrists who work in all different types of settings. For example, clinicians will learn how to incorporate MI into the brief medicine management visit, and the standard intake interview and assessment. MI can increase a clinician’s capacity to tolerate uncertainty while potentially decreasing clinician burnout.
The authors underscore the importance of direct feedback, coaching, and observed practice to develop proficiency in MI. The process of developing MI skill is a lifelong endeavor. In sum, this is a user-friendly, engaging, and comprehensive text that should be required reading for all practicing clinicians.
Dr. Ascher is a senior resident in psychiatry at Beth Israel Medical Center, New York, and a member of the Motivational Interviewing Network of Trainers (MINT). Dr. Levounis is chair of the department of psychiatry at the New Jersey Medical School, Newark, and also the coauthor of the book "Handbook of Motivation and Change: A Practical Guide for Clinicians" (Washington: American Psychiatric Publishing Inc., 2010).
