Season 6 of CASAT Conversations features professionals in various fields

>> Speaker A: CASAT Podcast Network Welcome to season six of CASAT Conversations, where we sit down with professionals who have spent decades in their fields like mental health, addiction treatment, business, sociology and more. In this special season, our guests share valuable wisdom from their careers, reflect on what has kept them grounded and inspired, and offer advice for future generations. Whether you're new to the field, uncertain about your next steps, or feeling burned out, these conversations provide guidance and reassurance from those who've walked this path. Let's dive into today's episode.

>> Speaker B: Dr. David Mee-Lee is a psychiatrist and addiction specialist whose career has been dedicated to bridging the mental health and addiction treatment fields. With a passion for dismantling stigma and fostering person Centered Care, Dr. Mee-Lee has spent decades building innovative healthcare programs and transforming systems to improve access and quality. From founding an addiction treatment unit in the early 1980s to to consulting with managed care organizations serving millions, his work has left an indelible mark on the healthcare landscape. As a dynamic and engaging speaker, Dr. Mee-Lee is well known for training on topics such as the ASAM criteria, facilitating behavior change, co occurring disorders, understanding addiction, person centered services, trust treatment planning, organizational development, and justice services in treatment. Now retired, he enjoys exploring the world through travel while continuing to advocate for compassionate, effective care. Today on CASAT Conversations, we are honored to welcome Dr. Mee-Lee to share insights from his remarkable career, offering lessons and inspiration to help guide future generations. Welcome Dr. Mee-Lee We're so happy to have you here.

>> Dr. David Mealy: Well, thank you, Heather. it's a pleasure to be here and thanks for the invitation.


What initially drew you to psychiatry and addiction treatment

>> Speaker B: So, as we get started, can you share what initially drew you to psychiatry and addiction treatment and how your early experiences shaped your career path?

>> Dr. David Mealy: Well, I think I knew fairly early in, in my medical school, training and soon after getting out of my training that I didn't want to be just a kind of mechanical doctor who looked at throats and listened to hearts and prescribed medications or some surgical procedure. So I didn't want to be a kind of human mechanic and wanted to be able to talk to people and interact with them. So that sort of led me to think much more about psychiatry, pretty early on. And also, of course I'm the youngest of three, so both my older brother and my older sister are, also physicians. So I'd had certainly some exposure to the various fields that are available. And my oldest, sibling, my brother, who's eight years older than me, he had done psychiatry. So you can see that I'm sort of influenced by the family but for myself, really wanted to not be a human mechanic. That was the psychiatry direction. But then the addiction treatment direction was pretty early on after I got training and I was assigned to an addiction treatment team in an inpatient psychiatric unit that had four teams, two adult teams, an adolescent team and an addiction treatment team. And I was assigned to the addiction treatment team not because of my exquisite knowledge about addiction, treatment, but because, no, they couldn't get anybody else to work on that team. So I got as the new kid on the block assigned and happily learning from addiction counselors, in long term recovery, realized, hey, I sort of like addiction treatment, which is sort of counterintuitive because a lot of people don't want to work with people with addiction or mental health and addiction issues and so forth. But what I found is that if people get it and get into recovery, they heal and become very productive, even better than they were pre morbidly as it were. Whereas if you help somebody with schizophrenia or bipolar disorder, you can help stabilize them. But it's not often that they actually get into recovery and turn out to be even more productive than when they first, got sick in some psychiatric or mental disorder. So, that's a long answer to say that, the addiction treatment specialty area that I got onto fairly early on was because of the, hope of seeing people heal much more quickly than my other, major mental illness patients. and that's why I think I got more and more into addiction treatment, fairly early in my career really.

>> Speaker B: So this idea of hope in seeing your patients grow really brought you a sense of purpose, it sounds like.

>> Dr. David Mealy: Yeah, and I guess I'm impatient, so I like to see people get well instead of just sort of getting stabilized, which often happens with more severe mental illness. I think the other area that attracted me to addiction treatment was that was really the one area of psychiatry and mental health work where you could bring in spirituality. Because at least in the training that I had on the job training really, because we didn't really learn a lot about addiction treatment in medical school and even in psychiatry, unfortunately. the on the job training that I got from people and counselors in long term Recovery and very 12 step based was that you can really integrate spirituality into holistic sort of, work, which was another attraction for me in terms of addiction treatment. That was one area where you could kind of talk about spiritual things and that it was not only allowed but actually helpful.


In older days of mental health and addiction you were not supposed to discuss religion

>> Speaker B: I'm curious if you'll share with us some of the impacts of bringing spirituality into care. How, how you saw it support your patient.

>> Dr. David Mealy: Yes. Well, I think in the older days of mental health and addiction you were kind of not supposed to talk about religion. And especially if you had patients who as part of their psychosis perhaps had kind of distorted experiences with the church and with religion and with God talking to them and things like that. So we were kind of taught very early on to be careful about dealing with religion. There's so many different perspectives and spirituality. What was the definition of spirituality? Even today if you ask people what does spirituality mean? You're going to hear as many different definitions as there are people responding to you. But in addiction treatment, it was very much a part of the treatment. And I think today views have changed significantly in terms of the importance of involving spirituality again, God as we understand him or her or whatever you mean by spirituality. But what I think of it as being something outside of yourself. So that you're not just feeling like you are alone in this battle with addiction or mental health and that you by some sort of will of working hard, no pain, no gain, a kind of on your own in this battle, against disease sort of mentality. Whereas spirituality I think introduced in the correct way helps people have a sense of hope and have a sense of something outside of themselves which can really create a sense of hope. And that I'm not alone in this and whether you see it as sort of God or a higher power, but spirituality in the sense of community and, and sense of relationship and the sense of not being alone and not having to struggle by yourself. That sort of aspect of spirituality I think has been happily introduced more and more into holistic care and has a tremendous power to create a sense of hope, which is really a big determinant of whether people get well if they don't have a sense of hope. There's not really just even taking medications or doing anything with a therapist. If you don't have a sense of hope, it really doesn't turn out too successfully. So it's not something we can do to people. We have to engage them in a self change process.


You've been an advocate for holistic care as well as person centered care

>> Speaker B: I'm aware of you've been such an advocate for holistic care, as well as person centered care. I'm curious if you'll share with us some of the key lessons that you've learned about creating and sustaining effective person care systems.

>> Dr. David Mealy: Well, you know, pretty early in when I was graduating, from my mental health training George Engel, who was a psychiatrist, introduced to what back then was a term that I hadn't heard of before and. But which we now know as biopsychosocial. And that has been an important, influencer in my thinking. Because when he introduced the term biopsychosocial, he wasn't really even talking about mental health. He was talking about all illness. That if you have somebody with a severe heart attack and they're in the emergency room and the family members come and the doctor's talking to them on the other side of the curtain and says, oh, your dad's had a severe, heart attack. I don't know if he's going to make it. And he's hearing this. That's going to affect his drive to get well. And so George Engel was talking about it's not just the biological, physical, illness. There's a, psychological and psycho, mental health aspect to illness. There's a social, aspect to illness. People who have relationships and are not alone in their illness do better than people who are alone. So biopsychosocial. And even now if you add biopsychosocial, spiritual is a great concept to have in terms of understanding the etiology of all illness, but also understanding how illnesses present themselves and then how in treatment that holistic perspective is so important. For example, people who have, addiction. It's not just a brain disease, biological neurotransmitters. There are psychiatric, and psychological and personality aspects that can contribute to the origin of addiction. There are social, public health principles where, social determinants of health. There's many, aspects in the etiology of addiction and mental, illness. And who crosses that line into presenting as a patient depends on their own mix of those biopsychosocial factors. Somebody may have a lot of genetic predisposition, but not a lot of social determinants of health that influence it. Somebody might have a lot of social determinants of health like poverty and housing and money and food deserts and so forth. Somebody may have more personality, and impulse control problems that contribute to them. Crossing the line. So who crosses the line into quotes? Illness is their own personal recipe of those biopsychosocial, aspects and then how their illness presents. Some people have more biological presentations. Some people have more social and legal and family problems. Some people have more mental health presentations and then the same in treatment. Then we have to focus on for this particular person, what is their mix of biopsychosocial spiritual factors in their etiology, in the way it's presenting. And therefore then in treatment, how do we focus treatment to meet their specific needs? So individualized treatment isn't just, well, be nice to people and treat them as individuals. It's really doing a careful assessment of what are their particular needs that need to be addressed and then tailoring treatment to those specific needs and then tracking whether that's really working. and so to me, person centered, individualized treatment is just what we do in all of healthcare. You wouldn't want to go to a doctor who says, I give the same cancer treatment to everybody, regardless of their severity or their particular kind of cancer. You wouldn't do the same for somebody with diabetes. I just give exactly the same treatment. You want to know, you know, people's severity and what aspects, and we're getting better even in general health care, of looking at social determinants of health and recognizing that it isn't just about the surgical procedure or the medication or the, or the biophysical intervention. It's really about hitting all of the areas of a person's life, their spirituality, their mental health, their physical environment and so forth.

>> Speaker B: I love this idea of everyone's personal recipe. You know, I'm aware of what you shared in the beginning about I don't want to be a human mechanic, you know, and kind of how that set you on this path, in psychiatry and in addiction treatment, and the importance of diagnostics. Right. As you're talking about assessments. And so it's an, it's an interesting metaphor or analogy to consider as we think about working with people and what person centered care really truly means.

>> Dr. David Mealy: Yeah. Yep.


You've been a strong advocate for reducing stigma against addiction and mental illness

>> Speaker B: You've been such a strong advocate for reducing stigma against individuals with addiction and mental illness. What strategies have you found most effective in mitigating stigma within the healthcare field?

>> Dr. David Mealy: Well, you know, a lot of people, perpetuate stigma, because they often don't know what they don't know. You know, when, in the old days before women's rights came up, you know, we would often refer to, oh well, the girls at the office or you know, we would have terms that we weren't being because we didn't know then about sort of treating people with equal respect, around that gender aspect. And so we would use terms that might be belittling or convey an attitude that somebody is less than. And it's the same with terminology and stigma and mental health and addiction. So it's still very prevalent today that people say alcoholics and addicts and substance abuse and, and the people use that and they aren't aware that when you're sort of personifying the person as their diagnosis, like he's a schizophrenic or a borderline or a bipolar, or they're alcoholic, and addict instead of. They're a person who happens to suffer from bipolar disorder, schizophrenia, addiction. well, if you don't know that, so you. So the first step is just to help raise people's awareness and consciousness to. You are not using that in any negative intending way, but it actually does have an impact. And research can show, for example, with, if you call somebody a substance abuser that, that gets linked in people's mind with child abuser, sex abuser, elder abuser, and you have a negative connotation towards somebody who you think of as a substance abuser versus somebody who happens to suffer from the illness of substance use disorder or suffers from addiction. And so the first step I think is just to raise people's awareness by some education because they don't know what they don't know. now if they continue, once they know that a term is, stigmatizing and does damage to people and they continue to do it, then you have to engage them sort of in a motivational interviewing way to sort of start where they're at and try to understand why they're having trouble integrating the knowledge that they have and why they might even be willfully wanting, to stigmatize people. And that's a whole process of how do we engage people? Because in our country at this point we have half the population that is quite comfortable with using stigmatizing terminology. And we know that you can't just vote that out of existence or you can't just yell at people. We have to engage people in a change process where, we hope that they will see, that using stigmatizing language or terminology is not really helpful in engaging people. At least that's my view. There might be other people say no, using stigmatizing language is good because I think all those alcoholics and addicts need to pull themselves up by their bootstraps like I did. So they may say, I don't want to be politically correct and say the right thing, because I think they are a bunch of losers. so again, it might be just innocent not knowing what they don't know. It might also be a philosophy that, that perpetuates the stigma and terminology. And you can't change that just by education. You have to change that. The way we engage all people in A soft change process. And you can't do it by shaming or yelling at people or telling them they're bad because they still keep using that language. They hang on to it because of some deeply held beliefs which they're not going to change by you self righteously putting them down. So that's where all change process involves restrictions, respecting people and engaging them in a compassionate way to understand how come you keep using that stigmatizing language now that you know that it has an impact and is this willful misconduct or is it kind of still that you don't fully understand the impact of what you're doing. But that's really engaging them in a change process that starts with respect and compassion and engaging people in a change process like we do with all change.

>> Speaker B: I'm curious if you would walk us through like that wonderful example you provided of someone who's not willing to change and kind of owns it in their identity as a philosophy. if you would give us an example of how you would engage them.

>> Dr. David Mealy: Well I think it's true not just with people who may want to do that, but it's true of all change behavior. And that is you have to start where the person's at. And what's the concept that a lot of people know about Prasasko and die Kilmeny Stages of change is I think a very useful model to help you join with people where they're at because you might want them to be at action for changing their language or their behavior or their attitudes. but if they're at pre contemplation where it's not even on the radar screen or they don't even see any problem with that, you can't start interacting with them as if they should be at action for something they don't even have an interest in changing. So they're not being resistant or in denial. They're just not on their radar screen. They're not interested in changing that or in motivational interviewing language. It's that sustain talk that they are not necessarily being negative or oppositional. It's just they're happy with the status quo. So you have to start with accepting them where they're at and then find ways to attract them into a change process. Which means how might I move them from not even being interested at all to getting to the point where they might be ambivalent and be thinking well maybe there is something to that? Oh, well I'm not really sure I want to change that, but, well, they might have a point about that. And there's different ways that people are in the political realm, for example, or in the stigma realm, trying to move them from I'm not interested in this to well maybe I could consider that. And one of the ways in, like in medical school sometimes people have done that is to have in addiction somebody in long term recovery come and talk to the medical students about their journey from active harmful addiction to recovery and giving people a glimpse through that story of that real person of the pain of addiction, but also the joy of recovery. And that helps move people who wouldn't even thought about addiction move from I'm not even interested in addiction to wow, this is a person whose life was transformed. And that's a pretty amazing inspiring story that might move somebody all the way to I want to work with addiction treatment and people with addiction, but it might move them from pre contemplation to contemplation and say hey, maybe my attitude's about addiction of I need to change that from thinking they're a bunch of losers who are weak willed to maybe it's an illness that I, as a helping person and a medical student or a doctor could really be part of that has moved them from pre contemplation, not interested at all to maybe this is something that could be just through that experience of interacting with a person whose story they were inspired by. And I think that's true in political change and so forth where a lot of organizations are trying to bring together people of opposing views and helping them to see, hey, you're just a person like me too who's well intentioned and we are people of goodwill. It's just that we've see things differently because of culture, upbringing, exposure and so forth. But when people get to know each other as people, that begins to change attitudes. But it has to start with where they're at, not coming from. you should be doing this, in other words, expecting people to be at preparation or action for which they don't even have any interest in changing. So it's really the change process that goes across the board. But then in terms of stigma and other terminology and so forth, it's the same process of attracting people into a change process, not mandating or shaming people into a change process.

>> Speaker B: I'm also aware of talking at people versus deeply listening. Right, and so you're also pointing towards yes, being curious about the individual, non judgmental and this practice of deep listening to that other human being that's right.

>> Dr. David Mealy: I mean, you can't know what stage of change they're at or what their, what drives their particular views. Unless you really listen, like you say, and get to know and ask more questions than really, advocating any, ideas to change. So that's fundamental to starting where people are at, not where you think they should be at.

>> Speaker B: Yeah. In today's world, I feel like this is such a important skill, I guess, that we all need to learn. you know, mental health providers are generally trained in these skills and I think that's why, mental health services are so needed right now. and what would it be like if we taught people how to listen to one another and some of these basic humans, human, I don't know, kindness principles. Yeah. What, what might our world be like then?

>> Dr. David Mealy: Right. And you can even take it from a selfish point of view. If you want people to think and be the way you are, you're not going to get that unless you listen, listen to them and meet them where they're at. There's going to be no chance of just yelling at each other. So even if it's just from a Selfish or not. Selfish may not be the word, but even from your own desire to change the world, or to help people to, really move, in a direction that you think will be better for everybody, you're not going to do it unless you start with compassion and acceptance and respect. Anyway, it's not going to be effective. I saw a Rumi quote, that said something to the effect of yesterday when I was wise, I wanted to change the world. today, now that I'm older, I want to change myself. So all of this stuff begins with yourself and your attitudes about how do I meet people with respect and compassion, and face, the world from that sort of high vibrational point of view as opposed to, I'm going to change the world and make these people, think and behave better.


David says learning about behavior change changed the way he approaches personal relationships

>> Speaker B: I'm curious how that perspective shifted or grew for you throughout your career. Right. If you think about, David starting his career and who you are today, I guess my question is what influenced you along the way?

>> Dr. David Mealy: Yeah, I think that's a good question, because it'd be interesting to track exactly which influences and when started to shift that thinking. But I think part of it is fairly early on, again starting with just some, awareness. you know, I remember when I first heard about stages of change that just clicked because for a long time probably I was thinking, well, I know what's best for this person. And obviously if they're psychotic and attacking people, I know what they should do. And, and so you attempt to, for the patient's own good, the client's own good, do good to and with them and for them. But you also see how that doesn't work when you don't engage the person themselves. And then you get introduced to concepts like motivational interviewing, stages of change, person centered care, and you say, ah, that gives me some conceptual understanding about why what I've been doing hasn't been working. Where my best intentions of helping people to change didn't go anywhere. Just because I wanted the best for them and worked my hardest to make them change. It doesn't work because I didn't understand the science of change. And so once you get introduced to the science of change and start applying that, you see, ah, this is not only more respectful and compassionate, but it's more effective. And it works when you find out what does this person want, what works for them, and to make sure that you do a more individualized approach. So in the professional world it was learning more about how people change and the science of behavior change and then applying that and seeing the effect of that. And then in the personal world, you start realizing that it's the same thing in your relationships with your primary partner or with your kids or with friends, that it's no different in terms of your personal relationships, that you don't resolve family, arguments and so forth by just using authoritarian methods or by yelling or by trying to persuade or, or trying to make logical arguments. It's the same change process. And then you start realizing, oh, this all starts with me having to change my attitude about things because the only relationship you'll have for the rest of your life is the relationship with yourself. And then you start realizing, okay, it's not really effective for myself to have self shame and to feel bad about I made a mistake or all those kinds of things. You know, we're often more unkind to ourselves than we are to somebody else who we would be more forgiving. so it's an evolution, I think, of both knowledge and understanding the science of behavior change, understanding, how spirituality can provide hope, see how that's effective in your work, but then see how that's effective in your, personal relationships. And then finally coming to really, do I love m myself? Do I really respect myself in the same way that I'm willing to respect other people? And yet I haven't maybe even done it for myself? So that's really, I guess my evolution about how, I come to this at this, ripe old age.

>> Speaker B: I'm curious, how would you describe your relationship with yourself today?

>> Dr. David Mealy: Well, I think, you know, I think my wife passed away very suddenly about five and a half years ago. And that really, brought even more strongly to the awareness about can I live with myself by myself? You know, when you're married for 46 years, you have a family, you're on almost automatic pilot of survival and living the life. And when you are, suddenly alone, it brings back all of the things that you kind of taught but maybe didn't live. You know, things you were taught. Like you're responsible for your own happiness. Nobody else's job is to make you happy. you don't have to be alone. You can form relationships, all that. But when you are actually thrust into being alone, you're confronted with, I was confronted with, do I really live? All these things I believe and have taught and that sound right, you're responsible for your own happiness and all of that. Or am I going to now try to find somebody else to fill the void or go back to work and work harder to take care of the pain? So I think it was, an opportunity with her sudden death and almost like a gift. I see it as to look at how do you actually live with the relationship you'll have to the day you die? And is there really self love and the ability to live alone? Or are you going to try to fill that void with activity or other people? Because I've seen other people who lost their loved one, very suddenly and thinking m of a particular man who married again very quickly within a few months, and then that ended in divorce. And it never really healed. The real thing that he was trying to, heal by just getting into another relationship or getting into work or whatever. So it was a time of reflection that I think helped me, now feel so much more grounded in. I could live alone if I needed to. But I also enjoy, a relationship where both, people are committed, to be responsible for their own happiness. But from that position of wholeness now can come together and have an even better, existence together and joy together because we're not relying on the other person to make us happy. Or it's their responsibility to respect me, so I respect myself. Or it's their responsibility to love me so that I can love myself. It's from loving yourself that you can then come in wholeness to another relationship and have an even better, joyful experience together. Not that there aren't bumps that come up, but those bumps that come up are opportunities for growth and expansion, not for blaming or, displeasure with your partner. That's probably more information than you wanted, but that's where I'm at.

>> Speaker B: I find it fascinating and I'm sure listeners will find it fascinating and appreciate. I think most of the people who listen are on this journey of human discovery, and growth. And so getting to hear about your journey is, is a true gift. So thank you for sharing it with us.

>> Dr. David Mealy: Yeah, sure.


You've witnessed significant changes in healthcare delivery and policy

>> Speaker B: throughout your career I know you've witnessed significant changes in healthcare delivery and policy. What advice would you give to future leaders about navigating and influencing such changes effectively?

>> Dr. David Mealy: Well, I think you first have to know what changes you want to make. So if you're into wanting to change systems, obviously something's prompted that. So I think it starts first with yourself saying, well, what is my message and mission? What is it that I want to get across? and then to think about like in any change process, how will that be best heard? And I think it starts with once you kind of know the direction you want to go. It starts with first trying to identify with people their particular struggle or their particular reason for why they would even be wanting to hear about, some change. So for example, I realized pretty early on, that I was needing to move away from fixed length of stay programs because the first addiction treatment program I, was involved with and started and directed was a 21 day hospital based program. And managed care was just awakening then in the, the early 80s and they were putting pressure on us to have more flexible individualized programs. Now of course we initially started to fight them because no, we have a 21 day program. That's how treatment's done. But because of that consciousness raising, to me to then think, well, wait a second, why do we have a 21 day hospital based program? We don't have 21 day schizophrenia hospital based programs, we don't have 21 day diabetes hospital based programs where everybody starts in the hospital or in an inpatient unit. So it got me to think about, well, what sort of system would I want to develop? And then when I started wanting to try to influence, helping to change that system, I realized I couldn't just mandate that. I had to try to attract people to that change. And early on that meant trying to identify with people, well, are you struggling with managed care too? Are you being assaulted with your 28 day program or your 6 month outpatient program or your IOP 6 week program are you finding people that confronting you about you're not allowed to do that anymore or at least you can do it, but we're not going to pay for it. So you had to help identify with and engage people in. Yeah, I share that same problem and I've been there and I know what that's like. So engaging people in meeting them with the pain that I originally had to meet with 21 day programs and having that assaulted, meeting people with their pain. So it's again meeting people where they're at, beginning to identify what their pain is and then trying to inspire them that there's another way that you can be doing the same caring work for your patients and clients, but in a way which actually when you think about it, is going to be better for your clients because you're going to hang in with them longer and not just graduate them after a set amount of time and then send them on their way to aftercare. You're going to actually hang in with them just like we do with other chronic illnesses. And you're going to be there for them for not just 28 days or six months, but for a lifetime if they need it or if they get into self mutual help recovery and don't need you, that's good too. So the changing process starts with, with knowing what your mission is, being clear on what changes you want to make, but then working with people to look at what would be the staff and the program changes and the attitude changes and the policy changes that we would need to make to actually create and transform our system of care. Because it isn't just about training counselors or therapists us, it's a whole system. How do we change the payment system, how do we change the policies, how do we change the training that we give people, how do we skill build? So again, it has to be a holistic process of change, not just okay well we'll send our counselors for a six week training program and then expect the whole system to change when they're up against policy and payment systems and government regulations that don't match doing perhaps an individualized treatment approach for example. M so again, just as we work with people in a holistic way, we have to work with systems change in a holistic way. And just as we have to engage people and start where they're at in a change process, you have to start with the system where it's at and attract them into a change process that will take time, not just by, okay, starting October 1st, this is the new policy that's not going to work because everybody's not bought in, everybody's not trained to do that. A lot of the policies and payment systems and all that don't dovetail to make that even be successful. so it's really what we know about holistic care and individualized engagement for individual clients and patients. It's the same principles for systems change.

>> Speaker B: Yeah, that makes perfect sense.


I also am thinking about evidence based programs. Many funders through grants require evidence-based programs

I also am thinking about evidence based programs. And you know, so many funders through grants, require evidence based programs. And I'm curious, you know, how you've seen that world shift during your career. Because there's a real importance in making sure that programs are backed by evidence. But I've also seen systems get stuck in it because programs that were evidence based 30 years ago are still being used today and sometimes with outdated science or information. And so I'm curious if you have any thoughts on that.

>> Dr. David Mealy: Yeah, so William Miller of motivational interviewing wrote a paper where he talked about evidence based practices. we give too much reverence to when we need to give evidence based practices respect, but not reverence. So there's been a movement where if we just get everybody be trained on evidence based practice practices and be trained and fidelitous to those will automatically get good outcomes. Well, what we know from over 40 years of research on how people change is that the methods and techniques and practices that you use certainly do contribute to good outcomes but they are really lower and have less impact than two other things that have a better impact on people's outcomes. And the first one is a therapeutic alliance. How much are you tuned in with people to really help them to be an engaged, fully participating person? Because a therapeutic alliance, the three legged stool of therapeutic alliance, is agreement on goals, an agreement on method within the context of a trusting, respectful, safe, honest relationship. So that really has the biggest impact on people's outcomes. Because if you're working on helping a person to stop drinking and drugging and they're really working on getting their kids back and you don't have an agreement on the goals and if your methods are go to AEA and stop drinking and get rid of that abusing partner and they love their partner and hate AA and don't want to go into recovery, you don't have an agreement on the methods. And then if you have policies that say if you use drugs we'll kick you out and get a, if you get a positive drug screen you don't have a trusting relationship, they'll never tell you that they're used. So the therapeutic alliance has a bigger impact on the outcome than the evidence based practice used. And then the second thing is a sense of hope gives a much better chance for an outcome than just using evidence based practice. So if you're using an evidence based practice with a client and a patient that's not engaged in a therapeutic alliance and who has no sense of hope, who are just going through the motions to get you off their back, and you think you're using a manualized evidence based practice and that is going to have a good outcome, you're not going to have a good outcome. So there's been too much reverence to think that if we just use evidence based practice and don't use that in the context of the therapeutic alliance and creating hope that we'll get a good outcome. That's not going to work because we put too much emphasis on just using evidence based practice. That doesn't mean we shouldn't use it. We want to have the best tools in our toolkit, but it's only as you use those tools in the context of engaging the person in a self change process with a sense of hope and respect and compassion that evidence based practices have any real lasting impact.

>> Speaker B: Thank you for your perspective. I appreciate it immensely. Something that I think about a lot and have seen a lot in the work that I've done. So I appreciate that.


As you reflect on your career, what will be your lasting impact on addiction

so as you reflect on your career, what will, what do you hope will be your lasting impact on the field of addiction and mental health?

>> Dr. David Mealy: Well, for probably you know, 40 years I've been really working on how do we move, especially in addiction treatment, away from program driven fixed length of stay, one size fits all services to person centered outcomes driven individualized treatment. That really has been a driving mission in all of the training and work that I've done. So that's what I would hope would continue to be built upon and I think has been built, build upon. As we've seen people move from a program driven graduate go to aftercare to a more continuum of care and chronic disease management model with the focus being on engaging people in long term recovery and hanging in with people, for what that takes rather than just sort of graduating them from a program and then admittedly giving them aftercare. But it's not being able with the same intentionality as we do with other chronic diseases where we are very intentional about hanging with people. We don't just send people to diabetes after care, after graduating from a program, we hang in with people who have hypertension, we hang in with people who have schizophrenia, we hang in with people with bipolar disorder for a lifetime if necessary. And we've needed to do that with addiction treatment. And I think the work that I've done has advanced that perspective. and so I rest easy with at least you know, getting that in people's attention and seeing that built upon, albeit the fact that we still in many places still acting like 1970, and still have fixed length of stay programs that are not in a chronic disease model and that still graduate. People and clients think they're done once they graduate from a program. So if I wanted to be glass half empty, I'd say I've had no impact because I still see people saying how long do I have to be here? And having counselors say well you have to be here for three months or something. And payment systems that still at least in the public sector, perpetuate a sort of fixed length of stay program if I want to be glass half full. I've seen a tremendous change in people's attitudes and systems to become like with other illnesses, hanging with people for life, but at an intensity that matches their severity and needs.

>> Speaker B: Well, I deeply respect the work that you've done. I've been honored to get to work with you a little along the way and really appreciate all that you've contributed to the field.


What advice would you offer to inspire the next generation of mental health professionals

as we wrap up, I'd love to just ask you this final question. what guidance would you offer to inspire the next generation of professionals?

>> Dr. David Mealy: Well, I think sometimes when people get out of training they are in the I'm going to change the world. I've got the latest knowledge, I want to start applying all of this stuff and it would be easy again to get into a situation where you're doing things to people and are well intentioned, but sort of go like running at a problem as fast as you can and then quickly getting burned out as you discover that just all of your efforts doesn't change the world. It doesn't change patients and clients. So the advice I would give is to first recognize that you can help contribute to a person change process but the treatment and the piece that you give is just really a tiny piece. And what your job really is to engage the person and inspire and attract them into a self change process where they're going to make the right choices in the dark of night when nobody's watching, not just when you have them in treatment or at your session where you engage them to make the right decisions with, when nobody's watching, when they can then sustain any change from their own self empowered position. So your job is really not to help people, but to help people help themselves. And so in any moment that you're interacting with a person, you're asking yourself, how, in this moment am I helping them to help themselves? Not how am I helping them? Because if you help them to help themselves, you have really contributed to their life. It's the old fisherman thing, do I give a fish or do they help them to learn how to fish? And that's the same in all helping stuff. How do I help this person, with depression, help themselves with that so that they're not dependent on me or on a system to, be able to sustain them the change. So we have an important place to play in treatment, but only in so much as we help people to help themselves and engage them in a self change process, not in being the almighty one to fix people.

>> Speaker B: Well, I appreciate you being here to share your wisdom that you've gained along the way. And, yeah, thank you for your time and for being with us today.

>> Dr. David Mealy: Sure. Thank you for the invitation. Happy to do it.


This podcast is brought to you by the CASAT Podcast Network

>> Speaker A: Thank you for listening to CASAT Conversations, your resource for exploring behavioral health topics. We hope you found today's conversation timely and meaningful. Please share this podcast with your friends and colleagues. If you want to learn more, visit us at our blog at casatondemand.org. CASAT Podcast Network this podcast has been brought to you by the CASAT Podcast Network, located within the center for the Application of Substance Abuse Technologies, a part of the School of Public Health at the University of Nevada, Reno. For more podcast information, information and resources, visit casat.org